For debate: advanced bleeding control potentially saves lives in armed forces and should be considered.

INTRODUCTION: Advanced bleeding control options for truncal and junctional haemorrhage including resuscitative endovascular balloon occlusion of the aorta (REBOA) have been used in managing catastrophic bleeding. The primary aim is to report on potential indications for advanced bleeding control in combat casualties during the Dutch deployment in Uruzgan, Afghanistan, between August 2006 and August 2010. The secondary aim is to report on training methods for advanced bleeding control in (para)medical personnel. METHODS: The trauma registry from the Dutch role 2 enhanced medical treatment facility at Tarin Kowt, Uruzgan, Afghanistan, was used to analyse patients who sustained a battle injury with major haemorrhage. Furthermore, a comprehensive search was performed on training (para)medical personnel in advanced bleeding control. RESULTS: There were 212 possible indications for advanced bleeding control with mortality of 28.8% (61/212). These possible indications consisted of 1.9% (4/212) junctional lower extremity injuries with a 75% (3/4) mortality rate, 59% (125/212) visceral vascular injuries with a mortality rate of 12.5% (26/125). The junctional and visceral injuries (n=129) were all potential indications for advanced bleeding control options, such as REBOA. Further 39.2% (83/212) casualties with central thoracic or neck injuries had a mortality rate of 38.6% (32/83). Based on an Abbreviated Injury Scale chest or abdomen score ≥461 indications for advanced bleeding control were identified. A 24-hour average of 8.8 packets of red blood cells, 4.2 packets of plasma and 1.9 packets of platelets was used to prevent exsanguination. The total out-of-hospital survival rate was 64% (39/61). CONCLUSION: Retrospective analysis revealed 212 potential indications for advanced bleeding control with a mortality of 28.8% (61/212). Advanced bleeding control, such as REBOA, might have improved survival in approximately 61 of 212 casualties. Advanced bleeding control could be used as an adjunct to improve outcomes in major truncal or junctional haemorrhage in prehospital, remote settings and implementation should be considered. Vascular access training and REBOA placement for (para)medical military personnel should be explored in future research.

Genome-wide association study of monoamine metabolite levels in human cerebrospinal fluid.

Studying genetic determinants of intermediate phenotypes is a powerful tool to increase our understanding of genotype-phenotype correlations. Metabolic traits pertinent to the central nervous system (CNS) constitute a potentially informative target for genetic studies of intermediate phenotypes as their genetic underpinnings may elucidate etiological mechanisms. We therefore conducted a genome-wide association study (GWAS) of monoamine metabolite (MM) levels in cerebrospinal fluid (CSF) of 414 human subjects from the general population. In a linear model correcting for covariates, we identified one locus associated with MMs at a genome-wide significant level (standardized ß=0.32, P=4.92 × 10(-8)), located 20 kb from SSTR1, a gene involved with brain signal transduction and glutamate receptor signaling. By subsequent whole-genome expression quantitative trait locus (eQTL) analysis, we provide evidence that this variant controls expression of PDE9A (ß=0.21; P unadjusted=5.6 × 10(-7); P corrected=0.014), a gene previously implicated in monoaminergic transmission, major depressive disorder and antidepressant response. A post hoc analysis of loci significantly associated with psychiatric disorders suggested that genetic variation at CSMD1, a schizophrenia susceptibility locus, plays a role in the ratio between dopamine and serotonin metabolites in CSF. The presented DNA and mRNA analyses yielded genome-wide and suggestive associations in biologically plausible genes, two of which encode proteins involved with glutamate receptor functionality. These findings will hopefully contribute to an exploration of the functional impact of the highlighted genes on monoaminergic transmission and neuropsychiatric phenotypes.

[An instrument for the assessment of the training qualities of clinician-educators]. / Een instrument voor de evaluatie van opleiderskwaliteiten van stafleden.

OBJECTIVE: The development and testing of a questionnaire to enable anesthesiology residents to assess the training qualities oftheir clinician-educators. DESIGN: Questionnaire. METHODS: The taskforce drafted a questionnaire based on the 26 item Stanford Faculty Development Program questionnaire (SFDP26) and adapted to the Dutch situation. Following its discussion in separate meetings ofanesthesiology residents and clinical staff, the questionnaire was further edited. The resulting instrument contained 6 teaching domains and 26 items. The questionnaire was made available electronically to anesthesiology residents only. Participation was voluntary, confidential and anonymous. Group results were presented at a plenary session. Anesthesiology staff received their individual scores by e-mail; results were confidential. RESULTS: 21 residents assessed 39 anesthesiologists. A total of 423 questionnaires were completed. Factor analysis resulted in the reduction and re-grouping of the teaching domains. The internal consistency ofthe teaching domains was high (Cronbach-alpha > or = 0.86). The assessment results of the teaching qualities of the anesthesiology faculty were positive. 'Communication of goals' was the lowest scoring (mean = 3.41) and 'Professional attitude towards residents' the highest scoring teaching domain (mean = 4.07). Gender did not correlate with the assessment scores of faculty. 'Year of training' was negatively correlated with most of the teaching domains. CONCLUSION: A feasible and reliable instrument for the evaluation of Dutch clinician-educators is now available.