BACKGROUND: Several studies have described predictive models to identify trauma patients who require massive transfusion (MT). Early identification of lethal exsanguination may improve survival in this patient population. The purpose of the current study was to validate a simplified score to predict MT at multiple Level I trauma centers. METHODS: All adult trauma patients treated at three Level I trauma centers from July 2006 to June 2007 who (1) were transported directly from the scene,(2) were trauma activations, and (3) received any blood transfusions during admission were included. Assessment of Blood Consumption (ABC) score developed using the same inclusion criteria for patients admitted to a single trauma center (Vanderbilt University Medical Center [VUMC]-1) between July 2005 and June 2006. ABC score calculated by assigning a value (0 or 1) to each of the four parameters: penetrating mechanism, positive focused assessment with sonography for trauma for fluid, arrival blood pressure <90 mm Hg, and arrival pulse >120 bpm. A score of 2 was used as "positive" to predict MT. Area under receiver-operating characteristic curve was calculated to compare the predictive ability of the score at each institution. RESULTS: There were 586 patients in the developmental (VUMC-1), 513 patients at trauma center 1 (VUMC-2), 372 at trauma center 2 (PMH), and 133 at trauma center 3 (Johns Hopkins Hospital). MT rate was similar between centers: 14% to 15%. Sensitivity and specificity for the ABC score predicting MT ranged from 75% to 90% and 67% to 88%, respectively. Correctly classified patients and area under receiver-operating characteristic curve, however, were 84% to 87% and 0.83 to 0.90, respectively. CONCLUSIONS: The ABC score is a valid instrument to predict MT early in the patient's care and across various demographically diverse trauma centers. Future research should focus on this score's ability to prospectively identify patients who will receive MT.

BACKGROUND: Massive transfusion (MT) protocols improve survival in patients with exsanguinating hemorrhage. Both the increased plasma to red blood cells (RBC) and platelets to RBC ratios, and the "protocolization" of product delivery seem to be critical components of the reduction in mortality. The purpose of this study was to identify the incidence and impact of MT protocol noncompliance and to intervene in provider-related events associated with poor compliance and outcomes. METHODS: A MT protocol was initiated in 2006 at a Level I trauma center. All cases of protocol activation were reviewed by a multidisciplinary performance improvement (PI) group for compliance and the need for "real-time" protocol adjustments. Educational conferences, Grand Rounds presentations, and individual provider education were performed on a quarterly basis. Compliance of seven measures were evaluated as follows: type and screen sent from emergency department (ED), activation of protocol in ED, activation by trauma attending, administration of 2:3 plasma to RBC, administration of 1:5 platelets to RBC, protocol discontinuation on leaving operating room, and no products wasted. Univariate, multivariate, and time-series analyses were performed. RESULTS: All 125 MT protocol activations occurring from February 2006 to January 2008 were reviewed. Full compliance for all PI measures during the entire period was 27%. There were no differences in demographics, injury severity, or physiologic scores between patients for whom activations were compliant and those who were noncompliant. Full compliance was an independent predictor of survival (86.7% vs. 45.0%, p < 0.001). Both activation of the protocol in the ED and achievement of prespecified ratios of plasma: RBC (2:3) and platelets: RBC (1:5) were independent predictors of 24-hour and 30-day survivals. All PI measures demonstrated improved compliance during the study period with the exception of ED activation. Failure to send type and screen from the ED is an independent predictor of wasted blood products. CONCLUSION: Early activation of a MT protocol and achieving predefined ratios was associated with improved survival. ED activation and direct blood bank notification by the trauma attending were associated with a reduction in blood product wastage. A multidisciplinary PI process helps to identify provider/specialty noncompliance and to assess the impact of these factors, and it was associated with improvement in compliance and MT outcomes over time.

BACKGROUND: Hepatic injury remains an important cause of exsanguination after major trauma. Recent studies have noted a dramatic reduction in mortality amongst severely injured patients when trauma exsanguinations protocols (TEP) are employed. We hypothesised that utilisation of our institution's TEP at the initiation of hospital resuscitation would improve survival in patients with significant hepatic trauma. PATIENTS AND METHODS: All patients who (1) sustained intra-abdominal haemorrhage with Grades III-V hepatic injury and (2) underwent immediate operative intervention between February 2004 and January 2008 were included in the study. TEP was instituted in February 2006, and all subsequent patients who met inclusion criteria and were treated with TEP constituted the study group. Patients who met inclusion criteria, were treated before introduction of TEP, and received at least 10 units packed red blood cells in the first 24h constituted pre-TEP comparison group. Univariate and multivariate analyses evaluated the effects of TEP on the study population. RESULTS: Seventy-five patients were included in the study: 39 in the pre-TEP cohort (31% 30-day survival) and 36 in the TEP cohort (53% 30-day survival). There were no differences in demographics, extent of hepatic injury, or operative approach between the patient groups (all p>/=0.27). Injury Severity Scores were significantly higher in the TEP group (41+/-18 vs. 28+/-15, p<0.01). TEP patients received more plasma and platelets during operative intervention and significantly less crystalloid (all p<0.01). Occurrence of cardiac dysfunction and abdominal compartment syndrome was significantly lower in TEP patients who survived 24-h post-injury (both p</=0.04). After adjusting for the significant negative effects of Grade V injury and involvement of major hepatic vasculature (both p</=0.02), TEP significantly improved 30-day survival: OR=0.22, 95% CI: 0.06-0.81, p=0.02. CONCLUSIONS: TEP allows for an effective use of plasma and platelets during intra-operative management of severe hepatic injury. Utilisation of TEP is associated with significant reductions of cardiac dysfunction and development of abdominal compartment syndrome, as well as, significant improvement in 30-day survival.

BACKGROUND: Large-volume blood transfusions have been implicated in the development of hyperkalemia. The purpose of the current study was to determine whether critically injured patients receiving massive transfusions are at an increased risk of hyperkalemia. METHODS: Massive transfusion (MT) cohort, all trauma patients (02/2004-01/2008) taken directly to the OR and receiving >/=10 units of RBC in first 24h. Comparison cohort (No-RBC), all patients (02/2004-01/2008) transported directly to the OR who received no blood products in the first 24h. Hyperkalemia defined as K+> 5.5 mEq/L. RESULTS: There were 266 MT patients, 237 No-RBC patients. MT patients were more likely to have hyperkalemia in the immediate postoperative setting (1.8% versus 4.6%, P = 0.049). However, linear regression did not identify intraoperative blood transfusions as a predictor of postoperative K+ values (P = 0.417). Logistic regression identified only preop K+(OR 1.79, P = 0.021) and postop pH (OR 0.009, P = 0.001), but not MT, as independent risk factors for postop hyperkalemia. CONCLUSIONS: Despite concerns of hyperkalemia following MT, we found less than a 5% incidence of postop K+(>5.5 mEq/L). After adjusting for the significant effects of preop K+ and postop pH, MT patients were at no higher risk of hyperkalemia than those who received no blood products.

The frequency of typical and atypical Beijing strains of Mycobacterium tuberculosis was determined in the Netherlands; Vietnam; and Hong Kong Special Administrative Region, People's Republic of China. The strains' associations with drug resistance, M. bovis BCG vaccination, and patient characteristics were assessed. BCG vaccination may have positively selected the prevalent typical Beijing strains.

INTRODUCTION: Massive transfusion (MT) protocols have been shown to improve survival in severely injured patients. However, others have noted that these higher fresh frozen plasma (FFP):red blood cell (RBC) ratios are associated with increased risk of organ failure. The purpose of this study was to determine whether MT protocols are associated with increased organ failure and complications. METHODS: Our institution's exsanguination protocol (TEP) involves the immediate delivery of products in a 3:2 ratio of RBC:FFP and 5:1 for RBC:platelets. All patients receiving TEP between February 2006 and January 2008 were compared with a cohort (pre-TEP) of all patients from February 2004 to January 2006 that (1) went immediately to the operating room and (2) received MT (>or=10 units of RBC in first 24 hours). RESULTS: Two hundred sixty-four patients met inclusion (125 in the TEP group, 141 in the pre-TEP). Demographics and Injury Severity Score were similar. TEP received more intraoperative FFP and platelets but less in first 24 hours (p < 0.01). There was no difference in renal failure or systemic inflammatory response syndrome, but pneumonia, pulmonary failure, open abdomens, and abdominal compartment syndrome were lower in TEP. In addition, severe sepsis or septic shock and multiorgan failure were both lower in the TEP patients (9% vs. 20%, p = 0.011 and 16% vs. 37%, p < 0.001, respectively). CONCLUSIONS: Although MT has been associated with higher organ failure and complication rates, this risk appears to be reduced when blood products are delivered early in the resuscitation through a predefined protocol. Our institution's TEP was associated with a reduction in multiorgan failure and infectious complications, as well as an increase in ventilator-free days. In addition, implementation of this protocol was followed by a dramatic reduction in development of abdominal compartment syndrome and the incidence of open abdomens.

BACKGROUND:: Despite recent attention and impressive results with damage control resuscitation, the appropriate ratio of blood products to be transfused has yet to be defined. The purpose of this study was to evaluate whether suggested blood product ratios yield superior survival rates. MATERIALS:: After IRB approval, a retrospective evaluation was performed on all trauma exsanguination protocol (TEP, n = 118) activations from February 1, 2006 to July 31, 2007. A comparison cohort (pre-TEP, n = 140) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. We then compared those who received FFP:RBC (2:3) and platelet:RBC (1:5) ratios with those who did not reach these ratios. Multivariate analysis was performed for independent predictors of mortality. RESULTS:: A total of 259 patients were available for study. Patients receiving FFP:RBC at a ratio of 2:3 or greater (n = 64) had a significant reduction in 30-day mortality compared with those who received less than a 2:3 ratio (n = 195); 41% versus 62%, p = 0.008. Patients receiving platelets:RBC at a ratio of 1:5 or greater (n = 63) had a lower 30-day mortality when compared with those with who received less than this ratio (n = 196);(38% vs. 61%, p = 0.001). Regression model demonstrated that a ratio of FFP to PRBC is an independent predictor of 30-day mortality, controlling for age and TRISS (OR 1.78, 95% CI 1.01-3.14). CONCLUSIONS:: Increased FFP:PRBC and PLT:PRBC ratios during a period of massive transfusion improved survival after major trauma. Massive transfusion protocols should be designed to achieve these ratios to provide maximal benefit.

BACKGROUND:: The importance of early and aggressive management of trauma- related coagulopathy remains poorly understood. We hypothesized that a trauma exsanguination protocol (TEP) that systematically provides specified numbers and types of blood components immediately upon initiation of resuscitation would improve survival and reduce overall blood product consumption among the most severely injured patients. METHODS:: We recently implemented a TEP, which involves the immediate and continued release of blood products from the blood bank in a predefined ratio of 10 units of packed red blood cells (PRBC) to 4 units of fresh frozen plasma to 2 units of platelets. All TEP activations from February 1, 2006 to July 31, 2007 were retrospectively evaluated. A comparison cohort (pre-TEP) was selected from all trauma admissions between August 1, 2004 and January 31, 2006 that (1) underwent immediate surgery by the trauma team and (2) received greater than 10 units of PRBC in the first 24 hours. Multivariable analysis was performed to compare mortality and overall blood product consumption between the two groups. RESULTS:: Two hundred eleven patients met inclusion criteria (117 pre-TEP, 94 TEP). Age, sex, and Injury Severity Score were similar between the groups, whereas physiologic severity (by weighted Revised Trauma Score) and predicted survival (by trauma-related Injury Severity Score, TRISS) were worse in the TEP group (p values of 0.037 and 0.028, respectively). After controlling for age, sex, mechanism of injury, TRISS and 24-hour blood product usage, there was a 74% reduction in the odds of mortality among patients in the TEP group (p = 0.001). Overall blood product consumption adjusted for age, sex, mechanism of injury, and TRISS was also significantly reduced in the TEP group (p = 0.015). CONCLUSIONS:: We have demonstrated that an exsanguination protocol, delivered in an aggressive and predefined manner, significantly reduces the odds of mortality as well as overall blood product consumption.

Two experiments are described where an apparent decrease in frequency was detected when the optical path was in the vicinity of a mass. In the first experiment the 21-centimeter absorption line from Taurus A was observed near occultation by the sun. In the second experiment the frequency of a portable cesium clock was compared with the frequency of a similar clock which transmits its signals from Cape Fear, North Carolina. A decrease of frequency of the received signals as a function of the distance between the two clocks was apparent. Several relevant observations (the red shift of lines from the sun, the Mossbauer determination of the gravitational red shift, and the cosmological red shif) are discussed in view of the present results. confirmation.

The aim of this study was to establish bone mineral density (BMD) reference norms for Hong Kong Chinese using Hologic QDR 2000 and 4500 densitometers, and to estimate the prevalence of osteoporosis in the population. Altogether, 4,274 subjects (2,415 females and 1,859 males), aged 9-94 years old, were recruited using a combination of private solicitation and public advertising from schools, community centers, nursing homes, housing estates, and the general community in Hong Kong. Among females, BMD increased by 20% at the total hip and 48% at the lumbar spine between ages 10 and 20 but remained essentially constant between ages 20 and 40. Between ages 40 and 70, BMD declined by 17% at the total hip and 23% at the spine. Total hip BMD continued to drop after age 70 but little change in spine BMD was observed. Among males, BMD increased by 45% at the total hip and 77% at the spine between age 10 and 30. Between ages 30 and 80, total hip BMD decreased by 20%. Lumbar spine BMD decrease was milder, showing a loss of 4% between ages 30 to 50 and remaining relatively constant afterwards. The prevalence of osteoporosis was consistently overestimated when using Hologic-supplied Caucasian cutoffs as compared with local Chinese cutoffs. The prevalence of osteoporosis among Chinese women 50 years or older was 37% and 16% at the spine and total hip, respectively, while that among Chinese men 50 years or older was 7% and 6% at the spine and total hip, respectively. Prior studies have been limited by size or restricted to women. This study represents the largest sample of Hong Kong Chinese amassed to date, provides continuous BMD reference values from ages 10 to 85 for both women and men, and yields more reliable estimates of the prevalence of osteoporosis for the population.