text:
Home » Trauma Mythology: Looking Beyond the ABCD and ATLS
Trauma Mythology: Looking Beyond the ABCD and ATLS
ATLS Update
Anticoagulation in the Trauma Patient
Managing the Airway of the Pediatric Trauma Patient: Meeting the Challenge
anticoagulated
Benjamin J. Lawner, DO, MS, EMT-P, FACEP, Medical Director of Prehospital Services, Allegheny General Hospital, Pittsburgh; Clinical Associate Professor, Department of Emergency Medicine, Temple University School of Medicine, Philadelphia
Faye Pedersen, MD, Emergency Medicine Residency, Allegheny Health Network, Pittsburgh
Michael Shukis, MD, Emergency Medicine Residency, Allegheny Health Network, Pittsburgh
Colin Kaide, MD, Associate Professor of Emergency Medicine, The Ohio State University, Columbus
The incidence of cervical spine injury in the setting of blunt trauma is estimated to be 2-4%. This estimate skyrockets to more than 30% when focusing on obtunded or unconscious patients.
Late-generation computed tomography (CT) scanners perform admirably in the detection of clinically significant spinal trauma.
The rate of missed injuries is exceedingly low, and CT scanners are nearly ubiquitous in modern trauma centers.
Patients who fail NEXUS or a clinical decision rule should undergo CT scanning, and magnetic resonance imaging can be reserved for those with persistently abnormal motor deficits.
Anticoagulated patients with a normal neurological exam, normal initial head CT, and adequate social support may be candidates for discharge.
Consider thromboelastography to guide blood and blood component therapy in the setting of an anticipated massive transfusion.
The relatively low cost and ubiquitous nature of the FAST exam make it ideally suited as an initial screening tool for patients with blunt abdominal trauma.
Trauma presents a variety of time-sensitive and clinically important challenges to the emergency physician (EP). EPs routinely are tasked with the initial resuscitation and stabilization of trauma patients. The rapid and reliable identification of a life-threatening illness is an overriding principle of evidence-based trauma care. EPs and other clinicians involved in trauma care rely on established guidelines to inform treatment decisions. Although they are intended to support a universal standard of care, guidelines sometimes may contribute to clinical dogma and inadvertently discourage critical analysis of new and emerging literature. Indeed, there is a certain "lag time" that follows the adoption of clinical guidelines and the integration of new research. This article examines some commonly held assumptions related to the emergency care and stabilization of trauma patients. This review article will incorporate both clinical guidelines and recent emergency medicine-focused literature. It provides the practicing clinician with information needed to inform important clinical decisions about spinal immobilization, thromboelastography, direct oral anticoagulants (DOACs), and the Focused Abdominal Sonography in Trauma (FAST) exam.
The PubMed database was queried to identify articles relevant to a particular clinical question. Key word search terms were developed for each topic, and the authors independently reviewed abstracts and determined suitability for inclusion. Inclusion criteria were articles published within the past 10 years, full text articles, and English language. Case reports and brief research reports were excluded from the literature review. Articles were excluded if there was a lack of consensus on behalf of study authors. On rare occasions, select older manuscripts were highlighted to provide necessary clinical context.
Myth: CT Alone Is Insufficient for Radiographic Clearance of a Cervical Spine
Altered mental status may be a significant predictor of underlying cervical spine injury. In accordance with existing standards of care, a blunt trauma patient with an altered sensorium is presumed to have an underlying injury to the cervical spine. Although relatively uncommon, a missed cervical spine injury has the potential to result in significant morbidity and mortality. The incidence of cervical spine injury in the setting of blunt trauma is estimated to be 2-4%.1,2
Further complicating the question of cervical spine clearance is the fact that many blunt trauma patients present to the emergency department (ED) with an abnormal mental status. Estimates for cervical spine injury skyrocket to more than 30% when focusing on obtunded or unconscious patients.1,2 Accordingly, EPs and trauma clinicians have a low threshold to image and immobilize the cervical spine initially in a patient with a significant mechanism of injury. The authors of one study that evaluated routine toxicological testing found that almost 50% of trauma patients tested positive for alcohol or drugs.3 Furthermore, more than 20% of patients with a confirmed unstable cervical spine injury were found to have intoxicants in either their blood or urine.3
Computed tomography (CT) has emerged as the standard of care for initial imaging, as it is relatively widespread and does not require an extended investment of clinician time. CT has evolved significantly since its inception. The first-generation CT scanners incorporated only a few slices, while current scanners have multidetector (MD) capability that permits three-dimensional reconstruction of injury patterns. However, CT scans are less reliable for the investigation of underlying ligamentous or cord injury. Ligamentous disruption and the presence of fractures often are used as surrogate markers for cord injury, and those patients generally require additional imaging and consultation to clear their spine radiographically. Considering the increased sensitivity of MDCT scanners, which patients require magnetic resonance imaging (MRI): all patients or just those with an abnormal mental status?
In 2013, Raza et al published the results of a combined meta-analysis and cohort study.1 The authors retrospectively examined 10 studies that focused exclusively on obtunded blunt trauma patients and MDCT findings. The authors also performed MRI on 53 obtunded trauma patients who had negative cervical spine CT scans. Data pooled from 10 studies revealed a 99.7% negative predictive value for a normal CT.
The authors cited several limitations in the calculation of sensitivity values given that two of the included studies did not have any true positive results. In the cohort study of patients who underwent MRI of the cervical spine, no unstable injuries were discovered. The study authors could not specifically answer a question about whether an unstable cervical spine injury could be present in a patient with a normal MDCT. Indeed, the percentage of patients with missed injuries following MDCT was exceedingly low, and most of the injuries discovered on subsequent MRI did not result in a meaningful change in patient management. The authors concluded that radiologic clearance following a normal MDCT was a reasonable approach in the blunt trauma patient.
A prospective, multicenter observational study was published in the Journal of Trauma and Acute Care Surgery in 2016.2 The authors of this study prospectively enrolled patients who failed NEXUS low-risk criteria. The trial's goal was to assess the accuracy of MDCT for the identification of clinically significant spinal trauma. Clinical significance was defined as patients who required one of the following: surgical intervention, a spinal orthotic brace, or a halo traction device. More than 10,000 adult patients were enrolled at U.S. Level I and Level II trauma centers. Most patients (49%) reported midline cervical tenderness, and a small percentage (5.6%) of the study population had a neurologic symptom that precluded clinical clearance. MDCT performed extremely well as a screening examination for significant spinal injury. For all patients, CT scanning exhibited a sensitivity of 98.5% and a specificity of 91.0%. A few important injuries were missed. MRI revealed a fracture of the anterior portion of the T9 vertebra, and another negative CT scan missed an inferior articular facet fracture. The neurosurgical service caring for these patients considered the injuries to be stable. If initial CT scans were paired with the presence of a neurological finding during the initial physical exam, the sensitivity and negative predictive value of CT scanning would increase to 100%. Simply stated, the spinal clearance algorithm should not stop at negative initial CT if the patient has demonstrated motor deficits on physical examination.
This prospective study lends substantial support to the use of CT as an initial and definitive method of ruling out cervical spine injury. However, the presence of an abnormal motor examination or the patient's inability to move all four extremities warrants additional investigation. Late-generation CT scanners perform admirably in the detection of clinically significant spinal trauma. The rate of missed injuries is exceedingly low, and CT scanners are nearly ubiquitous in modern trauma centers. Patients who fail NEXUS or a clinical decision rule should undergo CT scanning, and MRI can be reserved for those with persistently abnormal motor deficits.
Finally, a study published in Annals of Emergency Medicine featured cost modeling to examine the utility of MRI for cervical spine clearance.4 The authors acknowledged certain variations in clinical practice. Namely, MRI is used to definitively establish the absence of potentially unstable injuries in patients who present to the ED with an intact neurological exam. The authors referenced national databases and created several clinical scenarios for follow-up to match true positive, false positive, true negative, and false negative settings for MRI results. The structured scenarios also considered the costs associated with prolonged disability, including the real potential for missed injuries following an initially negative CT scan.
The authors concluded that MRI, when added to patient scenarios that involved a negative initial CT scan, did not contribute meaningfully to patient outcomes. MRI did not offer any health benefits and came at a significantly increased cost. When coupled with the extremely low risk for missed cervical spine injuries (0.011%), follow-up MRI scanning did not provide patients with any added benefit.
Limitations of this article were acknowledged readily. Clinical scenarios were extrapolated from existing data and assumptions about missed injuries and theoretical information about patient disability. That said, it is important for practicing clinicians to realize that the likelihood of a missed injury in the setting of a normal CT scan and the absence of any neurological deficit is extremely rare. Risk tolerance among practicing emergency and trauma clinicians is difficult to quantify, but the information about the prevalence of unstable injuries can be used to inform decisions about additional imaging in CT-negative patients.
MDCT and a reassuring motor exam can be used to rule out clinically important cervical spine injuries.
Reserve MRI to clear the cervical spine in patients unable to participate in a motor examination. (See Figure 1.)
Figure 1. Suggested Approach to Radiological Clearance of Cervical Spine With Multidetector Computed Tomography
Myth: All Patients Taking Anticoagulation Therapy Require Admission and Imaging for Delayed Intracranial Hemorrhage
Traumatic brain injury (TBI) results in 1.3 million ED visits, 275,000 hospitalizations, and 52,000 deaths annually in the United States. Patients older than 65 years of age account for 10% of the ED visits and 30% of admissions for TBI.5 Concurrently, there is also an increased use of prescription oral anticoagulants. From 1998 to 2004, there was a 45% increase in warfarin prescriptions.6 DOACs, previously known as novel oral anticoagulants (NOACs), bind directly to factors X and II without the need to complex first with antithrombin. These agents, including rivaroxaban, apixaban, edoxaban, betrixaban, and dabigatran, are prescribed with increasing frequency. Many of the anticoagulated patients have concomitant vascular diseases that necessitate dual (DOAC and antiplatelet) and triple (DOAC, antiplatelet, and aspirin) therapy.
Clinical decision rules, such as the Canadian CT Head Rule, the New Orleans criteria, and the NEXUS-II criteria, do not apply to patients taking anticoagulation therapy. Patients who experience injury while taking long-term anticoagulation have an increased incidence of intracranial hemorrhage (ICH) compared to those not taking anticoagulation (8% vs. 5.3%, P < 0.0001) and increased mortality with ICH (21.9% vs. 14.2%, P = 0.04).7 For anticoagulated patients taking warfarin who have minor head injuries (loss of consciousness [LOC], amnesia/confusion, Glasgow Coma Scale [GCS] of 13-15) and minimal head injuries (no LOC, amnesia, or confusion, GCS of 15), the rate of ICH was 21.9% and 4.8%, respectively, suggesting the need to maintain a low threshold for ordering CT scans for anticoagulated patients.6 This correlates with Cohn et al's paper that found a risk of ICH of 6.2-29% in patients taking warfarin therapy.5 The risk of ICH in patients taking DOACs still is being studied. In the absence of specific guidelines related to initial imaging and final disposition, it is common practice for these patients to undergo initial noncontrast CT scanning on presentation.
What Is the Disposition of Anticoagulated Patients After Head Injury?
For patients with more than minor head trauma, neurological deficits, or CT positive for ICH, there is little debate about obtaining repeat imaging or admission. However, patients who experience minor head injury while taking anticoagulation but who have benign initial head CTs present a quandary for the emergency physician because there are no uniform guidelines about the necessity of repeat imaging to evaluate for delayed ICH. National and international guidelines on the management of mild traumatic brain injury (mTBI) offer limited and sometimes conflicting recommendations. The Eastern Association for the Surgery of Trauma (EAST) recognizes the lack of consistent definitions for injury but provides a Level 3 recommendation that patients taking warfarin who are supra-therapeutic and have normal initial CT be admitted for a period of observation.8 The European Federation of Neurological Societies suggests a 12- to 24-hour period for close neurologic observation and repeat CT prior to discharge. The Australian head injury guideline suggests performing a routine repeat CT scan within 24 hours or an urgent repeat CT scan if the patient shows signs of deterioration, but reserves clinical judgment for disposition if the initial CT scan and international normalized ratio (INR) are normal. Furthermore, the guideline suggests that prolonged observation and close follow-up either in the hospital or in the community are reasonable until additional evidence is available to guide management.9,10
What Is the Prevalence of Delayed Intracranial Hemorrhage?
The prevalence of delayed intracranial hemorrhage (DICH) in the anticoagulated patient after head injury has not been as well studied until recently. Miller et al performed a systematic review to identify the incidence of DICH in mTBI patients who were anticoagulated.11 The researchers identified five studies, two that were retrospective and three that were prospective with cohorts that included 1,257 patients with minor head injury taking warfarin. The risk of DICH varied between 0 to 72 per 1,000 patients. The study by Nishijima et al had the largest sample size (687), and Miller et al suggested that this study was most applicable to the U.S. population given its multicenter design. Nishijima's study found the risk of DICH to be six per 1,000 cases (95% confidence interval [CI], 2-15).11,12
Because of the Risk of DICH, What Is the Value of Repeat Imaging or 24-hour Observation?
Most centers have institutional protocols for patients who experience head injury while taking anticoagulation therapy. Protocols can include admission, repeat imaging, and neurological checks. Menditto et al reviewed the European protocol of 24-hour observation to detect the incidence of DICH. Five of 87 patients (6%) were found to have new hemorrhages, and one experienced neurological deterioration and underwent craniotomy.13 Two of these five patients returned after discharge. The researchers concluded that their findings support the advisability of initial CT scanning and 24-hour observation.
There are arguments against the protocol of admission or even repeat CT scanning. Kaen et al conducted a prospective study that included 137 patients and observed intracranial bleeding in the subsequent CT in two patients (1.4%), neither of whom required neurosurgical intervention.14 Cohn et al studied four articles to evaluate whether observation or repeat imaging is warranted.5 They concluded that the incidence of delayed ICH after a benign CT ranged from 0.6% to 6%; however, the majority of these patients required no neurosurgical intervention or had no documented adverse outcome. The incidence of death or deterioration requiring surgical intervention was 0 to 1.1%.
In a retrospective single study conducted in the Netherlands, 211 of 6,830 patients with suspected head trauma met inclusion criteria for elevated INR on anticoagulation and minor TBI and a normal presenting head CT.15 Five patients had deterioration, although one of the five had a missed subdural hemorrhage on initial CT with clinical deterioration requiring craniotomy and eventually died. The other four patients developed neurological symptoms after the 24-hour period. One had surgical intervention, but all four had complete recovery. Because of the low risk of secondary deterioration in the 24-hour period, the authors suggested that their study did not support the recommendation of the current guidelines arguing for the 24-hour period, particularly since neurological decline occurred after the observation period.
Can Anticoagulated Patients With Normal Initial Head CT Be Discharged?
Some would argue that a period of observation in the anticoagulated patient who experiences head injury frequently is appropriate to address other medical problems that contributed to the incident, including an assessment of risk factors, use of medication, whether continuing anticoagulation is appropriate, and evaluation of overall fitness for safe discharge. Prior medical conditions or the inability to perform an appropriate neurological assessment because of known medical conditions and social situations (inability to follow up, noncompliance, inability to perform neurological checks) may necessitate a short admission.
Some authors also have suggested that anticoagulated patients with mTBI can be discharged home safely with a negative imaging result. Rendell et al proposed that because of a reassuringly small risk of DICH, it would seem reasonable to discharge patients with an INR of less than 3 and a normal initial CT, with good instructions and follow-up.16 In a recent prospective, observational cohort study at 11 centers, Chenoworth et al followed patients with blunt head trauma taking anticoagulant and antiplatelet medications for delayed hemorrhage within 14 days.17 Of the 859 patients enrolled in the study, 343 were taking anticoagulation or antiplatelet medications, but only three patients (0.3%; 95% CI, 0.1-1.0%) had DICH at the 14-day follow-up. Of the three patients, one was taking warfarin alone and the other two were not taking any anticoagulation or antiplatelet medications, and hemorrhage was noted outside the 24-hour observation period. Despite some patients lost to follow-up or death unconfirmed to have DICH, the authors noted a low incidence of DICH after blunt trauma, even while patients were taking anticoagulation or antiplatelet medications, and further suggested that mandatory 24-hour observation and serial CT may be unnecessary.
Admitting every anticoagulated elderly patient for repeat head CT and frequent neurological checks to monitor for deterioration may not always be feasible economically or practically for the community and hospital. Healthcare is not a limitless pool of resources, and emergency medicine providers often are tasked with helping allocate resources. To put this into perspective, the number needed to treat (NNT) (to hospitalize mTBI patients using oral anticoagulation with initial head CT) for the Schoonman study was 211. (Although this is somewhat incorrect in that the initial CT for the patient who experienced neurological decline was positive in this study.)15 For the Mendetti study, the NNT was 97.13 In terms of economics, an editorial suggests that the 24-hour observation and routine serial CT would cost an average of approximately $1 million per patient saved.5
Alternatives to repeat head CT or admission are needed. The Australian head injury guideline suggests that either clinical or community follow-up is reasonable. Using the model of centers that follow up on patients with diabetes, chronic obstructive pulmonary disease, and congestive heart failure, it might not be unreasonable to establish mTBI centers that will assess these patients for clinical decline to save them hospital admission.
An aging and medically complex population likely will demand more resources. Studies are needed urgently to corroborate clinical practices and risk-stratify head-injured patients appropriately. Admitting all head injury patients for serial examinations and additional scanning increases costs and may not contribute to improved patient outcomes. It is clear that the use of DOACs is associated with a heightened risk of ICH and delayed bleeding. Patients who present to the ED with a normal mental status, adequate social support, and robust outpatient follow-up may represent a population suitable for outpatient follow-up. Additional studies are needed to develop evidence-based clinical decision rules to support such dispositions. Shared medical decision-making, paired with emergency physician gestalt, may help inform a reasonable discharge plan.
Myth: All Bleeding Trauma Patients Require a Thromboelastogram
A thromboelastogram (TEG) is a measure of whole blood that analyzes clot formation and viscoelasticity under low shear stress, and is an assessment of the coagulation cascade. Specifically, TEG examines clot formation, stabilization, and breakdown. In addition to measuring clot strength, one of its unique features is that it is useful in quantifying fibrinolysis, allowing for tailoring of antifibrinolytic drugs such as cryoprecipitate and fibrinogen concentrate.18 TEG has been used for some time in other fields of medicine, including cardiothoracic surgery and liver transplantation, to inform transfusion practices. TEG recently has become more prevalent in the assessment of trauma patients for trauma-induced coagulopathy.19
Massive post-traumatic bleeding is the leading cause of potentially reversible death in patients who sustain severe trauma. Authors of a single-center, randomized clinical trial published in the Annals of Surgery attempted to compare conventional coagulation assays (CCA) with TEG in trauma patients who required mass transfusion protocol (MTP) activation.20 The primary outcome was survival at 28 days. Ultimately, the researchers found that the TEG-guided MTP group had improved mortality over the CCA group (CCA 36.4% mortality vs. TEG 19.6%; P = 0.049). The researchers also concluded that most of these deaths occurred in the first six hours, with worse outcomes in the CCA group. Both groups used the same amount of red blood cell units, but the TEG group deviated from the traditional 1:1:1 by using less platelets and fewer plasma units on average. This allows for more goal-directed transfusions. This was demonstrated in additional papers that also found decreased hospital length of stay and ICU length of stay associated with TEG-directed resuscitation.21
The utility of TEG has been well demonstrated to guide management in post-traumatic coagulopathy, but TEG's role becomes less clear when the patient is anticoagulated prior to a traumatic injury. Conventional anticoagulants, such as vitamin K antagonists and unfractionated and low molecular-weight heparins, have a well-established dose response curve established by CCAs.
In 2015, Dias et al demonstrated the ability to use rapid TEG to create a dose response curve for rivaroxaban, apixaban, and dabigatran on blood from healthy patients that was exposed to anticoagulants.22 This test was not performed on patients who had to take the medicine for underlying pathology and was not tested in a trauma setting. It was unclear if TEG should be used to guide reversal of anticoagulation in these patients.22 Ali et al attempted to answer this question in a retrospective chart review of blunt trauma patients. They found that coagulopathy was not significantly different in the anticoagulated vs. nonanticoagulated groups (15% vs. 11%, respectively; P = 0.99), and instead recommended that CCA, as well as medical history and last known anticoagulant ingestion, still should be used to guide reversal decisions.23 This was a limited study, as it was performed at a single center with a very small sample size of 54. Additional testing is warranted to determine if this finding holds for a larger, more generalized population.
Concurrent intoxication with alcohol has the potential to confound TEG's utility. As previously stated, there is a high correlation between alcohol and trauma. In 2015, Howard et al performed a prospective case-control study with 415 trauma patients and found that alcohol caused a hypocoagulable state as interpreted by TEG, but showed no evidence of coagulopathy on CCAs.24 It also did not change management or outcomes in these patients, as their transfusion requirements remained the same, and there was no change in mortality outcome.24 This could indicate a false-negative hypocoagulable state in patients who ingest alcohol prior to trauma or it could represent a test that is more sensitive than clinically necessary to guide transfusion practices.25
Thromboelastography has emerged as an important adjunct for patients who require massive transfusions of blood products or who exhibit fibrinolysis. The availability of rapid, point-of-care testing has resulted in increased use of the clotting assay. Clinicians tasked with the initial and ongoing resuscitation of hemorrhaging patients may find utility in the test's ability to quantify fibrinolysis or indicate the need for specific blood components. Its utility as a screening test for all trauma arrivals is questionable because the results may not affect downstream management. Conversely, TEG represents a more accurate measurement of the dynamic coagulopathy in trauma and may be considered for hemodynamically unstable patients. Specifically, TEG results can predict the need for massive transfusion and guide ongoing decisions about blood components or adjuncts such as tranexamic acid.26
Thromboelastography may not be useful as an initial screening test for all bleeding trauma patients.
Myth: Gotta Get That FAST, Fast! All Patients With Blunt Abdominal Trauma Require a CT Scan
The FAST examination is incorporated routinely for most patients who arrive in the ED as a trauma alert. Established guidelines recommend that the FAST exam be performed on almost all patients who experience blunt abdominal trauma (BAT).27-29 It is widely accepted that penetrating abdominal injuries mandate operative exploration or surgical fixation. Conversely, blunt trauma patients present clinical challenges for emergency resuscitation teams. These patients may undergo CT scanning and extended periods of observation prior to eventual disposition. The FAST exam often is used indiscriminately upon arrival, and its results are incorporated into decisions about accelerated diagnostic management, operative intervention, or a period of watchful waiting.
The widespread availability of ultrasound technology contributes to the incorporation of the FAST exam into diagnostic algorithms. Physicians from various specialties have demonstrated proficiency in image acquisition and interpretation, and the studies indicate that FAST can be performed in the ED with high specificity and reasonable sensitivity.28,30 Although FAST is less than ideal for the diagnosis of solid organ injury, test results may guide downstream decisions about surgical management or medical intervention.31,32
Considering broad indications and widespread use, an ongoing debate persists with respect to the limitations of the FAST exam. To support its continued role in the evaluation of the BAT patient, it is imperative to evaluate this technology for its clinical benefit. Fortunately, emergency physicians, trauma surgeons, and other clinicians engaged in the initial evaluation and resuscitation of trauma patients have expressed interest in this very question. (See Table 1.)
Table 1. Summary of Studies on FAST Exams
Number of Patients; Sensitivity/Specificity
Dammers D, et al;
FAST performed on patients with blunt abdominal trauma who are hemodynamically stable vs. negative events (exploratory laparotomy, embolization, death from abdominal trauma)
Sensitivity: 67%
Specificity: 99%
Ultrasound can provide prognostic information during the early stage of resuscitation in hemodynamically stable patients with blunt abdominal trauma.
Tsui CL, et al;
Emergency physician performance of FAST in blunt abdominal trauma; patients observed with serial exams or underwent scan in six hours
FAST can be a valuable screening tool.
Smith ZA, et al;
FAST with hemodynamic assessment vs. hemodynamic assessment alone and confirmed by computed tomography, laparotomy
Blunt abdominal trauma:
Specificity: 100%
Penetrating trauma:
FAST is valuable in all trauma patients, especially if hemodynamically stable, to improve diagnostic capabilities vs. hemodynamic assessments alone.
Barbosa RR, et al;
Measured impact of positive FAST to operating room time since increased time to operating room was associated with increased mortality
In patients with positive FAST who required urgent laparotomy, a delay in operating room time was associated with increased mortality. If FAST is positive, decisions must be made quickly to obtain additional diagnostic studies or proceed to the operating room.
Stengel D, et al;
Assessed whether algorithms using ultrasound reduced morbidity and mortality in patients with blunt abdominal trauma
Cochrane review of four randomized, controlled trials
FAST may prompt reduction in the frequency of ordering CT scans, but the review does not provide sufficient evidence to comment on ultrasound-based algorithms in trauma.
One study conducted in a Chinese ED retrospectively evaluated emergency physicians' performance of a screening FAST exam on BAT patients. FAST exams were performed in 242 of 273 cases of BAT.33 The authors noted an exceptionally high sensitivity and specificity, at 86% and 99%, respectively. (A positive scan was defined as the presence of free intraperitoneal fluid.) The FAST scan had a high negative predictive value at 0.98. Therefore, the authors suggested that FAST exams serve as a valuable screening tool. Because there is a threshold below which free fluid may be missed by the ultrasound examination, patients in this study were observed for at least six hours so that a serial exam or CT exam could be performed. Five false-negative scans were reported, and all involved "small amounts of free intraperitoneal fluid" seen on CT scan. Three patients had mesenteric hematomas, and two cases involved liver lacerations. The authors observed that the use of a full or partially full bladder as an acoustic window may have aided in the discovery of a small amount of free fluid. Other international studies have replicated encouraging results regarding the sensitivity of ultrasound in the setting of BAT. The authors reported results from four other trials that cited sensitivities ranging from 81-86.5%.33
A more recent study by Smith and Wood supports the case for conducting FAST exams on abdominal trauma patients.34 The prospective study included 166 patients who presented with abdominal trauma to a 554-bed government hospital in a South African ED. Patients were assessed immediately for hemodynamic stability and had scans performed in the ED. Scans were confirmed by diagnostic means in 47.6% of cases — CT (56), laparotomy (21), and diagnostic peritoneal lavage (2). The remaining scans were confirmed by a blinded ED ultrasonographer. All patients were followed for at least 24 hours. The authors of this study reported 100% specificity and positive predictive value for FAST in all types of trauma, which was consistent with prior studies. The FAST exam sensitivity was better for blunt abdominal trauma (93.1%) than for penetrating trauma (90%). The authors further noted that the study demonstrated a significant statistical relationship between hemodynamically unstable blunt trauma patients and those with positive scans (P = 0.004). Despite the high sensitivity for ultrasound, it is important to consider the limitations of any study modality when interpreting results. Two patients in the false-negative scan cohort required emergency laparotomy. Bowel injury and solid organ injury that does not result in the production of significant abdominal free fluid can confound initially negative results.34
Within much of the emergency medicine and trauma literature, there is consensus about performing a FAST examination. Focused abdominal ultrasound is useful as an initial screen for significant trauma, and the technology is widely available. The finding of positive abdominal free fluid heightens clinical suspicion for a life-threatening injury. When paired with hemodynamic compromise, the presence of free fluid is associated with increased mortality.34 What should occur following the identification of free abdominal fluid? The answer remains clear when faced with an unstable trauma patient. In the patient who is hemodynamically stable, next steps involve the synthesis of excellent clinical judgment and the performance of gold standard radiologic tests such as the CT scan.
In a retrospective analysis of patients from the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study, investigators examined a subset of patients who presented to area trauma centers and received a FAST exam. Of 1,245 injured patients enrolled in the original study that looked at massive blood transfusion, 115 received a FAST evaluation and underwent emergency laparotomy within 90 minutes.35 These patients required the "highest level activation" at area trauma centers. All hemodynamically unstable patients had an emergency laparotomy that was deemed therapeutic. Furthermore, the study authors reported a significant association between delayed time to operative management and mortality at 24 hours. The association between definitive hemorrhage control and improved outcomes is well known to emergency and trauma clinicians. Despite the link between positive free fluid and mortality, the positive FAST exam did not necessarily correlate with the need for an emergent operation.
When including the larger cohort of PROMMTT patients, only 72% of patients with a positive FAST exam received a laparotomy within 24 hours. The authors reported that certain injury patterns were "amenable" to non-operative management. Direct transfer to the operating room would lead to an increased proportion of nontherapeutic laparotomies and expose patients to additional and perhaps unnecessary risk. The study reaffirms the long-standing practice of transitioning unstable patients with a positive FAST result to the operating room. With respect to stable patients, additional diagnostic studies may be required for operative planning or definitive diagnosis. Because positive FAST findings are associated with adverse outcomes, even hemodynamically stable patients should be prioritized for downstream CT scans and the "highest levels of trauma activation." When patients arrive at hospitals without immediate surgical capability, the authors recommended that clinicians consider transferring FAST-positive patients to area trauma centers prior to obtaining a confirmatory CT scan.
Limitations to the application of FAST in abdominal trauma were highlighted in a recent Cochrane review. In 2015, Stengel et al assessed the clinical effectiveness of an evaluation algorithm that incorporated the FAST exam into a diagnostic pathway for BAT.36 The authors searched available randomized, controlled trials to determine the effect of FAST examination on patient mortality. They also examined the effect of ultrasound on the use of MDCT or other invasive procedures. The cost-effectiveness of ultrasound also was included as an outcome measure. Four trials met criteria for inclusion, and the authors found significant heterogeneity between the trial results. The lack of input from randomized, controlled trial authors, coupled with significant methodological flaws, made it difficult to draw definitive conclusions about the ability of a FAST-based diagnostic algorithm to influence patient outcomes.
Pooled data from the randomized, controlled trials revealed a trend toward reduced MDCT use by as much as 50%. Mortality data were available for three trials, and researchers observed no evidence of a difference in patients undergoing a FAST-diagnostic pathway. However, the Cochrane reviewers encouraged caution when looking at FAST as a sole imaging modality for BAT. The review referenced data from a German trauma registry and commented that a "primary CT scan is lifesaving" and further observed that CT scans represent the standard of care when making decisions about "admission and clinical monitoring." The randomized, controlled trials featured in the review affirmed the high specificity of FAST scans for significant abdominal trauma. However, the overall sensitivity of the FAST exam remained low, at or below 90%.
Although an initially negative FAST result is reassuring, it cannot be compared to the ability of MDCT to definitively rule out the presence of solid organ injury or developing hemorrhage. The study authors acknowledged that FAST is well positioned to function as an initial triage tool and may have additional implications in prehospital or mass casualty scenarios.36 Clinical guidelines and well-established practices support the use of the FAST examination for the evaluation of BAT patients.29,37 FAST exams can be performed reliably and offer clinicians valuable prognostic information, especially when free fluid is discovered. Because these scans represent no increased risk and have the potential to complement a clinical examination, the FAST exam is recommended almost universally in the initial evaluation of stable blunt trauma patients.
The relatively low cost and ubiquitous nature of the FAST exam make it ideally suited as an initial screening tool for patients with BAT.
When incorporated into existing trauma protocols, the FAST exam may expedite time to operative intervention and improve mortality in a select group of patients.
Guidelines provide emergency clinicians with information needed to make sound, consistent, and evidence-based decisions about diagnostic and therapeutic treatment strategies. Despite their widespread availability, they are not intended to substitute for clinical judgment and experience. Myths develop when practice patterns become ingrained as they are passed down from one generation of clinicians to another. The practice of emergency medicine is at the intersection of protocols and evidence-based practice. Trauma care requires adherence to routine so that critical patients can be triaged, examined, and directed to definitive care rapidly. Unfortunately, axioms featured in courses such as Advanced Trauma Life Support and Advanced Cardiac Life Support can become so entrenched into practice that they somehow transform into dogma.
This review article dissected four commonly held assumptions about specific trauma-based care pathways. First, not all patients with a cervical spine injury require MRI. MDCT scanners are exceptionally accurate. Instead, MRI should be reserved for the small cohort of patients who have motor weakness on exam and an altered mental status. Second, the widespread prescription of DOACs has challenged the applicability of clinical decision rules. Patients taking DOACs are at high risk for intracranial injury and require a slightly tailored approach for ED disposition. Patients with a clear sensorium, a minor mechanism of injury, and an initially negative MDCT may be candidates for close interval outpatient follow-up after blunt head trauma. Admission should be pursued for patients who sustained a loss of consciousness following the injury. Third, TEG has been incorporated into clinical guidelines recently. TEG can guide the administration of blood and blood products in acutely unstable patients. It has little to no role in the screening of an undifferentiated trauma patient population. Finally, the FAST exam has demonstrated utility in the workup of patients with BAT. It cannot be used to rule out retroperitoneal, solid organ, or bowel wall injury definitively. It is performed with little to no risk to the patient and potentially can identify life-threatening injuries early in the course of evaluation.
Raza M, Elkhodair S, Zaheer A, Yousaf S. Safe cervical spine clearance in adult obtunded blunt trauma patients on the basis of a normal multidetector CT scan — a meta-analysis and cohort study. Injury 2013;44:1589-1595.
Inaba K, Byerly S, Bush LD, et al. Cervical spine clearance: A prospective Western Trauma Association multi-institutional trial. J Trauma Acute Care Surg 2016;81:1122-1130.
Martin MJ, Bush LD, Inaba K, et al. Cervical spine evaluation and clearance in the intoxicated patient: A prospective Western Trauma Association multi-institutional trial and survey. J Trauma Acute Care Surg 2017;83:1032-1040.
Wu X, Malhotra A, Geng B, et al. Cost-effectiveness of magnetic resonance imaging in cervical spine clearance of neurologically intact patients with blunt trauma. Ann Emerg Med 2018;71:64-73.
Cohn B, Keim SM, Sanders AB. Can anticoagulated patients be discharged home safely from the emergency department after minor head injury? J Emerg Med 2014;46:410-417.
Alrajhi KN, Perry JJ, Forster AJ. Intracranial bleeds after minor and minimal head injury in patients on warfarin. J Emerg Med 2015;48:137-142.
Pieracci F, Eachempati S, Shou J, et al. Use of long-term anticoagulation is associated with traumatic intracranial hemorrhage and subsequent mortality in elderly patients hospitalized after falls: Analysis of the New York State Administrated Database. J Trauma 2007;63:519-524.
Barbosa RR, Jawa R, Watters JM, et al. Evaluation and management of mild traumatic brain injury: An Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73(5Suppl4):S307-S314.
Vos PE, Alekseenko Y, Battistin E, et al; European Federation of Neurological Societies. Mild traumatic brain injury. Eur J Neurol 2012;19:191-198.
NSW Ministry of Health. Adult Trauma Clinical Practice Guidelines. Initial Management of Closed Head Injury in Adults, 2nd ed. 2011. Available at: https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/195150/Closed_Head_Injury_CPG_2nd_Ed_Full_document.pdf. Accessed July 24, 2018.
Miller J, Lieberman L, Nahab B, et al. Delayed intracranial hemorrhage in the anticoagulated patient: A systematic review. J Trauma Acute Care Surg 2015;79:310-313.
Nishijima DK, Offerman SR, Ballard DW, et al. Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 2012;59:460-468.e7.
Menditto VG, Lucci M, Polonara S, et al. Management of minor head injury in patients receiving oral anticoagulant therapy: A prospective study of a 24-hour observation protocol. Ann Emerg Med 2012;59:451-455.
Kaen A, Jimenez-Roldan L, Arrese I, et al. The value of sequential computed tomography scanning in anticoagulated patients suffering from minor head injury. J Trauma 2010;68:895-898.
Schoonman GG, Bakker DP, Jellema K. Low risk of late intracranial complications in mild traumatic brain injury patients using oral anticoagulation after an initial normal brain computed tomography scan: Education instead of hospitalization. Eur J Neurol 2014;21:1021-1025.
Rendell S, Sultan L. Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infairmay. BET 3: Observation is unnecessary following a normal CT brain in warfarinised head injuries: An update. Emerg Med J 2014;31:339-342.
Chenoweth JA, Gaona SD, Faul M, et al. Incidence of delayed intracranial hemorrhage in older patients after blunt head trauma. JAMA Surg 2018;153:570-575.
da Luz LT, Nascimento B, Rizoli S. Thrombelastography (TEG®): Practical considerations on its clinical use in trauma resuscitation. Scand J Trauma Resusc Emerg Med 2013;21:29.
Smart L, Mumtaz K, Scharpf D, et al. Rotational thromboelastometry or conventional coagulation tests in liver transplantation: Comparing blood loss, transfusions, and cost. Ann Hepatol 2017;16:916-923.
Gonzalez E, Moore EE, Moore HB, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: A pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg 2016;263:1051-1059.
Mohamed M, Majeske K, Sachwani GR, et al. The impact of early thromboelastography directed therapy in trauma resuscitation. Scand J Trauma Resusc Emerg Med 2017;25:99.
Dias JD, Norem K, Doorneweerd DD, et al. Use of thromboelastography (TEG) for detection of new oral anticoagulants. Arch Pathol Lab Med 2015;139:665-673.
Ali JT, Daley MJ, Vadiei N, et al. Thromboelastogram does not detect pre-injury anticoagulation in acute trauma patients. Am J Emerg Med 2017;35:632-636.
Howard BM, Kornblith LZ, Redick BJ, et al. The effects of alcohol on coagulation in trauma patients: Interpreting thrombelastography with caution. J Trauma Acute Care Surg 2014;77:865-871.
Cook MR, Louis SG, McCully SP, et al. Positive blood alcohol is associated with reduced DVT in trauma. Injury 2015;46:131-135.
Cotton BA, Faz G, Hatch QM, et al. Rapid thromboelastography delivers real-time results that predict transfusion within 1 hour of admission. J Trauma 2011;71:407-417.
Dammers D, El Moumni M, Hoogland II, et al. Should we perform a FAST exam in haemodynamically stable patients presenting after blunt abdominal injury: A retrospective cohort study. Scand J Trauma Resusc Emerg Med 2017;25:1-8.
Savatmongkorngul S, Wongwaisayawan S, Kaewlai R. Focused assessment with sonography for trauma: Current perspectives. Open Access Emerg Med 2017;9:57-62.
American Institute of Ultrasound Medicine. AIUM Practice Parameter for the Performance of the Focused Assessment With Sonography for Trauma (FAST) Examination. Available at: https://www.aium.org/resources/guidelines/fast.pdf. Accessed March 19, 2018.
Boulanger BR, McLellan BA, Brenneman FD, et al. Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury. J Trauma 1999;47:632-637.
Ollerton JE, Sugrue M, Balogh Z, et al. Prospective study to evaluate the influence of FAST on trauma patient management. J Trauma 2006;60:785-791.
Mohammadi A, Ghasemi-Rad M. Evaluation of gastrointestinal injury in blunt abdominal trauma "FAST is not reliable": The role of repeated ultrasonography. World J Emerg Surg 2012;7:2.
Tsui CL, Fung HT, Chung KL, Kam CW. Focused abdominal sonography for trauma in the emergency department for blunt abdominal trauma. Int J Emerg Med 2008;1:183-187.
Smith ZA, Wood D. Emergency focussed assessment with sonography in trauma (FAST) and haemodynamic stability. Emerg Med J 2014;31:273-277.
Barbosa RR, Rowell SE, Fox EE, et al. Increasing time to operation is associated with decreased survival in patients with a positive FAST examination requiring emergent laparotomy. J Trauma Acute Care Surg 2013;75(1 Suppl1):S48-S52.
Stengel D, Rademacher G, Ekkernkamp A, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev 2015;9:CD004446.
Richards JR, McGahan JP. Focused Assessment with Sonography in Trauma (FAST) in 2017: What radiologists can learn. Radiology 2017;283:30-48.
Trauma Reports
Trauma Reports (Vol. 19, No. 5) - September 2018
Financial Disclosure: Dr. Kaide (peer reviewer) is a stockholder and chief content editor for Callibra Inc., which makes software for discharge instructions. Dr. Dietrich (editor in chief), Dr. Lawner (author), Dr. Pedersen (author), Dr. Shukis (author), Ms. Behrens (nurse planner), Ms. Mark (executive editor), Ms. Coplin (executive editor), and Ms. Hatcher (editorial group manager) report no relationships with companies related to this field of study.


text:
Q: Updated NPM now Gulp doesn't work within Git Bash As the title says, I recently updated NPM and now Gulp is no longer a command in my Git Bash terminal on Windows 10.
I've tried uninstalling, reinstalling, editing path variables and have had no luck. Running this command to install I get the following:
$ npm install --global gulp-cli

C:\Program Files\Git\usr\local\gulp -> C:\Program
Files\Git\usr\local\node_modules\gulp-cli\bin\gulp.js
C:\Program Files\Git\usr\local
`-- gulp-cli@1.3.0

But then running this it seems it thinks it's in a different directory:
$ where gulp

C:\Users\MyUserName\AppData\Roaming\npm\gulp.cmd

I've also tried doing this in the Windows command line and it works. I'm guessing my Git Bash is looking for it in the wrong place? Just unsure as how to rectify.
Any help would be muchly appreciated!

A: Seems the update added a prefix path above all the default values in my NPM config file telling it to install into the Git folder.
Taking this out and resetting to the default values fixed it.

redpajama_set_name: RedPajamaStackExchange


text:
Sokehs Island är en ö i Mikronesiens federerade stater (USA).   Den ligger i kommunen Sokehs Municipality och delstaten Pohnpei, i den centrala delen av landet,  km nordost om huvudstaden Palikir. Arean är  kvadratkilometer.

Terrängen på Sokehs Island är kuperad. Öns högsta punkt är  meter över havet.

Tropiskt regnskogsklimat råder i trakten. Årsmedeltemperaturen i trakten är  °C. Den varmaste månaden är oktober, då medeltemperaturen är  °C, och den kallaste är januari, med  °C. Genomsnittlig årsnederbörd är  millimeter. Den regnigaste månaden är oktober, med i genomsnitt  mm nederbörd, och den torraste är april, med  mm nederbörd.

Kommentarer

Källor

Öar i Pohnpei
Öar i Mikronesiens federerade stater större än 5 kvadratkilometer

redpajama_set_name: RedPajamaWikipedia


text:
namespace Raspberry.IO.Components.Converters.Mcp3002
{
    public static class Mcp3002AnalogPinExtensionMethods
    {
        #region Methods

        /// <summary>
        /// Creates an analog input pin.
        /// </summary>
        /// <param name="connection">The connection.</param>
        /// <param name="channel">The channel.</param>
        /// <returns>The pin.</returns>
        public static Mcp3002InputAnalogPin In(this Mcp3002SpiConnection connection, Mcp3002Channel channel)
        {
            return new Mcp3002InputAnalogPin(connection, channel);
        }

        #endregion
    }
}

redpajama_set_name: RedPajamaGithub


Dr Louise Sime explains her fears for vital work by the British Antarctic Survey as well as the impact that leaving the EU could have on individual staff.
Dr Louise Sime is a paleoclimate modeller at the iconic British Antarctic Survey. Her research group uses ice core samples to infer climate change over hundreds of thousands of years.
As ice sheets build up, the ice preserves an incremental record of climate conditions. Paleoclimatologists analyse the chemistry of the water, air bubbles and other inclusions to diagnose environmental chemistry and temperature.
Louise uses model simulations of water isotopes to help interpret ice core observations. "Isotopes in the ice represent a long-term proxy record of climate. The simulations help us understand how ice sheets, sea ice and climate behaved in the past," she says.
The ice core data allow Louise to evaluate how well her climate model behaves.
The BAS group's climate simulations are helping to predict polar change over the coming century. They use ice core data from the Last Interglacial period, 130,000 to 116,000 years ago, to test their ability to predict a relatively warm climate.
During her ten years at BAS, Louise has worked on the multinational European Project for Ice Coring in Antarctica (EPICA).
"Drilling and measuring major Antarctic ice cores is expensive, and logistically complex. It benefits hugely from cross-European collaboration.
EPICA has produced an incredible wealth of data representing environmental change. Drilling for ice cores reached a depth of more than 3km. The core record dates back 740,000 years, showing eight glacial cycles.
Buoyed by the project's success, the EU has now funded an even more ambitious project to find the "oldest ice" in Antarctica. The multinational team hopes to acquire an ice core record dating back 1.5 million years and the scientists at BAS plan to be a part of it, she says.
Antarctic research is a global enterprise. Almost half of Louise's research group at BAS are from other EU countries.
Louise's concerns about Brexit hit even closer to home. "My partner is a German scientist, and we have two British-German children.


Schizoaffective disorder is a rare mental illness; its effects on the people who have it are extremely varied.
People with schizoaffective disorder experience symptoms that resemble both schizophrenia (hallucinations or delusions and another symptom) and mood episodes (manic episode or depressive episode).
Schizoaffective disorder is a rare condition.
Genetics If you have a parent or sibling with schizoaffective disorder, you are more likely to develop the condition.
Brain Chemistry and Structure People with schizoaffective disorder may have certain differences in brain function.
Drug Use Some drugs, such as cannabis, have been linked to the development of schizoaffective disorder.
Schizoaffective disorder affects each person differently. Some people experience cycles of severe symptoms, followed by periods of improvement.
Your healthcare provider will complete a mental health assessment if he or she suspects schizoaffective disorder.
You will also be referred to a psychiatrist.
In the past, the process of diagnosing schizoaffective disorder may have been less precise than it is today. In 2013, the American Psychiatric Association revised its guidelines to give doctors more guidance on identifying schizoaffective disorders. As a result, today there is more of a distinction between having schizophrenia and mood episodes and having schizoaffective disorder. The criteria encourages clinicians to consider the whole disease course and see if mood episodes have been present for most of it.
To receive a diagnosis of schizoaffective disorder, you must experience certain psychotic symptoms during a period of two weeks or longer when you do not experience mood episodes, such as manic or depressive episodes. In addition, mood episodes must be present during most of your illness.
Some people only experience psychotic symptoms during a disturbance in mood. In these instances, doctors diagnose bipolar disorder or depression with psychotic features. (4) The difference is slight, but it can affect the type of medication used during treatment.
Schizoaffective disorder is treated with a combination of medication and psychotherapy (talking with a professional therapist).
There is no cure for schizoaffective disorder, but symptoms can be managed and minimized with proper treatment.
Antipsychotic Drugs These medicines are prescribed to help reduce or eliminate symptoms such as hallucinations or delusions.
Antidepressants These drugs help balance chemicals in the brain that effect mood and emotion. Antidepressants can lessen feelings of sadness or emptiness.
Mood Stabilizers These drugs help even out the "highs" and "lows" that are characteristic of bipolar disorder.
Cognitive Behavioral Therapy You'll talk with a therapist to develop coping strategies for certain symptoms.
Self-Help Groups These are meetings that occur in safe environments where you can interact with people who are going through the same things as you. Professional therapists may or may not be involved.
Family Therapy This involves seeing a therapist along with some or all of your family members.
It's helpful when your family knows as much about your medical condition as possible. Therapists can also help your family find problem-solving skills and coping strategies.
Rehabilitation These programs can include job training and counseling, financial management, and the development of communication skills.
Rehabilitation programs teach strategies that help people with schizoaffective disorder function better in their communities.
Schizoaffective Disorder. National Alliance on Mental Illness.
Schizoaffective Disorder. U.S. National Library of Medicine MedlinePlus February 2, 2016.
Fischer BA, Buchanan RW. Schizophrenia in Adults: Clinical Manifestations, Course, Assessment, and Diagnosis. UpToDate. January 26, 2018.
Malaspina D, Owen MJ, Heckers S, et al. Schizoaffective Disorder in the DSM-5. Schizophrenia Research. October 2013.
OConghaile A, DeLisi LE. Distinguishing Schizophrenia From Posttraumatic Stress Disorder With Psychosis. Current Opinions in Psychiatry. May 2015.
Sareen J. Posttraumatic Stress Disorder in Adults: Epidemiology, Pathophysiology, Clinical Manifestations, Course, Assessment, and Diagnosis. UpToDate. January 25, 2018.
Mental Health Medications. National Alliance on Mental Illness. August 2017.
Dixon LB, Goldman H, Srihari VH, Kane JM, et al. Transforming the Treatment of Schizophrenia in the United States: The RAISE Initiative. Annual Review of Clinical Psychology. January 12, 2018.


Genomic medicine: evolution or revolution?
After watching a recent NHS England board meeting – in which there was considerable excitement about the future role of genomics in the health service, it was actually an aside from Bruce Keogh that really got me thinking about the progress we have already made in genomic medicine in the UK. It was his view that, despite "several false dawns of genomics", we were now at an "historic moment" of change.
It is true that the meeting appreciated the enormous advances we have made in the field of genomics, but it seemed to me that by dismissing past efforts, a little of the importance and history of genomic medicine in the UK had been lost along the way. What really worried me about this interpretation was that it presented a picture of genomics being a new concept – something untested, or that been tried and failed. It also portrayed the 100,000 Genomes Project as the very first stage in a journey towards the 'future' of genomics in medicine.
In reality, this version could not be further from the truth. It is a fact that genomics is constantly evolving, but it has not simply emerged overnight. It is also unfair to label previous initiatives to embed genomics into the NHS as a failure, and by categorising them a 'false dawn', Bruce Keogh has (however inadvertently) done just that.
It is interesting that this rhetoric actually contradicts the 2012 Human Genomics Strategy Group position, which provided a good snapshot of how far we have already come. The report demonstrated that the foundations are not only in place, but that they are delivering real results. I find it fair to say that in 2014, we are not starting from a blank page, but are thus building on those solid foundations. The 100,000 Genomes Project is, of course, part of that journey, but I would argue that it is only possible because of the context of those previous successes, rather than being the trigger for a completely new way of delivering healthcare.
This distinction is more important than it might first appear – it is not just a question of semantics. For in order to adequately plan for a future in which genomics could be truly embedded in our healthcare system, it is crucial to understand successes and obstacles we have faced in the past. There is a danger, for example, when designing the new 100,000 genomes database, of overlooking the value of existing databases (such as DECIPHER). The focus should instead be on how we streamline and share all the disparate sources of information so that we can learn and progress at a much faster rate.
We must never, therefore, underplay the importance of genomics in being part of a more personalised approach to healthcare. We are at a pivotal point in history and on the cusp of real change, but rather than us approaching this from a standing start, I see the 100,000 Genomes Project as a springboard to realise the change we have always wanted – only much more quickly. I hope that NHS England, with its responsibility for provision of all genomic services, is able to see this too.


Professional video, entertaining with great message!
Very well done! Not really high school material though..
was beautifully done! the girls are all so talented and the scenery, props and costumes looked great. i didn't find the content to be appropriate to girls in their stage of life.. it would have been nicer to see a play done on a topic more relevant to their stage in life.
THE PLAY WAS WONDERFUL BUT I MUST STRONGLY WARN EVERYONE THIS IS ONLY FOR MARRIED WOMEN.
To all those saying it should be for married women only, while I see where your coming from, I have to disagree. Anything that could be considered an issue is too veiled for children to comprehend. Anyone who does comprehend is probably old enough anyways.
The film was really professional and was done really well! HOWEVER i was really shocked and surprised that the play discussed topics that pertain to MARRIED WOMEN ONLY! AND NOT TO GIRLS i think such a play should not be performed by a high school!!!!!!!! this DVD SHOULD BE LABELED FOR MARRIED WOMEN!!!!!!!


text:
RILP () – білок, який кодується однойменним геном, розташованим у людей на 17-й хромосомі. Довжина поліпептидного ланцюга білка становить 401 амінокислот, а молекулярна маса — 44 200.

Кодований геном білок за функцією належить до фосфопротеїнів.
Задіяний у таких біологічних процесах, як транспорт, транспорт білків, альтернативний сплайсинг.
Локалізований у мембрані, цитоплазматичних везикулах, лізосомі, ендосомах.

Література

Примітки

Див. також
 Хромосома 17

Некатегоризовані білки


1. Voltage and current continuously are adjustable from zero to rated value.
2. This machine has perfect protection circuit ,auto recovery funcion.
3. Can test voltage, check GSM mobile phone singal .
4. Two different current model can be chose.
5. Voltage and current are displayed at the same time.
6. upholds high precision and great stability.
Send your inquiry to our good quality 15V Laboratory dc power supply 220V/110V BEST-1501T products.


text:
Slandering Jesus
Category: Berit Kjos
by Berit Kjos
" After the discovery of fourth-century books at Nag Hammadi the ancient movement known today as Gnosticism... could now be studied in the writings of Gnostics themselves. Contributing factors to renewed interest in old mystical systems are Carl Jung's school of depth psychology, Gershom Scholem's studies of Jewish mysticism [Kabbalah], and much fuller study of Asian mystical systems. "[1] "The Gnostic Gospel of Thomas"
"Beware lest anyone cheat you through philosophy and empty deceit, according to the tradition of men, according to the basic principles of the world, and not according to Christ." ' Colossians 2:6-9
The assaults against Christianity began early. By the time the apostle Paul had written his epistles to the young churches he had founded, the seeds of Gnostic deception had already been scattered. In his letter to the Colossian church, Paul dealt specifically with some of those false teachings, but Gnosticism has always been a bit like a chameleon. Because its foundation rests on mystical revelations or knowledge (gnosis) rather than actual truth or reality, it could change its "colors" to fit any context.
Now as then, Gnosticism infiltrates churches because it sometimes masquerades as "Christianity." By using Biblical words and names (such as Jesus, spirit, creation, heaven, Adam and Eve) with radical new meanings, its followers would teach believable distortions. Since their key words sounded familiar, their myths and mysticisms seemed normal as well as exciting.
The newly translated "Gospel of Judas" is such a story. It's not true! But it fits the purposes of those who seek justification for slandering Jesus, undermining the Bible, and ridiculing those who trust God's Word.
Actually, Gnosticism turns truth upside down! ' It makes Satan look good, for he supposedly brought enlightenment or mystical knowledge (gnosis) to humanity. It makes its creator-god bad, for he conceived evil in the world. And in this particular manuscript, Judas Iscariot -- who betrayed his Master -- is presented as Jesus' best friend. The Gnostic Jesus shares mystical gnosis with Judas alone -- in secret, unlike the Biblical Jesus who taught and trained His disciples to speak His Word openly to the public. The National Geographic Society's website lets us glimpse this distortion:
"The Gospel of Judas gives a different view of the relationship between Jesus and Judas, offering new insights into the disciple who betrayed Jesus. Unlike the accounts in the canonical Gospels of Matthew, Mark, Luke, and John, in which Judas is portrayed as a reviled traitor, this newly discovered Gospel portrays Judas as acting at Jesus' request when he hands Jesus over to the authorities."[2]
We shouldn't be surprised. As Jesus warned us, "many false prophets will rise up and ¯ » ¿ ¯ » ¿deceive many." [Matthew 24:11] But the source of these deceptions is not merely man's capricious mind and imagination. Rather, it's "the serpent of old, called the Devil and Satan, who deceives the whole world." [Revelation 12:9] And we need to discern his tactics! Ephesians 6:10-18, which outlines the main truths in the "Armor of God," includes this reminder:
"For we do not wrestle against flesh and blood, but against principalities, against powers, against the rulers of the darkness of this age, against spiritual hosts of wickedness in the heavenly places. Therefore take up the whole armor of God, that you may be able to withstand in the evil day, and having done all, to stand."
Nine tattered fragments from this "Gospel of Judas" were recently translated into English. They include some strange words with unusual Gnostic meanings such as Aeons. To most people, this word might mean long periods of time. For Gnostics it's more likely to suggest male/female gods within an occult spiritual hierarchy.
Some of the more readable statements are posted at nationalgeographic.com. This website introduces the manuscript as "The secret account of the revelation that Jesus spoke in conversation with Judas Iscariot during a week, three days before he celebrated Passover."[3] In this false "gospel," t he words below were supposedly spoken by "Jesus" to his friend Judas:
"Step away from the others and I shall tell you the mysteries of the kingdom. It is possible for you to reach it, but you will grieve a great deal. In the vision I saw myself as the 12 disciples were stoning me and persecuting [me severely]."
"Lift your your eyes and look at the cloud and the light within it and the stars surrounding it. The star that leads the way is your star. Judas lifted his eyes and saw the luminous cloud, and he entered it." [4]
Bishop Irenaeus, a respected 2nd Century theologian and a disciple of the martyred Polycarp, was familiar with this false "gospel." To warn the early Church against such false teaching, he wrote a book titled "Against Heresies." It includes this statement:
"They declare that Judas the traitor was thoroughly acquainted with these things, and that he alone, knowing the truth as no others did, accomplished the mystery of the betrayal; by him all things, both earthly and heavenly, were thus thrown into confusion. They produce a fictitious history of this kind, which they style the Gospel of Judas."[5]
Unlike ' Irenaeus, many contemporary "Bible scholars" have embraced the deception. Claiming to know God, they betray His teachings. So when The National Geographic Society selected a Codex Advisory Panel to evaluate the readable fragments from the manuscript, these advisers were excited. The new story fit their quest for ammunition against the actual Word of God. Ponder some of their comments:
Bart D. Ehrman heads the Department of Religious Studies at the University of North Carolina at Chapel Hill. He says, "The reappearance of the Gospel of Judas will rank among the greatest finds from Christian antiquity.... [I]t portrays Judas quite differently from anything we previously knew. Here he is not the evil, corrupt, devil-inspired follower of Jesus who betrayed his master; he is instead Jesus' closest intimate and friend, the one who understood Jesus better than anyone else.... This gospel has a completely different understanding of God, the world, Christ, salvation, human existence...."
Marvin Meyer, the director of the Coptic Magical Texts Project at Claremont Graduate University, is a Fellow of the Jesus Seminar and celebrated scholar on Gnosticism. He says, " The Gospel of Judas can be dated, with some certainty, to around the middle of the second century.... The gospel is thus an early source for our knowledge of an important mystical movement within early Christianity and Judaism, namely the Sethian gnostic school of religious thought."
Elaine Pagels has authored numerous books and articles on Gnosticism, including Beyond Belief: The Secret Gospel of Thomas. A member of the Task Force on Progressive Religion in America, she was awarded a Rockefeller Fellowship. She says, "Like the Gospel of Thomas... the Gospel of Judas offers startling new perspectives on familiar gospel stories: These discoveries are changing the way we understand the beginnings of Christianity."
Gregor Wurst, a Catholic professor at the University of Augsburg, Germany, serves on the editorial board of the Nag 'Hammadi and Manichaean [Gnostic] Studies series. He says, "If the Gospel of Judas... can be convincingly identified as being a Coptic translation of the original Greek Gospel of Judas that Bishop Ireneaus mentioned around A.D. 180 in his book, 'Against Heresies,' it will be an important step in the study of ancient gnosticism."[6]
Stephen Emmel is professor at the Institute of Egyptology and Coptology at the University of M ƒ ¼nster. He tells us that recovery of this ancient manuscript offers an "extraordinary opportunity to gain deeper insight into the thoughts and perceptions of our ancestors. The knowledge that we will gain will eventually have, I hope, some positive influence on the future of humankind..."
Don't believe it! Mary Ann Collins' warning in her article on The Da Vinci Code bears repeating:
"Perhaps you are saying to yourself, 'No thinking person would take that kind of thing seriously.' That is exactly what one Evangelical leader thought -- until he started talking with people who had read [the Gnostic suggestions in] The Da Vinci Code. He discovered that the book hardens the unbelief of people who aren't Christians, and it turns honest seekers away from Christianity. The book even caused some Christians to become confused and disillusioned."[7]
Small wonder. In our postmodern culture -- which trusts mystical experiences more than God's unchanging Word -- few will be able to resist today's onslaught of seductive lies. God told us it would happen:
"The coming of the lawless one is according to the working of Satan, with all power, signs, and lying wonders, and with all unrighteous deception among those who perish, because they did not receive the love of the truth, that they might be saved. And for this reason God will send them strong delusion, that they should believe the lie, that they all may be condemned who did not believe the truth but had pleasure in unrighteousness." 2 Thessalonians 2:9
1. The Gnostic Gospel of Thomas at http://www.gnosis.org/thomasbook/intro.html
2. The Lost Gospel at http://www9.nationalgeographic.com/lostgospel/
3. Document, page 33 at http://www9.nationalgeographic.com/lostgospel/document.html
4. Ibid., pages 35 and 57 .
5. http://www.tertullian.org/rpearse/manuscripts
/gospel_of_judas/#Jan2001
6. Codex Advisory Panel at www9.nationalgeographic.com/lostgospel/about_profiles.html
7. Mary Ann Collins, The Da Vinci Code , www.crossroad.to/articles2/006/da-vinci-code.htm

redpajama_set_name: RedPajamaCommonCrawl


text:
Inflexion
We are entrepreneurs on a journey and so understand the exciting challenges brought by the unexpected. We get it, so our respect for what you've achieved already means we guide rather than take over when we join your journey.
We bring great people together. We have one of the UK's largest private equity teams as well as a strong network of experts in the UK and internationally to help you reach your ambitions.
We love growth. On average, the companies we work with see headcount double and revenue grow by 21% year-on-year.
Purpose-driven investing means making businesses better for everyone.
Inflexion Exchange
Inflexion Network
Funds and investors
Inflexion Foundation
Cyber security – the changing nature of challenges
The current crisis has forced businesses to rethink their 'business as usual', with a disparate workforce creating opportunity for cyber criminals. In addition to mitigating these risks, it is worth considering how much of the contingency planning may become the new normal. Inflexion's digital team, led by Alex Mathers, is in regular dialogue with our portfolio to keep on top of this.
Businesses have needed to make a lot of swift, tactical decisions over the last few weeks, particularly around enabling business to continue as usual. "Most of these decisions were made with the expectation that the disruption would be a few weeks, but we now need to bear in mind it may actually be needed for much longer," says Sean Sutton, partner at PwC UK Cyber Security.
With more people working remotely, threat actors see more opportunity – just as home workers may be less equipped to deal with them. Many companies have enacted remediation to mitigate the risks in the immediate-term. But as a few weeks of remote working turns into months, longer-term remedies may be needed to secure newly implemented remote working. PwC UK outlines areas where tactical solutions can be progressed into more strategic solutions:
Monitor for shadow IT – With a more distributed workforce there is increased likelihood of new software and new devices starting to be used without IT involvement, which can create blind spots and increase risks. Initially firms expanded their monitoring to identify new devices, and reassessed web proxy filtering. Now it is best to implement holistic shadow IT monitoring /automate workflow approval.
Secure remote access – For now firms can increase VPN capacity by working with existing
suppliers or extending current solutions, although it is important to make sure that any deployments are managed in a secure way. For the longer term additional solutions and approaches might be required to support a longer period of remote working and operations.
Implement multi-factor authentication (MFA) – enabling MFA into on-premise systems was a key early step many firms took – with some also switching to cloud applications with native two factor authentication. As with remote access, in time moving to a 'zero trust' model regardless of whether users are inside or outside the corporate network may be a better solution.
Review on-premise security controls – Reviewing and tightening data access and security controls to find and close any gaps were important early steps. In time, implementing a dynamic / adaptive security control model, applying real-time contextual information, may be more powerful.
Enhance security monitoring – Security monitoring abilities were increased and 24/7 shift rotation was adopted by many firms. In the longer-term firms should determine people, processes and technology for security operations centre (SOC) surge capacity.
Adapt cyber responses – Many firms were quick to ensure third-party incident response capabilities were on standby and focused threat intelligence to identify Covid-19-specific threats. Going forward, cross-industry support should be expanded to increase market resilience.
If you're making a tactical decision, make sure it can work in the longer-term. This may catalyse a shift in mindset.
Many remote working functions were set up to be temporary, but PwC UK feel home working will become a permanent feature of many businesses.
Changes to business in a post-pandemic world
As businesses return, changes to previous practices and norms should be expected.
Expansion of ecosystem business models – Business models that encompass networks of third-parties are able to adapt and change to deal with rapidly evolving risks, more effectively than traditional supplier-customer models.
Accelerated adoption of cloud – Businesses have really increased their uptake of the cloud. Most organisations have adopted cloud for some functions, but there may be a broader reassessment of how it can help alleviate some of the recent challenges related to remote working.
Redefined meaning of a resilient business – Businesses are changing how they think of resilience. What does resilient look like in your supply chain? Disaster recovery and business continuity planning have for many years have a degree of focus on pandemic-scenario planning. Now we're experiencing it, companies will revisit their plans and apply lessons learnt.
Augmented reality – Use of new tech could change the way businesses and users interact with each other by extending location agnostic services and capabilities and by maximising virtual experiences. The roll-out of 5G will support wider adoption and application.
Cross-business industry resilience – Assessing how businesses work together during these periods could influence how resilience is addressed in future.
Emerging threat landscape
"Threat actors are always quick to identify new ways to exploit vulnerabilities, whether technical or psychological," cautions Rachel Mullan, senior manager at PwC UK Threat Intelligence. The group's research has uncovered a mix of espionage and cyber-crime activity from a variety of actors.
"They're using C-19-based phishing lures to infect victims with malware. It's slowed in the last few days but we're not yet sure if it's a genuine lull or whether they're planning something new. We are also seeing hundreds of c19-related domains being created every day, some of which may be malicious infrastructure for use in future campaigns."
She also points to an uptick in mobile malware, appearing on download sites, as well as 'smishing' (think phishing but by text message).
The lures are shifting. Initially they were on the health side, but now they are more on the remote-working side.
"Ransomware actors have been active, expanding the range of sectors they target and the value of ransom demands are increasing. TrickBot, which is associated with Ryuk ransomware, began using C-19 lures in mid-March and TA505, the actors behind mailto and Buran ransomware have recently followed suit."
Alex Mathers
T. +44 (0)20 7487 9888
E. alex.mathers@inflexion.com
Sarah Gestetner
E. sarah.gestetner@inflexion.com
Inflexion Private Equity Partners LLP is authorised and regulated by the Financial Conduct Authority.
Registered office: 47 Queen Anne Street, London W1G 9JG. Registered in England and Wales No. OC316601.
Inflexion is a registered trademark. © Inflexion 2019.
IFX COVID 19 Risk Assessment


text:
Vodní lázeň je označení určitého způsobu ohřívání či vaření (a to zejména v chemii, alchymii a gastronomii), které má být pomalé  nebo nemá překročit určitou teplotu.

Princip spočívá v tom, že mezi zdroj tepla (například plamen z hořáku) a nádobu s ohřívanou látkou je vložena větší nádoba s vodou, do které je nádoba s ohřívanou látkou ponořena (ale nemusí - potom mluvíme spíše o parní lázni). Voda se zahřívá postupně a rovnoměrněji v porovnání oproti přímému ohřevu nad plamenem se zahřívá i vnitřní nádoba.

Maximální dosažitelná teplota vnitřní nádoby je přitom teplota varu vody, tedy 100 stupňů Celsia (při normálním tlaku). Dokud se voda neodpaří, lze tuto teplotu vnitřní nádoby takto snadno udržovat dlouho dobu i na poměrně nestabilním plameni. Případně lze tímto způsobem udržovat i jiné teploty, pokud se místo vody použije jiná tekutina s jinou teplotou varu.

Při použití v kuchyni se používá obvykle skutečně voda, a to například pro roztátí čokolády nebo ztekutění krystalizovaného medu.

Termika
Příprava jídla


Sport Club do Recife (known as Sport and Sport Recife, abbreviated as SCR) is a Brazilian sports club, located in the city of Recife, in the state of Pernambuco. It was founded on May 13, 1905, by Guilherme de Aquino Fonseca, who lived for many years in England, where he studied at Cambridge University. The biggest rival of the club is Nautico.


text:
Commons: 12 March 2018
Housing, Communities and Local Government
Volume 637: debated on Monday 12 March 2018
(Harrow West) (Lab/Co-op)
4. What estimate he has made of the profits derived from the Help to Buy scheme by house builders. (904292)
The Minister for Housing
(Dominic Raab)
The Help to Buy equity loan scheme alone helped 116,000 first-time buyers to get on to the property ladder and stimulated the supply of new housing—both key aims of this Government.
My constituents, some of whom have been on the wrong end of aggressive behaviour by Persimmon, are concerned to know that since Help to Buy was introduced, the biggest private house builders have increased house prices by up to 10%, with almost all of that banked as profit and much of it paid out in senior managers' enormous bonus payments. Should not the Secretary of State and his ministerial colleagues be doing more to tame the aggressive behaviour of developers such as Persimmon, rather than subsidising them through Help to Buy?
It is good news that Help to Buy has helped more homes to get built. It has contributed to about 14% of new build since 2015. I personally share some of the hon. Gentleman's concerns about executive pay, but I gently remind him that it was this Government who introduced the corporate governance reforms in August, including to make sure that there is greater transparency and greater shareholder grip over directors' pay.
(Rochdale) (Lab)
The Minister will know that some 10% of those on the Help to Buy scheme earn over £80,000 a year. Even in London, they are people who can afford to buy without this taxpayer subsidy. In the light of the Secretary of State's earlier comments about responsibility to the taxpayer, will he contrast the poorest homeowners who will lose help with mortgage interest with these heavily subsidised, well-off people up and down the country?
I think that some factual clarification would help the hon. Gentleman, because four out of five of those benefiting from Help to Buy have been first-time buyers, and three out of five households benefiting from Help to Buy had combined incomes of £50,000 or less. We are on their side; it is a shame that Labour is not.