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Purpose: To evaluate the splenic uptake function after irradiation with high-energy X-rays. Materials and methods: Fourteen male Wistar rats were distributed into three groups. Group 1 (n = 6) – control, non-irradiated; Group 2 (n = 4) – animals that were irradiated and studied 24 h after irradiation; and Group 3 (n = 4) – animals that were irradiated and studied 48 h after irradiation. The animals were irradiated with 8 Gy X-rays in the abdominal region. According with the groups, after 24 or 48 h, 1 ml/kg of a 50% colloidal carbon solution was injected in the left internal jugular vein. After 40 min, the spleens were removed for histological studies. Macrophages containing carbon pigments in their cytoplasms were counted in 16 consecutive microscopic fields, and their means were considered as the uptake pattern of each animal. Results: In the control groups, carbon pigments were captured by macrophages in the red and white pulps, while in the irradiated groups, the uptake in the marginal zone, around the white pulp, was enhanced. There was no disorder on the splenic parenchyma or necrosis in histological analyzes. Qualitatively rare apoptotic events were observed, with no difference between control and irradiated animals. Conclusion: The high-energy X-ray, used in radiotherapy, modifies the splenic clearance, enhancing the amount of marginal zone macrophages containing colloid particles. This radiation was not associated with morphological changes, nor with necrosis or apoptosis of splenic tissue.

Elasmobranchs can bioaccumulate and biomagnify pollutants. However, few studies are directed to the effects of pollutants on the health of these animals, and in most cases, are limited to the analysis of biochemical markers. Thus, the incidence of genomic damage among shark species inhabiting a protected ocean island in the South Atlantic was investigated in association with the analysis of pollutants in seawater sample. High levels of genomic damage were identified, especially in Negaprion brevirostris and Galeocerdo cuvier, in addition to interspecific variations that may be related to characteristics such as animal size, metabolism and habits. High concentrations of Surfactants were observed in seawater sample, in addition to low concentrations of Cadmium, Lead, Copper, Chromium, Zinc, Manganese, and Mercury. The results evidenced the potential of shark species as a bioindicator of environmental quality and allowed assessing the anthropic impact on the archipelago, which currently drives its economy through tourism., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Both thrombelastography (TEG) and rotational thromboelastometry (ROTEM) have been investigated for diagnosis of coagulopathy and guidance of resuscitation in trauma and surgery. Given similarities between the two systems, it is important to determine whether one is superior to the other and how comparable they are to conventional coagulation tests (CCTs). Therefore, we conducted a comparative study of functional fibrinogen and coagulation assays using TEG and ROTEM and CCTs to determine their capability to monitor coagulation profiles, diagnose coagulopathy and predict blood transfusion requirements in trauma patients., Methods: Blood samples were collected from 45 patients at admission and during 48-h hospitalization as part of a randomized control trial on early fibrinogen replacement in trauma. Functional fibrinogen (FF) TEG, ROTEM FIBTEM and EXTEM, and CCTs were performed and compared., Results: We found significant differences between the placebo and fibrinogen groups over hospitalization time in FF TEG MA, ROTEM CT, MCF and LI30. FF TEG MA and ROTEM FIBTEM MCF mirrored plasma fibrinogen profiles, reached a maximum difference between the two groups 1-3 h after fibrinogen administration. In comparison, CCTs detected minimal hemostatic changes by fibrinogen treatment. TEG and ROTEM showed various degrees of correlations with CCTs. TEG MA and ROTEM MCF provided better predictions for plasma and RBC transfusions than CCTs, but poor accuracy for cryoprecipitate transfusion. Both TEG and ROTEM well predicted hypofibrinogenemia (fibrinogen concentration < 1 g/L), but poorly detected coagulopathy (INR ≥ 1.2)., Conclusions: TEG and ROTEM detected increases in clot strength following early use of fibrinogen. ROTEM also detected changes in coagulation time and clot lysis. Both were better than CCTs for monitoring coagulation profiles and predicting transfusion requirements., (Crown Copyright © 2019. Published by Elsevier B.V. All rights reserved.)

Background: A structured approach to hemorrhagic emergencies in obstetrics has gained popularity with the implementation of massive hemorrhage protocols. The trauma literature suggests that routine quality reviews should be in place to improve patient outcomes. The aim of this study was to develop quality indicators and assess compliance by the clinical team., Methods: A multidisciplinary team set the institutional quality indicators for the massive hemorrhage protocol review. A retrospective review of all obstetrical massive hemorrhage protocol activation events from September 2010 to January 2015 was performed. All protocol events occurred before the creation of the quality indicators. Data were retrieved from patient records., Results: There were 17 (0.09%) protocol activations for 19 790 deliveries during the study period. All 17 (100%) patients received at least one unit of red blood cells. Overactivation, defined as the transfusion of <2 units of red blood cells, occurred in two cases (12%). Common causes of non-compliance were: 24% (4/17) temperature monitoring, 18% (3/17) lactate measurement, 41% (7/17) arterial blood gas sampling, and 18% (3/17) hemoglobin maintenance within the target range of 55-95 g/L. Admission to intensive care and peripartum hysterectomy occurred in 12 and 5 cases (71% and 29%), respectively., Conclusions: Suboptimal compliance was found in multiple areas, which may be attributable to the low frequency of activation of our massive haemorrhage protocol in obstetrics. The quality targets identified in this report can act as a basis for other institutions developing quality indicators to evaluate performance., (Copyright © 2018. Published by Elsevier Ltd.)

Background: Massive hemorrhage protocols (MHP) are critical to standardized delivery of timely, safe, and resource-effective coordinated care for patients with life-threatening bleeding., Methods: A standardized MHP survey was sent to all hospitals (n = 150) in Ontario with a transfusion service. This study aim was to determine the proportion of hospitals with an MHP and assess for variability., Results: The overall survey completion rate was 133 of 150 hospitals (89%) (remaining 17 providing negative affirmation that they did not have an MHP). An MHP was in place at 97 of 150 (65%) hospitals (60% of small (<5000 red cell units/year) vs. 91% of medium/large). A total of 10 different names of protocols were reported, with "Massive Transfusion Protocol" (68%) predominating. Activation criteria were present in 82 of 97 (85%); commonly activated based on volume of blood loss (70%). Blood work was drawn at the discretion of the physician (37%) or at predefined intervals (31%; majority every 60 min). Common routine laboratory tests performed were CBC (87%) and INR (84%). Fibrinogen testing was available at 88 (66%) of 133 reporting hospitals and part of the standard testing at 73 of 97 (75%) hospitals with an MHP. Median targets of hemostatic resuscitations, stated in the protocol at 49% of hospitals with an MHP, were: platelets >50 × 10 9 /L, INR < 1.8, fibrinogen >1.5 g/L, and hemoglobin >70 g/L. Protocol required patient temperature monitoring in 65% and specified a reversal plan for patients on anticoagulants in 59%. At 36% of sites all patients are initially managed with O RhD negative blood. Overall, 61% of sites issue blood in predefined packs (vs. on demand). Hemostatic agents in protocols included: tranexamic acid (70%), prothombin complex concentrate (14%), fibrinogen concentrate (13%), and recombinant FVIIa (4%). Quality metrics were tracked in 32% of hospitals., Conclusions: A third of hospitals lack formal MHPs, with the majority lacking in smaller hospitals. The survey results indicate that there is marked variability in all key aspects of the reported MHPs. This may be due to differences in hospital resources and personnel, lack of supporting evidence to dictate requirements, and differences in knowledge base of the individuals involved in protocol setting., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Hypothermia (<36°C) exacerbates trauma-induced coagulopathy and worsens morbidity and mortality among severely injured trauma patients; there is a paucity of published data describing how well trauma centres adhere to standards regarding measurement of temperature, and best practices for preventing and treating hypothermia., Methods: We completed a retrospective quality audit of all severely injured trauma patients (Injury Severity Score (ISS≥20)) who had urgent surgery at Sunnybrook Health Sciences Centre (SHSC) between 2010 and 2014. Information regarding temperature monitoring was evaluated over the course of the initial resuscitation and admission. Independent risk factors for in-hospital mortality were elucidated through a multivariable regression analysis., Results: Out of a total of 4492 trauma patients, 495 were severely-injured and went to the operating room (OPR) after being treated in the trauma bay (TB) at SHSC between 2010 and 2014. The majority of the patients were male (n=384, 77.6%) and had a blunt mechanism of injury (n=391, 79.0%). The median ISS score was 29 (interquartile range (IQR) 26, 35). Eighty-nine (17.9%) patients died; 26 (5.2%) of these patients died intra-operatively. Less than one fifth of patients (n=82,16.6%) received a temperature measurement during pre-hospital transport phase. Upon arrival to the TB, almost two-thirds (n=301, 60.8%) of patients had their temperature recorded and a similar proportion (n=175, 58.1%) of those patients were hypothermic (<36°C). In the OPR, close to 80% (n=389, 78.6%) of patients had their temperature measured on both arrival; almost 60% (n=223, 57.3%) were hypothermic on arrival. Almost all patients had their temperature measured upon arrival to the ICU or specialized ward (n=450, 98.3%). Warming initiatives were documented in only 36 (7.3%) patients in the TB, yet documented in almost all patients in OR (n=464, 93.7%). An increased risk of in-hospital mortality was correlated with not taking a temperature measurement in the TB (Odds Ratio (OR) 2.86 (95% Confidence Interval (CI) [1.64-4.99]) or OPR (OR 4.66 (95% CI [2.50-8.69])., Conclusions: A majority of severely injured trauma patients are hypothermic well into the perioperative period after initial admission. An absence of having temperature measurement during initial hospitalization is associated with increased in-hospital mortality amongst this patient group. Quality improvement initiatives should aim to strive for ongoing temperature measurement as a key performance indicator and early prevention and treatment of hypothermia during initial resuscitation., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Decreased plasma fibrinogen concentration shortly after injury is associated with higher blood transfusion needs and mortality. In North America and the UK, cryoprecipitate transfusion is the standard-of-care for fibrinogen supplementation during acute haemorrhage, which often occurs late during trauma resuscitation. Alternatively, fibrinogen concentrate (FC) can be beneficial in trauma resuscitation. However, the feasibility of its early infusion, efficacy and safety remain undetermined. The objective of this trial was to evaluate the feasibility, effect on clinical and laboratory outcomes and complications of early infusion of FC in trauma., Methods: Fifty hypotensive (systolic arterial pressure ≤100 mm Hg) adult patients requiring blood transfusion were randomly assigned to either 6 g of FC or placebo, between Oct 2014 and Nov 2015 at a tertiary trauma centre. The primary outcome, feasibility, was assessed by the proportion of patients receiving the intervention (FC or placebo) within one h of hospital arrival. Plasma fibrinogen concentration was measured, and 28-day mortality and incidence of thromboembolic events were assessed., Results: Overall, 96% (43/45) [95% CI 86-99%] of patients received the intervention within one h; 95% and 96% in the FC and placebo groups, respectively (P=1.00). Plasma fibrinogen concentrations remained higher in the FC group up to 12 h after admission with the largest difference at three h (2.9 mg dL  -   1 vs. 1.8 mg dL  -   1 ; P<0.01). The 28-day mortality and thromboembolic complications were similar between groups., Conclusions: Early infusion of FC is feasible and increases plasma fibrinogen concentration during trauma resuscitation. Larger trials are justified., (© The Author 2016. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Hyperfibrinolysis may occur due to systemic inflammation or hepatic injury that occurs during liver resection. Tranexamic acid (TXA) is an antifibrinolytic agent that decreases bleeding in various settings, but has not been well studied in patients undergoing liver resection., Methods: In this prospective, phase II trial, 18 patients undergoing major liver resection were sequentially assigned to one of three cohorts: (i) Control (no TXA); (ii) TXA Dose I - 1 g bolus followed by 1 g infusion over 8 h; (iii) TXA Dose II - 1 g bolus followed by 10 mg/kg/hr until the end of surgery. Serial blood samples were collected for thromboelastography (TEG), coagulation components and TXA concentration., Results: No abnormalities in hemostatic function were identified on TEG. PAP complex levels increased to peak at 1106 μg/L (normal 0-512 μg/L) following parenchymal transection, then decreased to baseline by the morning following surgery. TXA reached stable, therapeutic concentrations early in both dosing regimens. There were no differences between patients based on TXA., Conclusions: There is no thromboelastographic evidence of hyperfibrinolysis in patients undergoing major liver resection. TXA does not influence the change in systemic fibrinolysis; it may reduce bleeding through a different mechanism of action. Registered with ClinicalTrials.gov: NCT01651182., (Copyright © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Cryoprecipitate, originally developed as a therapy for patients with antihaemophilic factor deficiency, or haemophilia A, has been in use for almost 50 yr. However, cryoprecipitate is no longer administered according to its original purpose, and is now most commonly used to replenish fibrinogen levels in patients with acquired coagulopathy, such as in clinical settings with haemorrhage including cardiac surgery, trauma, liver transplantation (LT), or obstetric haemorrhage. Cryoprecipitate is a pooled product that does not undergo pathogen inactivation, and its administration has been associated with a number of adverse events, particularly transmission of blood-borne pathogens and transfusion-related acute lung injury. As a result of these safety concerns, along with emerging availability of alternative fibrinogen preparations, cryoprecipitate has been withdrawn from use in a number of European countries. Compared with the plasma from which it is prepared, cryoprecipitate contains a high concentration of coagulation factor VIII, coagulation factor XIII, and fibrinogen. Cryoprecipitate is usually licensed by regulatory authorities for the treatment of hypofibrinogenaemia, and recommended for supplementation when plasma fibrinogen levels decrease below 1 g litre(-1); however, this threshold is empiric and is not based on solid clinical evidence. Consequently, there is uncertainty over the appropriate dosing and optimal administration of cryoprecipitate, with some guidelines from professional societies to guide clinical practice. Randomized, controlled trials are needed to determine the clinical efficacy of cryoprecipitate, compared with the efficacy of alternative preparations. These trials will allow the development of evidence-based guidelines in order to inform physicians and guide clinical practice., (© The Author 2014. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: To determine whether recombinant factor VIIa (rFVIIa) is associated with increased survival and/or thromboembolic complications., Introduction: Uncontrollable hemorrhage is the main cause of early mortality in trauma. rFVIIa has been suggested for the management of refractory hemorrhage. However, there is conflicting evidence about the survival benefit of rFVIIa in trauma. Furthermore, recent reports have raised concerns about increased thromboembolic events with rFVIIa use., Methods: Consecutive massively transfused (> 8 units of red blood cells within 12 h) trauma patients were studied. Data on demographics, injury severity scores, baseline laboratory values and use of rFVIIa were collected. Rate of transfusion in the first 6 h was used as surrogate for bleeding. Study outcomes included 24-hour and in-hospital survival, and thromboembolic events. A multivariable logistic regression analysis was used to determine the impact of rFVIIa on 24-hour and in-hospital survival., Results: Three-hundred and twenty-eight patients were massively transfused. Of these, 72 patients received rFVIIa. As expected, patients administered rFVIIa had a greater degree of shock than the non-rFVIIa group. Using logistic regression to adjust for predictors of death in the regression analysis, rFVIIa was a significant predictor of 24-hour survival (odds ratio (OR) = 2.65; confidence interval 1.26-5.59; p = 0.01) but not of in-hospital survival (OR = 1.63; confidence interval 0.79-3.37; p = 0.19). No differences were seen in clinically relevant thromboembolic events., Conclusions: Despite being associated with improved 24-hour survival, rFVIIa is not associated with a late survival to discharge in massively transfused civilian trauma patients.

Hyperosmotic-hyperoncotic solutions have been widely used during prehospital care of trauma patients and have shown positive hemodynamic effects. Recently, there has been a growing interest in intra-operative use of hypertonic solutions. We reviewed 30 clinical studies on the use of hypertonic saline solutions during surgeries, with the majority being cardiac surgeries. Reduced positive fluid balance, increased cardiac index, and decreased systemic vascular resistance were the main beneficial effects of using hypertonic solutions in this population. Well-designed clinical trials are highly needed, particularly in aortic aneurysm repair surgeries, where hypertonic solutions have shown many beneficial effects. Examining the immunomodulatory effects of hypertonic solutions should also be a priority in future studies.