Administration of tranexamic acid for victims of severe trauma within pre-hospital care ambulance services (PHCAS) in Malaysia.

INTRODUCTION: Trauma is a Global threat and the 5th highest cause of all-cause mortality in Malaysia caused predominantly due to road traffic accidents. Majority of trauma victims are young adults aged between 21-40 years old. In Malaysia, 24 out of 100,000 population die annually due to trauma, rating us amongst the highest in South East Asia. These alarming figures justify aggressive preventive and mitigation strategies. The aim of this paper is to promote the implementation of evidence-based interventions that will reduce the rate of preventable death because of trauma. Tranexamic acid is one of the few interventions in the early management of severe trauma with level-one evidence. Tranexamic acid has been proven to reduce all causes of mortality and mortality due to bleeding. Evidence proves that it is most effective when administered early, particularly within the 1st hour of trauma. This proposed guideline is formulated based upon quality evidence from multicentre studies, clinical practices in other countries and consideration of the local demographic factors with the intent of enabling an easy and simple pathway to administer tranexamic acid early in the care of the severely injured. CONCLUSION: The guideline highlights select pre-hospital criteria's and the methods for drug administration. The authors recognise that some variants may be present amongst certain institutions necessitating minor adaptations, nevertheless the core principles of advocating tranexamic acid early in the course of pre-hospital trauma should be adhered to.

Building a vision for the future: strategic planning in a shared governance nursing organization.

Today's health care delivery environment is marked by extreme turbulence and ever-increasing complexity. Now, more than ever, an organization's strategic plan must do more than outline a business plan. Rather, the strategic plan is a fundamental tool for building and sustaining an organizational vision for the future. The strong, dynamic strategic plan (1) represents a long-range vision for improving organizational performance, (2) provides a model for planning and implementing structures and processes for the management of outcomes, (3) reflects and shapes the organizational culture and customer focus, (4) provides decision support for difficult operational choices made day to day, and (5) integrates and aligns the work of the organization. This article describes the development, implementation, and evaluation of a methodology for strategic planning within a shared governance nursing organization. Built upon the strategic plan of the hospital, the process undertaken by the nursing organization reflects the following commitments: (1) to develop a strategic plan that is meaningful and part of daily work life at all levels of the nursing organization, (2) to make the plan practical and realistic through incremental building, (3) to locate and articulate accountability for each step, and (4) to build in a process for checking progress toward goal achievement and readjusting the plan as necessary.

Modulation of lymphocyte proliferative responses to mitogens and antigens by complement components C1, C4 and C2.

Recent data have shown a definite relationship between complement and lymphocytes. Genetic studies have demonstrated close linkage between the genes controlling synthesis of complement components C4 and C2 and the major histocompatibility complex. Working in a complement-free environment, we studied the effect of purified human complement components, individually and in various combinations, upon in vitro proliferative responses of human lymphocytes to mitogens and antigens. It was found that the early complement components C1, C4 and C2, together, modulate lymphocyte responses to these various stimuli. In general, doses up to 1,000 effective molecules of each component per lymphocyte enhanced the cells' responses to both mitogens and antigens. Higher doses, up to 3,000 effective molecules of each per lymphocyte, progressively inhibited the cells' responses to the mitogens whereas responses to the antigens showed continued enhancement. This effect was removed by prior heat-inactivation of the complement. It persisted when the cells were exposed to C1, C4 and C2 for 1 hr, then washed and cultured with mitogen. It required active C1 in the fluid-phase prior to addition of C4 and C2. It correlated with the amount of activated C2 to which the cells were exposed. Enriched populations of T and B cells were affected equally.

Aspergillus terreus, a pathogen capable of causing infective endocarditis, Pulmonary mycetoma, and allergic bronchopulmonary aspergillosis.

Aspergillus terreus is a rarely reported pathogen in humans, Recovery of this organism from the sputum may therefore be discounted as representing contamination this report describes 3 patients--1 with allergic bronchopulmonary aspergillosis (ABPA), 1 with aspergilloma, and 1 with infective endocarditis-- in whom A. terreus was proved to be the etiologic organism. Together, these 3 cases span the spectrum of disease usually associated with A. fumigatus. Detection of serum precipitins against Aspergillus is essential to a diagnosis of both ABPA and aspergilloma. In our 2 patients with these syndromes, serum precipitins were specific for A. terreus ane did not cross-react with A. fumigatus or mixed Aspergillus antigens. This finding suggests that screening of serum for precipitins were specific for A. terreus and did not cross-react with A. fumigatus or mixed Aspergillus antigens. This finding suggests that screening of serum for precipitins should be carried out with A. terreus antigen in patients suspected of harboring this organism.

Frequency of clinical isolation and winter prevalence of different Aspergillus species at a large southwestern army medical center.

The frequent occurrence of aspergillosis caused by species other than Aspergillus fumigatus at Brooke Army Medical Center prompted the authors to study the prevalence of the different Aspergillus species at Brooke Army Medical Center and at two other hospitals in San Antonio, Texas. Two parameters were analyzed: (1) frequency of isolation from clinical specimens over a five-year period and (2) relative prevalence in the atmosphere during the late fall and early winter using volumetric air-sampling. A fumigatus was infrequently recovered from clinical specimens and was one of the least prevalent species of Aspergillus in the air. A. terreus, a rare species in prevalence studies performed elsewhere, was frequently recovered from patients; it was the second most prevalent organism in the air after A. niger. Climatic conditions in the authors' area probably favor the growth of A. terreus over A. fumigatus. Since A. terreus has been shown to be a potential pathogen, an increased frequency of disease caused by this organism may be expected in this environment.

Allergic bronchopulmonary aspergillosis (ABPA) caused by Aspergillus terreus: specific lymphocyte sensitization and antigen-directed serum opsonic activity.

A 16-year-old male presented with a history of asthma and recurrent pneumonia. A diagnosis of ABPA was based upon the typical clinical presentation, peripheral eosinophilia, elevated IgE and positive immediate skin tests to Aspergillus. Sputum cultures grew A. terreus, a rare cause of human disease. Soluble and particulate antigens were prepared from this organism. Precipitins against A. terreus, but not against A. fumigatus, were detected in the patient's serum. His lymphocytes proliferated markedly in vitro when exposed to soluble A. terreus but not A. fumigatus antigen. The lymphocyte responses correlated with disease activity. Functional serum opsonic activity was measured using the technique of stimulated polymorphonuclear leucocyte chemiluminescence. The nonspecific opsonic activity of the patient's serum was within high normal range when zymosan was employed as an alternative pathway activator. Specific opsonic activity against particulate Aspergillus antigen was significantly increased in the patient's serum when compared with control sera. Despite the presence of specific antibody and opsonic activity against A. terreus, the patient's serum levels of C3, C4, and total hemolytic complement were normal. These findings are consistent with in vivo sequestration of the organism.

Antibody response to influenza immunization in adult patients with malignant disease.

Eight-two patients with solid tumors and lymphomas were immunized with New Jersey, Hong Kong, and Victoria influenza vaccines. Patients were divided into groups according to treatment: chemotherapy, radiotherapy, or no treatment. Four parameters were examined to assess the response to immunization: seroconversion, protective titer level, geometric mean titer, and response to multiple vaccines. Patients with lymphoma showed the lowest antibody response. Patients with solid tumors had antibody responses which were not significantly different from controls but were superior to lymphoma patients (p less than .01). Timing of chemotherapy, immunoglobulin levels, and lymphocyte counts did not appear to play a major role in determining the antibody response. Patients with neoplastic diseases should be immunized against the prevailing influenza virus. Patients with lymphoma should also receive antiviral prophylactic therapy during influenza epidemics.