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Lee VK, Lee T, Ghosh A, Saha T, Bais MV, Bharani KK, Chag M, Parikh K, Bhatt P, Namgung B, Venkataramanan G, Agrawal A, Sonaje K, Mavely L, Sengupta S, Mashelkar RA, Jang HL. An architecturally rational hemostat for rapid stopping of massive bleeding on anticoagulation therapy. Proc Natl Acad Sci U S A 2024; 121:e2316170121. [PMID: 38252814 PMCID: PMC10835033 DOI: 10.1073/pnas.2316170121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/08/2023] [Indexed: 01/24/2024] Open
Abstract
Hemostatic devices are critical for managing emergent severe bleeding. With the increased use of anticoagulant therapy, there is a need for next-generation hemostats. We rationalized that a hemostat with an architecture designed to increase contact with blood, and engineered from a material that activates a distinct and undrugged coagulation pathway can address the emerging need. Inspired by lung alveolar architecture, here, we describe the engineering of a next-generation single-phase chitosan hemostat with a tortuous spherical microporous design that enables rapid blood absorption and concentrated platelets and fibrin microthrombi in localized regions, a phenomenon less observed with other classical hemostats without structural optimization. The interaction between blood components and the porous hemostat was further amplified based on the charged surface of chitosan. Contrary to the dogma that chitosan does not directly affect physiological clotting mechanism, the hemostat induced coagulation via a direct activation of platelet Toll-like receptor 2. Our engineered porous hemostat effectively stopped the bleeding from murine liver wounds, swine liver and carotid artery injuries, and the human radial artery puncture site within a few minutes with significantly reduced blood loss, even under the anticoagulant treatment. The integration of engineering design principles with an understanding of the molecular mechanisms can lead to hemostats with improved functions to address emerging medical needs.
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Affiliation(s)
- Vivian K. Lee
- Center for Engineered Therapeutics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Health Sciences and Technology, Harvard–Massachusetts Institute of Technology, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Taewoo Lee
- Center for Engineered Therapeutics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Health Sciences and Technology, Harvard–Massachusetts Institute of Technology, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Amrit Ghosh
- Center for Engineered Therapeutics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Health Sciences and Technology, Harvard–Massachusetts Institute of Technology, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Tanmoy Saha
- Center for Engineered Therapeutics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Health Sciences and Technology, Harvard–Massachusetts Institute of Technology, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Manish V. Bais
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Department of Translational Dental Medicine, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA02118
| | - Kala Kumar Bharani
- Department of Veterinary Pharmacology and Toxicology, College of Veterinary Science, P. V. Narasimha Rao Telangana Veterinary University, Hyderabad 500030, India
| | - Milan Chag
- Care Institute of Medical Sciences, Ahmedabad 380060, India
| | - Keyur Parikh
- Care Institute of Medical Sciences, Ahmedabad 380060, India
| | - Parloop Bhatt
- Care Institute of Medical Sciences, Ahmedabad 380060, India
| | - Bumseok Namgung
- Center for Engineered Therapeutics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Health Sciences and Technology, Harvard–Massachusetts Institute of Technology, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Geethapriya Venkataramanan
- Center for Engineered Therapeutics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Health Sciences and Technology, Harvard–Massachusetts Institute of Technology, Massachusetts Institute of Technology, Cambridge, MA 02139
| | | | - Kiran Sonaje
- Axio Biosolutions Private Limited, Ahmedabad 382220, India
| | - Leo Mavely
- Axio Biosolutions Private Limited, Ahmedabad 382220, India
- Advamedica Inc., Boston, MA 02138
| | - Shiladitya Sengupta
- Center for Engineered Therapeutics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Health Sciences and Technology, Harvard–Massachusetts Institute of Technology, Massachusetts Institute of Technology, Cambridge, MA 02139
| | | | - Hae Lin Jang
- Center for Engineered Therapeutics, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115
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Avital G, Hernandez Torres SI, Knowlton ZJ, Bedolla C, Salinas J, Snider EJ. Toward Smart, Automated Junctional Tourniquets-AI Models to Interpret Vessel Occlusion at Physiological Pressure Points. Bioengineering (Basel) 2024; 11:109. [PMID: 38391595 PMCID: PMC10885917 DOI: 10.3390/bioengineering11020109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/05/2024] [Accepted: 01/18/2024] [Indexed: 02/24/2024] Open
Abstract
Hemorrhage is the leading cause of preventable death in both civilian and military medicine. Junctional hemorrhages are especially difficult to manage since traditional tourniquet placement is often not possible. Ultrasound can be used to visualize and guide the caretaker to apply pressure at physiological pressure points to stop hemorrhage. However, this process is technically challenging, requiring the vessel to be properly positioned over rigid boney surfaces and applying sufficient pressure to maintain proper occlusion. As a first step toward automating this life-saving intervention, we demonstrate an artificial intelligence algorithm that classifies a vessel as patent or occluded, which can guide a user to apply the appropriate pressure required to stop flow. Neural network models were trained using images captured from a custom tissue-mimicking phantom and an ex vivo swine model of the inguinal region, as pressure was applied using an ultrasound probe with and without color Doppler overlays. Using these images, we developed an image classification algorithm suitable for the determination of patency or occlusion in an ultrasound image containing color Doppler overlay. Separate AI models for both test platforms were able to accurately detect occlusion status in test-image sets to more than 93% accuracy. In conclusion, this methodology can be utilized for guiding and monitoring proper vessel occlusion, which, when combined with automated actuation and other AI models, can allow for automated junctional tourniquet application.
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Affiliation(s)
- Guy Avital
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
- Israel Defense Forces Medical Corps, Ramat Gan 52620, Israel
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Affiliated with the Faculty of Medicine, Tel Aviv University, Tel Aviv 64239, Israel
| | | | - Zechariah J Knowlton
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Carlos Bedolla
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Jose Salinas
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
| | - Eric J Snider
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX 78234, USA
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Wang W, Han P, Yang L, Meng Z, Gan H, Wu Z, Zhu X, Sun W, Gu R, Dou G. A novel sodium polyacrylate-based stasis dressing to treat lethal hemorrhage in a penetrating trauma swine model. J Trauma Acute Care Surg 2023; 94:608-614. [PMID: 36728318 PMCID: PMC10045977 DOI: 10.1097/ta.0000000000003869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/29/2022] [Accepted: 12/13/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Control of massive hemorrhage from penetrating wound sites is difficult in both combat and civilian settings. A new hemostatic dressing, sodium polyacrylate (PAAs)-based bag (PB), based on PAAs is designed for the first aid of massive penetrating hemorrhage. This study aimed to investigate the efficacy of PB in a penetrating trauma model in swine. METHODS A complex groin penetrating injury was produced in swine by completely excising the femoral vessels and surrounding muscles. After 15-second free bleeding, 18 healthy Guizhou female swine were administered PB (n = 6), CELOX-A (n = 6; Medtrade Products, Crewe, United Kingdom), or standard gauze (n = 6) for hemostatic intervention, followed by 3-minute compression if the bleeding persisted, with subsequent observation continuing for 1 hour. The primary outcomes included initial hemostasis, the incidence of applying manual pressure, and application time. RESULTS Sodium polyacrylate could rapidly absorb the liquid to expand, crosslink with a large number of red blood cells, induce cellular morphological alteration, and promote blood coagulation. Sodium polyacrylate-based bag and CELOX-A initiated and sustained hemostasis for 60 minutes, whereas 0% of the standard gauze achieved initial hemostasis. Maximum number of manual compressions were applied in standard gauze (6 of 6 [100%]), followed by CELOX-A (5 of 6 [80%]), while no manual pressure was required in the case of PB (0 of 6 [0%]). Application time for PB (19.0 ± 4.6 seconds) was significantly less than CELOX-A (169.0 ± 73.5 seconds) and standard gauze (187.8 ± 1.7 seconds). CONCLUSION We prepared a type of superabsorbent PAAs and made an original hemostatic dressing, PB. It can rapidly achieve durable hemostasis in the groin-penetrating trauma hemorrhage swine model without any external compression. The packet form makes PB easy to deploy and remove from wounds. Therefore, PB could be a promising hemostatic candidate for controlling penetrating hemorrhage.
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Cavanagh N, Blanchard IE, Weiss D, Tavares W. Looking back to inform the future: a review of published paramedicine research. BMC Health Serv Res 2023; 23:108. [PMID: 36732779 PMCID: PMC9893690 DOI: 10.1186/s12913-022-08893-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 11/28/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Paramedicine has evolved in ways that may outpace the science informing these changes. Examining the scholarly pursuits of paramedicine may provide insights into the historical academic focus, which may inform future endeavors and evolution of paramedicine. The objective of this study was to explore the existing discourse in paramedicine research to reflect on the academic pursuits of this community. METHODS We searched Medline, Embase, CINAHL, Google Scholar and Web of Science from January, 2006 to April, 2019. We further refined the yield using a ranking formula that prioritized journals most relevant to paramedicine, then sampled randomly in two-year clusters for full text review. We extracted literature type, study topic and context, then used elements of qualitative content, thematic, and discourse analysis to further describe the sample. RESULTS The initial search yielded 99,124 citations, leaving 54,638 after removing duplicates and 7084 relevant articles from nine journals after ranking. Subsequently, 2058 articles were included for topic categorization, and 241 papers were included for full text analysis after random sampling. Overall, this literature reveals: 1) a relatively narrow topic focus, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that most were observational studies (e.g., cohort, case control, and case series) or editorial/commentary; 3) a variety of observed trajectories of academic attention, indicating where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills historically considered core to paramedic clinical practice. CONCLUSIONS Included articles suggest a relatively narrow topic focus, a limited methodological focus, and observed trajectories of academic attention indicating where research pursuits and priorities are shifting. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy contributing to the health and social well-being of communities.
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Affiliation(s)
- N. Cavanagh
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - I. E. Blanchard
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada ,grid.22072.350000 0004 1936 7697Department of Community Health Sciences, University of Calgary, Cumming School of Medicine, Calgary, Alberta Canada
| | - D. Weiss
- grid.413574.00000 0001 0693 8815Alberta Health Services, Emergency Medical Services, Edmonton, Alberta Canada
| | - W. Tavares
- grid.512795.dThe Wilson Centre, Department of Medicine, University of Toronto/University Health Network, Toronto, Ontario Canada ,grid.17063.330000 0001 2157 2938Department of Health and Society, University of Toronto, Toronto, Ontario Canada ,York Region Paramedic and Senior Services, Community Health Services Department, Regional Municipality of York, Newmarket, Ontario Canada
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Zhang Z, Hou M, Liu T, Li F, Yang K, Ding S, Lin S. Microwave assisted preparation of a hemostatic gauze with mesoporous silica through in-situ synthesis. J Biomater Appl 2023; 37:1102-1111. [PMID: 36113422 DOI: 10.1177/08853282221126574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The medical disinfection cotton gauze is the most frequently used medical consumables for wound care. Here this ordinary commercial gauze was upgraded to a hemostatic gauze, which was loaded with mesoporous silica through in-situ synthesis and further microwave treatment. The original cotton gauze was pretreated with NaOH solutions for surface activation, soaked in double-silica source precursor solution for moderate in-situ synthesis, treated with microwave for quick template removement and dehydration. The final obtained hemostatic gauze (MS-G1) showed superior physical, biocompatible and hemostatic advantages. The newborn mesoporous silica was firmly anchored onto the cotton fiber surface with <20% leaching after 10 min of sonication. The microwave treatment not only shortened the time for template removal but also promotes the formation of mesoporous structure. The clotting blood time (CBT) of MS-G1 were only (62.00 ± 5.56 s), which was 23.14% shorter than that of original medical gauze, and even 3.6% shorter than Combat Gauze (CG). MS-G1 also showed excellent biocompatibility in cytotoxicity tests of L-929 cells, with a 116% proliferation rate at the concentration of 5 mg/mL. Furthermore, the hemostatic performance was explored on a rabbit wound model of hemorrhagic liver injury, and MS-G1 showed both shorter hemostasis time (113.75 s) and less blood loss (1.69 g) than that of CG (180.00 s, 5.13 g). The hemostatic gauze anchored with mesoporous silica was expected to be an excellent prehospital hemostatic dressing for field first aid.
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Affiliation(s)
- Zhuoran Zhang
- Institute of Medical Support Technology, Academy of Military Science, Tianjin 300161, China.,951 Hospital, Korla 841000, China
| | - Min Hou
- 951 Hospital, Korla 841000, China
| | - Tao Liu
- Institute of Medical Support Technology, Academy of Military Science, Tianjin 300161, China.,66345Tianjin University of Science and Technology, Tianjin 300161, China
| | - Fan Li
- Institute of Medical Support Technology, Academy of Military Science, Tianjin 300161, China
| | - Kun Yang
- Institute of Medical Support Technology, Academy of Military Science, Tianjin 300161, China
| | - Sheng Ding
- Institute of Medical Support Technology, Academy of Military Science, Tianjin 300161, China
| | - Song Lin
- Institute of Medical Support Technology, Academy of Military Science, Tianjin 300161, China
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Sandhu A, Claireaux HA, Downes G, Grundy N, Naumann DN. Emergency first responder management of combat injuries to the torso in the military, remote and austere settings. BMJ Mil Health 2022; 168:478-482. [PMID: 32229552 DOI: 10.1136/bmjmilitary-2020-001460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 03/14/2020] [Indexed: 11/04/2022]
Abstract
Traumatic injuries to the torso account for almost a quarter of all injuries seen in combat and are typically secondary to blast or gunshot wounds. Injuries due to road traffic collisions or violence are also relatively common during humanitarian and disaster relief efforts. There may also be multiple injured patients in these settings, and surgical care may be limited by a lack of facilities and resources in such a non-permissive environment. The first responder in these scenarios should be prepared to manage patients with severe injuries to the torso. We aim to describe the management of these injuries in the military and austere environment, within the scope of practice of a level 5 registered prehospital practitioner.
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Affiliation(s)
| | - H A Claireaux
- 4 Armoured Medical Regiment, Royal Army Medical Corps, Tidworth, UK
| | - G Downes
- 1 Armoured Medical Regiment, Royal Army Medical Corps, Tidworth, UK
| | - N Grundy
- 1 Armoured Medical Regiment, Royal Army Medical Corps, Tidworth, UK
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Birmingham, UK
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A Narrative Review of Different Hemostatic Materials in Emergency Treatment of Trauma. Emerg Med Int 2022; 2022:6023261. [PMID: 36311483 PMCID: PMC9616665 DOI: 10.1155/2022/6023261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/06/2022] [Accepted: 10/15/2022] [Indexed: 11/23/2022] Open
Abstract
Hemostatic materials are very important for the treatment of a large number of bleeding trauma patients in battlefield and disaster environments. Different types of hemostatic materials need to be used for emergency hemostasis according to different injury parts and severity. At present, the first-aid hemostatic materials have been well applied to the bleeding of body surface wounds, limbs, and junctions, but there are still no ideal hemostatic materials in the early treatment of first aid for the deep and incompressible bleeding of thoracoabdominal cavity and visceral organs. This paper reviews the classification and mechanism of hemostatic materials, as well as the application and research progress in trauma emergency, so as to provide reference for the application of hemostatic materials in early first-aid emergency.
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Gaw CE, Treat JR, Friedlaender EY, Del Pizzo J. Management of Bleeding Pyogenic Granulomas in Acute Care Settings. J Emerg Med 2022; 63:339-347. [DOI: 10.1016/j.jemermed.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/29/2022] [Accepted: 04/23/2022] [Indexed: 11/07/2022]
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Covey DC, Gentchos CE. Field tourniquets in an austere military environment: A prospective case series. Injury 2022; 53:3240-3247. [PMID: 35922340 DOI: 10.1016/j.injury.2022.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/07/2022] [Accepted: 07/25/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Field tourniquets are often used for battlefield extremity injuries. Their effectiveness has been documented by a large combat theater trauma center. However, their use and effectiveness by an austere forward surgical team has not been reported. Aims of this study were to determine: Whether field tourniquets: (1) Were placed for appropriate indications; (2) significantly reduced hemorrhage as measured by transfusion requirements; (3) influenced vital signs and injury severity scores; and (4) did they cause limb amputation, changed amputation level, or other complications. METHODS Twenty-five patients with 30 involved extremities presenting to a forward surgical team in Iraq met the inclusion criteria. We prospectively collected data regarding the presence, indications for, and effectiveness of field tourniquets based on the need for blood transfusion. We recorded any complications associated with their use. RESULTS Tourniquets significantly reduced hemorrhage from penetrating injuries as measured by transfusion requirements. Those having major vascular injuries with effective tourniquets, a total of 12 units of blood were transfused (1.7 units/vascular injury; 2 units/patient). However, 19 units were transfused in patients (3.3 units/vascular injury; 3.8 units/patient) who had an ineffective or no tourniquet (p = 0.0006). Transfusion requirements were related the presence of an effective tourniquet regardless of concomitant injuries. The group with effective tourniquets and compressed hemorrhage presented with higher mean systolic (p = 0.003) and diastolic (p = 0.023) blood pressures than the group with no tourniquets or ineffective ones. Complications included one peroneal nerve palsy and no amputations resulted from tourniquet application. CONCLUSION Field tourniquets applied for penetrating injuries with severe bleeding can significantly reduce transfusion requirements and help maintain adequate blood pressure. Tourniquets were not the proximate cause of amputation and did not determine the choice of immediate amputation level.
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Affiliation(s)
- D C Covey
- Department of Orthopaedic Surgery, University of California, San Diego, 200 West Arbor Drive, San Diego, CA 92103, USA; Level 2 United States Marine Corps Surgical Company, Al Anbar Province, Iraq.
| | - Christopher E Gentchos
- Concord Orthopaedics PA, 264 Pleasant Street, Concord, NH 03301, USA; Level 2 United States Marine Corps Surgical Company, Al Anbar Province, Iraq.
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Zhou M, Liao J, Li G, Yu Z, Xie D, Zhou H, Wang F, Ren Y, Xu R, Dai Y, Wang J, Huang J, Zhang R. Expandable carboxymethyl chitosan/cellulose nanofiber composite sponge for traumatic hemostasis. Carbohydr Polym 2022; 294:119805. [DOI: 10.1016/j.carbpol.2022.119805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/24/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022]
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Hu H, Luo F, Zhang Q, Xu M, Chen X, Liu Z, Xu H, Wang L, Ye F, Zhang K, Chen B, Zheng S, Jin J. Berberine coated biocomposite hemostatic film based alginate as absorbable biomaterial for wound healing. Int J Biol Macromol 2022; 209:1731-1744. [PMID: 35487376 DOI: 10.1016/j.ijbiomac.2022.04.132] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/13/2022] [Accepted: 04/17/2022] [Indexed: 01/08/2023]
Abstract
In wound treatment, severe bleeding and infection are always primary challenges. Therefore, it is highly desired to develop novel dressing with both hemostatic and antibacterial capability. Herein, a series of biocomposite hemostatic films (BHFs) based alginate/chitosan/collagen-berberine have been prepared and well characterized for further biofunctional study. We have demonstrated that the hemostatic and antibacterial activities were significantly enhanced by calcium/berberine dual-crosslinking system in the film. Through the synergistic effects, BHF-6B exhibited a shorter in vivo clotting and wound healing time than that of commercial dressing in rat tail amputation and full-thickness skin defect models. Additionally, BHF-6B showed excellent bacteriostatic activity with long-term effects. Moreover, hemolysis and cytotoxicity tests in vitro illustrated the prominent biocompatibility of the composite films. Notably, BHF-6B could be degraded quickly and completely in vivo. Overall, the present work indicated that the functionalized BHF-6B has great potential as an absorbable biomaterial for wound treatment.
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Affiliation(s)
- Haofeng Hu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Fulin Luo
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Qian Zhang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Ming Xu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Xin Chen
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Zhihao Liu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Haodong Xu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Lei Wang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Fei Ye
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China
| | - Kui Zhang
- International Innovation Center for Forest Chemicals and Materials, College of Chemical Engineering, Nanjing Forestry University, Nanjing 210037, China
| | - Bin Chen
- Department of Orthopedics, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, China
| | - Song Zheng
- Department of Orthopedics, The Second Affiliated Hospital of Jiaxing University, Jiaxing 314000, China
| | - Jia Jin
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou 310018, China.
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Goncharuk O, Korotych O, Samchenko Y, Kernosenko L, Kravchenko A, Shtanova L, Tsуmbalуuk O, Poltoratska T, Pasmurtseva N, Mamyshev I, Pakhlov E, Siryk O. Hemostatic dressings based on poly(vinyl formal) sponges. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 129:112363. [PMID: 34579882 DOI: 10.1016/j.msec.2021.112363] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Revised: 07/07/2021] [Accepted: 08/05/2021] [Indexed: 11/28/2022]
Abstract
The development of novel hemostatic agents is related to the fact that severe blood loss due to hemorrhage continues to be the leading cause of preventable death of patients with military trauma and the second leading cause of death of civilian patients with injuries. Herein we assessed the hemostatic properties of porous sponges based on biocompatible hydrophilic polymer, poly(vinyl formal) (PVF), which meets the main requirements for the development of hemostatic materials. A series of composite hemostatic materials based on PVF sponges with different porosities and fillers were synthesized by acetalization of poly(vinyl alcohol) with formaldehyde. Nano-sized aminopropyl silica, micro-sized calcium carbonate, and chitosan hydrogel were used to modify PVF matrixes. The physicochemical properties (pore size, elemental composition, functional groups, hydrophilicity, and acetalization degree) of the synthesized composite sponges were studied by gravimetrical analysis, optical microscopy, scanning electron microscopy combined with energy dispersive x-ray spectroscopy, infrared spectroscopy, and nuclear magnetic resonance. Hemostatic properties of the materials were assessed using a model of parenchymal bleeding from the liver of white male Wistar rat with a gauze bandage as a control. All investigated PVF-based porous sponges showed high hemostatic activity: upon the application of PVF-samples the bleeding decreased within 3 min by 68.4-94.4% (р < 0.001). The bleeding time upon the application of PVF-based composites decreased by 78.3-90.4% (p < 0.001) compared to the application of well-known commercial product Celox™.
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Affiliation(s)
- O Goncharuk
- Ovcharenko Institute of Biocolloidal Chemistry of National Academy of Sciences of Ukraine, Kyiv, Ukraine; Chuiko Institute of Surface Chemistry of National Academy of Sciences of Ukraine, Kyiv, Ukraine.
| | - O Korotych
- University of Florida, Chemical Engineering Department, Gainesville, United States of America; University of Tennessee, Department of Biochemistry and Cellular and Molecular Biology, Knoxville, TN, United States of America.
| | - Yu Samchenko
- Ovcharenko Institute of Biocolloidal Chemistry of National Academy of Sciences of Ukraine, Kyiv, Ukraine.
| | - L Kernosenko
- Ovcharenko Institute of Biocolloidal Chemistry of National Academy of Sciences of Ukraine, Kyiv, Ukraine
| | - A Kravchenko
- Chuiko Institute of Surface Chemistry of National Academy of Sciences of Ukraine, Kyiv, Ukraine
| | - L Shtanova
- Biology and Medicine Institute Science Educational Center of Taras, Shevchenko National University of Kyiv, Kyiv, Ukraine
| | - O Tsуmbalуuk
- Biology and Medicine Institute Science Educational Center of Taras, Shevchenko National University of Kyiv, Kyiv, Ukraine
| | - T Poltoratska
- Ovcharenko Institute of Biocolloidal Chemistry of National Academy of Sciences of Ukraine, Kyiv, Ukraine
| | - N Pasmurtseva
- Ovcharenko Institute of Biocolloidal Chemistry of National Academy of Sciences of Ukraine, Kyiv, Ukraine
| | - I Mamyshev
- Ovcharenko Institute of Biocolloidal Chemistry of National Academy of Sciences of Ukraine, Kyiv, Ukraine
| | - E Pakhlov
- Chuiko Institute of Surface Chemistry of National Academy of Sciences of Ukraine, Kyiv, Ukraine
| | - O Siryk
- Ovcharenko Institute of Biocolloidal Chemistry of National Academy of Sciences of Ukraine, Kyiv, Ukraine
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Mahmoudabadi S, Farahpour MR, Jafarirad S. Effectiveness of Green Synthesis of Silver/Kaolinite Nanocomposite Using Quercus infectoria Galls Aqueous Extract and Its Chitosan-Capped Derivative on the Healing of Infected Wound. IEEE Trans Nanobioscience 2021; 20:530-542. [PMID: 34406944 DOI: 10.1109/tnb.2021.3105356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Kaolinite nanocomposites (NCs) could be utilized as agents for wound healing owing to their efficiency and low toxicity. The present study was conducted to synthesize a novel silver/kaolinite NCs (Ag/Kaol NCs) and investigate their chitosan derivation (Ag/Kaol/Chit NCs) using oak extract. XRD, SEM, EDX, FT-IR, and DLS were employed for the investigation of structural and physio-chemical properties of the synthesized NCs. The obtained results revealed that synthesized Ag/Kaol NCs were mesoporous and spherical with sizes ranging from 7-11 nm. They also demonstrated successful synthesis between silver and kaolinite using the extract. Cytotoxicity and in vitro antibacterial activity were also investigated. The clinical effects of ointments containing the NCs for improving wound healing were studied on the wound area, total bacterial count, histological parameters, and protein expression of some genes. Nanocomposites were safe up to 0.50 mg/mL. The results of in vivo and in vitro antibacterial activity showed that Ag/Kaol NCs, were of antibacterial activity ( ). The results of antioxidant activity indicated that Ag/Kaol NCs have antioxidant structures. Our findings concerning molecular mechanism implied that Ag/Kaol/Chit increased the expression of Wnt/ β -catenin and collagen ( ). In sum, Ag/Kaol/Chit showed antibacterial activity and improved wound healing by decreasing the inflammation and promoting the proliferative phase. The novel NCs showed wound healing properties by decreasing inflammation and total bacterial count and increasing proliferative phase. The application of Ag/Kaol/Chit was suggested as a green agent for improving infected wound healing.
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Fan X, Li M, Li N, Wan G, Li Y, Ali MA, Tang K. One-step fabrication of chitosan sponge and its potential for rapid hemostasis in deep trauma. Biomed Mater 2020; 16:015010. [PMID: 32698163 DOI: 10.1088/1748-605x/aba878] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In this paper, a facile and efficient preparation strategy for a porous and hydrophilic chitosan sponge is demonstrated, combining a surfactant and a pore-foaming agent. The resulting chitosan sponge possesses an interconnected pore structure and soft texture, exhibits fast water absorption rate and capacity, and the compressed sponge can achieve full shape recovery 5 s after absorbing water. Moreover, our process removes the residual acid commonly found in chitosan sponges prepared by the acid method. In addition, the results demonstrate the useful characteristics of our chitosan sponge, in terms of its contribution to improved blood coagulation, together with its compression strength and biocompatibility. It also demonstrates effective antibacterial properties in relation to both Escherichia coli and Staphylococcus aureus. Further testing via animal experimentation reveals that rapid hemostasis can be achieved within 50 s using our chitosan sponge.
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Zanchetta FC, Trinca RB, Gomes Silva JL, Breder JDSC, Cantarutti TA, Consonni SR, Moraes ÂM, Pereira de Araújo E, Saad MJA, Adams GG, Melo Lima MH. Effects of Electrospun Fibrous Membranes of PolyCaprolactone and Chitosan/Poly(Ethylene Oxide) on Mouse Acute Skin Lesions. Polymers (Basel) 2020; 12:E1580. [PMID: 32708645 PMCID: PMC7408160 DOI: 10.3390/polym12071580] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 01/14/2023] Open
Abstract
Polycaprolactone (PCL) is a synthetic polymer with good mechanical properties that are useful to produce biomaterials of clinical application. It can be successfully combined with chitosan, which enhances the biomaterial properties through the modulation of molecular and cellular mechanisms. The objective of this study was to evaluate the effects of the use of electrospun fibrous membranes consisting of polycaprolactone (PCL) or polycaprolactone coated with chitosan and poly(ethylene oxide) (PCL+CHI/PEO) on mouse skin lesions. Sixty four Black-57 mice were divided into PCL and PCL+CHI/PEO groups. A 1 cm2 lesion was made on the animals' backs, and the membranes were sutured in place. The tissues were extracted on the 3rd, 7th, and 14th days after the lesion. The tissues were analyzed by histology with Hematoxylin and Eosin (H&E) and Sirius Red stains, morphometry, immunohistochemistry, and Western blot. On the 3rd, 6th, and 9th days after the lesion, the PCL+CHI/PEO group showed a higher wound-healing rate (WHR). On the 3 day, the PCL+CHI/PEO group showed a greater amount of inflammatory infiltrate, greater expression of proliferating cell nuclear antigen (PCNA), and smooth muscle actin (α-SMA) (p < 0.05) compared to the PCL group. On the 7th day after the lesion, the PCL+CHI/PEO group showed a greater amount of inflammatory infiltrate, expression of Tumor Necrosis Factor (TNF-α) and PCNA (p < 0.05). In addition, it showed a greater immunolabeling of Monocyte Chemoattractant Protein-1 (MCP-1) and deposition of collagen fibers compared to the PCL group. The PCL+CHI/PEO membrane modulated the increase in the inflammatory infiltrate, the expression of MCP-1, PCNA, and α-SMA in lesions of mice.
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Affiliation(s)
- Flávia Cristina Zanchetta
- School of Nursing, University of Campinas, Campinas CEP 13083887, Brazil; (F.C.Z.); (J.L.G.S.); (J.d.S.C.B.); (T.A.C.); (E.P.d.A.)
| | - Rafael Bergamo Trinca
- Department of Engineering of Materials and of Bioprocess, School of Chemical Engineering, University of Campinas, Campinas CEP 13083852, Brazil; (R.B.T.); (Â.M.M.)
| | - Juliany Lino Gomes Silva
- School of Nursing, University of Campinas, Campinas CEP 13083887, Brazil; (F.C.Z.); (J.L.G.S.); (J.d.S.C.B.); (T.A.C.); (E.P.d.A.)
| | - Jéssica da Silva Cunha Breder
- School of Nursing, University of Campinas, Campinas CEP 13083887, Brazil; (F.C.Z.); (J.L.G.S.); (J.d.S.C.B.); (T.A.C.); (E.P.d.A.)
| | - Thiago Anselmo Cantarutti
- School of Nursing, University of Campinas, Campinas CEP 13083887, Brazil; (F.C.Z.); (J.L.G.S.); (J.d.S.C.B.); (T.A.C.); (E.P.d.A.)
| | - Sílvio Roberto Consonni
- Department of Biochemistry and Tissue Biology, Institute of Biology, University of Campinas, Campinas CEP 13083970, Brazil;
| | - Ângela Maria Moraes
- Department of Engineering of Materials and of Bioprocess, School of Chemical Engineering, University of Campinas, Campinas CEP 13083852, Brazil; (R.B.T.); (Â.M.M.)
| | - Eliana Pereira de Araújo
- School of Nursing, University of Campinas, Campinas CEP 13083887, Brazil; (F.C.Z.); (J.L.G.S.); (J.d.S.C.B.); (T.A.C.); (E.P.d.A.)
| | | | - Gary G. Adams
- School of Health Sciences, Faculty of Medicine, The University of Nottingham, C Floor, South Block Link, Queen’s Medical Centre, Nottingham NG7 2HA, UK
| | - Maria Helena Melo Lima
- School of Nursing, University of Campinas, Campinas CEP 13083887, Brazil; (F.C.Z.); (J.L.G.S.); (J.d.S.C.B.); (T.A.C.); (E.P.d.A.)
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Jun J, Millican RC, Sherwood JA, Tucker BS, Vijayan VM, Alexander GC, Thomas V, Brott BC, Hwang PTJ. Evaluation of Viscoelastic Properties, Blood Coagulation, and Cellular Responses of a Temperature-Sensitive Gel for Hemostatic Application. ACS APPLIED BIO MATERIALS 2020; 3:3137-3144. [DOI: 10.1021/acsabm.0c00160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Joseph Jun
- Neuroscience, College of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Reid C. Millican
- Endomimetics, LLC, 1500 First Avenue North, Birmingham, Alabama 35203, United States
| | - Jennifer A. Sherwood
- Endomimetics, LLC, 1500 First Avenue North, Birmingham, Alabama 35203, United States
| | - Bernabe S. Tucker
- Department of Material Science and Engineering, The University of Alabama at Birmingham, Birmingham, Alabama 35294, United States
| | - Vineeth M. Vijayan
- Department of Material Science and Engineering, The University of Alabama at Birmingham, Birmingham, Alabama 35294, United States
- Center for Nanoscale Materials and Biointegration, The University of Alabama at Birmingham, Birmingham, Alabama 35294, United States
| | - Grant C. Alexander
- Endomimetics, LLC, 1500 First Avenue North, Birmingham, Alabama 35203, United States
| | - Vinoy Thomas
- Department of Material Science and Engineering, The University of Alabama at Birmingham, Birmingham, Alabama 35294, United States
- Center for Nanoscale Materials and Biointegration, The University of Alabama at Birmingham, Birmingham, Alabama 35294, United States
| | - Brigitta C. Brott
- Division of Cardiovascular Disease, Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama 35294, United States
| | - Patrick T. J. Hwang
- Endomimetics, LLC, 1500 First Avenue North, Birmingham, Alabama 35203, United States
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Abstract
Hemorrhage is the leading cause of preventable death in combat trauma and the secondary cause of death in civilian trauma. A significant number of deaths due to hemorrhage occur before and in the first hour after hospital arrival. A literature search was performed through PubMed, Scopus, and Institute of Scientific Information databases for English language articles using terms relating to hemostatic agents, prehospital, battlefield or combat dressings, and prehospital hemostatic resuscitation, followed by cross-reference searching. Abstracts were screened to determine relevance and whether appropriate further review of the original articles was warranted. Based on these findings, this paper provides a review of a variety of hemostatic agents ranging from clinically approved products for human use to newly developed concepts with great potential for use in prehospital settings. These hemostatic agents can be administered either systemically or locally to stop bleeding through different mechanisms of action. Comparisons of current hemostatic products and further directions for prehospital hemorrhage control are also discussed.
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Affiliation(s)
- Henry T Peng
- Defence Research and Development Canada, Toronto Research Centre, 1133 Sheppard Avenue West, Toronto, ON, M3K 2C9, Canada.
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Chen H, Shang X, Yu L, Xiao L, Fan J. Safety evaluation of a low-heat producing zeolite granular hemostatic dressing in a rabbit femoral artery hemorrhage model. J Biomater Appl 2019; 34:988-997. [DOI: 10.1177/0885328219888626] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Hao Chen
- Department of Chemistry, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xiaoqiang Shang
- Department of Chemistry, Zhejiang University, Hangzhou, Zhejiang, China
| | - Lisha Yu
- Department of Chemistry, Zhejiang University, Hangzhou, Zhejiang, China
| | - Liping Xiao
- Department of Chemistry, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jie Fan
- Department of Chemistry, Zhejiang University, Hangzhou, Zhejiang, China
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19
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Affiliation(s)
- Cpt D C Covey
- Department of Orthopaedic Surgery, University of California San Diego, San Diego, California
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20
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Liang Y, Xu C, Liu F, Du S, Li G, Wang X. Eliminating Heat Injury of Zeolite in Hemostasis via Thermal Conductivity of Graphene Sponge. ACS APPLIED MATERIALS & INTERFACES 2019; 11:23848-23857. [PMID: 31245992 DOI: 10.1021/acsami.9b04956] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Thermal release of zeolite is conducive in hemostasis, but losing control will cause serious burns. How to balance the advantages and disadvantages is a challenge. Herein, a zeolite/cross-linked graphene sponge (Z-CGS) was design to break through this challenge. The CGS managed the heat release of zeolite by thermal conduction of graphene. Infrared thermal imager demonstrated the mild exothermic process and good thermal conductivity of the optimized Z-CGS. It controlled wound temperature below 42 °C effectively, as compared to 70 °C of naked zeolite. Blood clotting index further confirmed the contribution of thermal stimulation in Z-CGS. On the synergy of thermal and charge stimulations of zeolite, as well as physical adsorption of CGS, Z-CGS achieved outstanding hemostatic performance. Bleeding was stopped within 69 s in rat artery injury model, faster than that of the Quikclot Combat Gauze. Additionally, cytotoxicity assay and pathological analysis highlighted its biocompatibility. Z-CGS, therefore, was an outstanding composite of combining advantages of zeolite and graphene, while getting rid of the shortcomings of the basic unit. The thermal conductibility of graphene renews an avenue for the safe and highly efficient use of zeolite in hemostasis.
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Affiliation(s)
- Yuping Liang
- Beijing Laboratory of Biomedical Materials , Beijing University of Chemical Technology , Beijing 100029 , P. R. China
| | - Congcong Xu
- Beijing Laboratory of Biomedical Materials , Beijing University of Chemical Technology , Beijing 100029 , P. R. China
| | - Fang Liu
- Department of Gastroenterology , China-Japan Friendship Hospital , Beijing 100029 , P. R. China
| | - Shiyu Du
- Department of Gastroenterology , China-Japan Friendship Hospital , Beijing 100029 , P. R. China
| | - Guofeng Li
- Beijing Laboratory of Biomedical Materials , Beijing University of Chemical Technology , Beijing 100029 , P. R. China
- Key Laboratory of Biomedical Materials of Natural Macromolecules , Beijing University of Chemical Technology, Ministry of Education , Beijing 100029 , P. R. China
| | - Xing Wang
- Beijing Laboratory of Biomedical Materials , Beijing University of Chemical Technology , Beijing 100029 , P. R. China
- Key Laboratory of Biomedical Materials of Natural Macromolecules , Beijing University of Chemical Technology, Ministry of Education , Beijing 100029 , P. R. China
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Welch M, Barratt J, Peters A, Wright C. Systematic review of prehospital haemostatic dressings. BMJ Mil Health 2019; 166:194-200. [DOI: 10.1136/jramc-2018-001066] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/03/2019] [Accepted: 01/10/2019] [Indexed: 11/04/2022]
Abstract
IntroductionHaemorrhage is one of the leading causes of battlefield and prehospital death. Haemostatic dressings are an effective method of limiting the extent of bleeding and are used by military forces extensively. A systematic review was conducted with the aim of collating the evidence on current haemostatic products and to assess whether one product was more effective than others.MethodsA systematic search and assessment of the literature was conducted using 13 health research databases including MEDLINE and CINAHL, and a grey literature search. Two assessors independently screened the studies for eligibility and quality. English language studies using current-generation haemostatic dressings were included. Surgical studies, studies that did not include survival, initial haemostasis or rebleeding and those investigating products without prehospital potential were excluded.Results232 studies were initially found and, after applying exclusion criteria, 42 were included in the review. These studies included 31 animal studies and 11 clinical studies. The outcomes assessed were subject survival, initial haemostasis and rebleeding. A number of products were shown to be effective in stopping haemorrhage, with Celox, QuikClot Combat Gauze and HemCon being the most commonly used, and with no demonstrable difference in effectiveness.ConclusionsThere was a lack of high-quality clinical evidence with the majority of studies being conducted using a swine haemorrhage model. Iterations of three haemostatic dressings, Celox, HemCon and QuikClot, dominated the studies, probably because of their use by international military forces and all were shown to be effective in the arrest of haemorrhage.
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Winstanley M, Smith JE, Wright C. Catastrophic haemorrhage in military major trauma patients: a retrospective database analysis of haemostatic agents used on the battlefield. J ROY ARMY MED CORPS 2018; 165:405-409. [DOI: 10.1136/jramc-2018-001031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/19/2018] [Accepted: 08/20/2018] [Indexed: 11/04/2022]
Abstract
ObjectivesCatastrophic haemorrhage is a leading cause of morbidity and mortality in trauma, in both military and civilian settings. There are numerous studies looking at the effectiveness of different haemostatic agents in the laboratory but few in a clinical setting. This study analyses the use of haemostatic dressings used in patients injured on the battlefield and their association with survival.MethodA retrospective database review was undertaken using the UK Joint Theatre Trauma Registry from 2003 to 2014, during combat operations in Iraq and Afghanistan. Data included patient demographics, the use of haemostatic dressings, New Injury Severity Score (NISS) and patient outcome.ResultsOf 3792 cases, a haemostatic dressing was applied in 317 (either Celox, Hemcon or Quickclot). When comparing patients who had a haemostatic dressing applied versus no haemostatic agent, there was a 7% improvement in survival. Celox was the only individual haemostatic dressing that was associated with a statistically significant improvement in survival, which was most apparent in the more severely injured (NISS 36–75).ConclusionWe have shown an association between use of haemostatic agents and improved survival, mostly in those with more severe injuries, which is particularly evident in those administered Celox. This supports the continued use of haemostatic agents as part of initial haemorrhage control for patients injured in conflict and suggests that civilian organisations that may need to deal with patients with similar injury patterns should consider their use and implementation.
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Boulton AJ, Lewis CT, Naumann DN, Midwinter MJ. Prehospital haemostatic dressings for trauma: a systematic review. Emerg Med J 2018; 35:449-457. [PMID: 29728411 DOI: 10.1136/emermed-2018-207523] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/07/2018] [Accepted: 04/13/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Haemorrhage is a major cause of mortality and morbidity following both military and civilian trauma. Haemostatic dressings may offer effective haemorrhage control as part of prehospital treatment. AIM To conduct a systematic review of the clinical literature to assess the prehospital use of haemostatic dressings in controlling traumatic haemorrhage, and determine whether any haemostatic dressings are clinically superior. METHODS MEDLINE and EMBASE databases were searched using predetermined criteria. The reference lists of all returned review articles were screened for eligible studies. Two authors independently undertook the search, performed data extraction, and risk of bias and Grading of Recommendations, Assessment, Development and Evaluation quality assessments. Meta-analysis could not be undertaken due to study and clinical heterogeneity. RESULTS Our search yielded 470 studies, of which 17 met eligibility criteria, and included 809 patients (469 military and 340 civilian). There were 15 observational studies, 1 case report and 1 randomised controlled trial. Indications for prehospital haemostatic dressing use, wound location, mechanism of injury, and source of bleeding were variable. Seven different haemostatic dressings were reported with QuikClot Combat Gauze being the most frequently applied (420 applications). Cessation of bleeding ranged from 67% to 100%, with a median of 90.5%. Adverse events were only reported with QuikClot granules, resulting in burns. No adverse events were reported with QuikClot Combat Gauze use in three studies. Seven of the 17 studies did not report safety data. All studies were at risk of bias and assessed of 'very low' to 'moderate' quality. CONCLUSIONS Haemostatic dressings offer effective prehospital treatment for traumatic haemorrhage. QuikClot Combat Gauze may be justified as the optimal agent due to the volume of clinical data and its safety profile, but there is a lack of high-quality clinical evidence, and randomised controlled trials are warranted. LEVEL OF EVIDENCE Systematic review, level IV.
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Affiliation(s)
- Adam J Boulton
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - David N Naumann
- NIHR Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Birmingham, UK
| | - Mark J Midwinter
- Faculty of Medicine, School of Biomedical Sciences, University of Queensland, Brisbane, Queensland, Australia
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A Biodegradable Hemostatic Gelatin/Polycaprolactone Composite for Surgical Hemostasis. Ann Plast Surg 2017; 78:S124-S128. [PMID: 28195889 DOI: 10.1097/sap.0000000000001017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Massive bleeding is the leading cause of battlefield-related deaths and the second leading cause of deaths in civilian trauma centers. One of the challenges of managing severe wounds is the need to promote hemostasis as quickly as possible, which can be achieved by using hemostatic dressings. In this study, we fabricated 2 kinds of gelatin/polycaprolactone composites with 2 ratios of gelatin/polycaprolactone, 1:1 and 2:1 (GP11 and GP21, respectively). Scanning electron microscopy revealed that the GP11 composite exhibited rougher and more porous structure than the GP21 composite did. Furthermore, both composites showed similar biocompatibility as that of tissue culture polystyrene. Moreover, both GP composites tended to show a gradual decrease in contact angle to zero within 40 minutes. The in vitro blood plasma coagulation assay revealed that the prothrombin time was significantly longer for the GP composites than it was for the Quikclot composite, whereas the activated partial thromboplastin time of the GP11 composite was significantly shorter than that of the gauze. Furthermore, the GP11 had the largest platelet adsorption of all the composites. The in vivo coagulation test showed an obvious shortening of the bleeding time with the Quikclot and GP21 compared with gauze sample. In conclusion, the GP composites showed superior biocompatibility and hemostasis to the gauze and comparable effects with the Qickclot composite. Therefore, the GP composites have the potential for development as biodegradable surgical hemostatic agents.
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Sen Gupta A. Bio-inspired nanomedicine strategies for artificial blood components. WILEY INTERDISCIPLINARY REVIEWS. NANOMEDICINE AND NANOBIOTECHNOLOGY 2017; 9:10.1002/wnan.1464. [PMID: 28296287 PMCID: PMC5599317 DOI: 10.1002/wnan.1464] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 01/23/2017] [Accepted: 01/29/2017] [Indexed: 11/12/2022]
Abstract
Blood is a fluid connective tissue where living cells are suspended in noncellular liquid matrix. The cellular components of blood render gas exchange (RBCs), immune surveillance (WBCs) and hemostatic responses (platelets), and the noncellular components (salts, proteins, etc.) provide nutrition to various tissues in the body. Dysfunction and deficiencies in these blood components can lead to significant tissue morbidity and mortality. Consequently, transfusion of whole blood or its components is a clinical mainstay in the management of trauma, surgery, myelosuppression, and congenital blood disorders. However, donor-derived blood products suffer from issues of shortage in supply, need for type matching, high risks of pathogenic contamination, limited portability and shelf-life, and a variety of side-effects. While robust research is being directed to resolve these issues, a parallel clinical interest has developed toward bioengineering of synthetic blood substitutes that can provide blood's functions while circumventing the above problems. Nanotechnology has provided exciting approaches to achieve this, using materials engineering strategies to create synthetic and semi-synthetic RBC substitutes for enabling oxygen transport, platelet substitutes for enabling hemostasis, and WBC substitutes for enabling cell-specific immune response. Some of these approaches have further extended the application of blood cell-inspired synthetic and semi-synthetic constructs for targeted drug delivery and nanomedicine. The current study provides a comprehensive review of the various nanotechnology approaches to design synthetic blood cells, along with a critical discussion of successes and challenges of the current state-of-art in this field. WIREs Nanomed Nanobiotechnol 2017, 9:e1464. doi: 10.1002/wnan.1464 For further resources related to this article, please visit the WIREs website.
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Affiliation(s)
- Anirban Sen Gupta
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
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26
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Awad ME, López-Galindo A, Setti M, El-Rahmany MM, Iborra CV. Kaolinite in pharmaceutics and biomedicine. Int J Pharm 2017; 533:34-48. [DOI: 10.1016/j.ijpharm.2017.09.056] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 09/18/2017] [Accepted: 09/19/2017] [Indexed: 12/29/2022]
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Basu A, Hong J, Ferraz N. Hemocompatibility of Ca2+
-Crosslinked Nanocellulose Hydrogels: Toward Efficient Management of Hemostasis. Macromol Biosci 2017; 17. [DOI: 10.1002/mabi.201700236] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/10/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Alex Basu
- Nanotechnology and Functional Materials; Department of Engineering Sciences; Uppsala University; Box 534 75121 Uppsala Sweden
| | - Jaan Hong
- Department of Immunology; Genetics and Pathology; Rudbeck Laboratory C5; Uppsala University; 75185 Uppsala Sweden
| | - Natalia Ferraz
- Nanotechnology and Functional Materials; Department of Engineering Sciences; Uppsala University; Box 534 75121 Uppsala Sweden
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Wijesuriya JD, Keogh S. Integrated major haemorrhage management in the retrieval setting: Damage control resuscitation from referral to receiving facility. Emerg Med Australas 2017; 29:470-475. [DOI: 10.1111/1742-6723.12742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 10/19/2016] [Accepted: 12/14/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Julian D Wijesuriya
- Central London School of Anaesthesia and Intensive Care Medicine; Royal Free Hospital; London UK
| | - Sean Keogh
- Faculty of Science, Health, Education and Engineering, University of the Sunshine Coast; Maroochydore Queensland Australia
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Abstract
To report the use and describe the interest of hemostatic dressings in a civilian setting, we provided medical prehospital teams with QuikClot Combat Gauze (QCG) and asked physicians to complete a specific questionnaire after each use. Thirty uses were prospectively reported. The wounds were mostly caused by cold steel (n=15) and were primarily cervicocephalic (n=16), with 19/30 active arterial bleedings. For 26/30 uses, hemostatic dressing was justified by the inefficiency of other hemostasis techniques. Those 30 applications were associated with 22 complete cessations of bleeding, six decreases of bleeding, and ineffectiveness in two cases. The application of QCG permitted the removal of an effective tourniquet that was applied initially for three patients. No side-effects were reported. The provision of hemostatic dressings in civilian resuscitation ambulances was useful by providing an additional tool to limit bleeding while rapidly transporting the injured patient to a surgical facility.
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Bleeding Control Using Hemostatic Dressings: Lessons Learned. Wilderness Environ Med 2017; 28:S39-S49. [DOI: 10.1016/j.wem.2016.12.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 09/21/2016] [Accepted: 12/06/2016] [Indexed: 11/20/2022]
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Zhou X, Zhang X, Zhou J, Li L. An investigation of chitosan and its derivatives on red blood cell agglutination. RSC Adv 2017. [DOI: 10.1039/c6ra27417j] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
RBC agglutination was determined by the number of protonated amine groups on chitosan and its derivatives.
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Affiliation(s)
- Xuan Zhou
- Beijing Key Laboratory of Energy Conversion and Storage Materials
- College of Chemistry
- Beijing Normal University
- Beijing 100875
- China
| | - Xinshuo Zhang
- Beijing Key Laboratory of Energy Conversion and Storage Materials
- College of Chemistry
- Beijing Normal University
- Beijing 100875
- China
| | - Jianjun Zhou
- Beijing Key Laboratory of Energy Conversion and Storage Materials
- College of Chemistry
- Beijing Normal University
- Beijing 100875
- China
| | - Lin Li
- Beijing Key Laboratory of Energy Conversion and Storage Materials
- College of Chemistry
- Beijing Normal University
- Beijing 100875
- China
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Qian Z, Wang H, Tuo X, Guo H, Xu P, Liu D, Wei Y, Liu H, Fan Y, Guo X. A porous sodium polyacrylate-grafted chitosan xerogel for severe hemorrhage control synthesized from one-pot reaction. J Mater Chem B 2017; 5:4845-4851. [PMID: 32264000 DOI: 10.1039/c7tb00802c] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In this study, we fabricated a SPA-co-CTS sponge and demonstrated a fast and powerful hemostatic effect bothin vitroandin vivo, which was a promising first-aid device for severe hemorrhage control.
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Affiliation(s)
- Zhiyong Qian
- School of Biological Science and Medical Engineering
- Beihang University
- Beijing
- China
- Department of Advanced Interdisciplinary Studies
| | - Haiping Wang
- Department of Transfusion
- 307 Hospital of Chinese PLA
- Beijing
- P. R. China
| | - Xiaoye Tuo
- Department of Burns and Plastic Surgery
- First Affiliated Hospital of PLA General Hospital
- Beijing
- P. R. China
| | - Hongyan Guo
- Stomatology Center
- General Hospital of Armed Police Forces
- Beijing
- P. R. China
| | - Peng Xu
- Stomatology Center
- General Hospital of Armed Police Forces
- Beijing
- P. R. China
| | - Donghua Liu
- Department of Advanced Interdisciplinary Studies
- Institute of Basic Medical Sciences
- Beijing
- P. R. China
| | - Yen Wei
- Department of Chemistry
- Tsinghua University
- Beijing
- P. R. China
| | - Haifeng Liu
- School of Biological Science and Medical Engineering
- Beihang University
- Beijing
- China
| | - Yubo Fan
- School of Biological Science and Medical Engineering
- Beihang University
- Beijing
- China
| | - Ximin Guo
- Department of Advanced Interdisciplinary Studies
- Institute of Basic Medical Sciences
- Beijing
- P. R. China
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Structural Alteration in Dermal Vessels and Collagen Bundles following Exposure of Skin Wound to Zeolite-Bentonite Compound. JOURNAL OF PHARMACEUTICS 2016; 2016:5843459. [PMID: 28116221 PMCID: PMC5225390 DOI: 10.1155/2016/5843459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 11/21/2016] [Accepted: 11/27/2016] [Indexed: 11/17/2022]
Abstract
Background. This study examines the impact of one-time direct application of haemostatic agent zeolite–bentonite powder to wounded skin on the healing process in rats. Materials and Methods. 24 male Sprague-Dawley rats were randomly allocated into two groups (n = 12): (1) the rats whose wounds were washed only with sterile normal saline (NS-treated) and (2) those treated with zeolite–bentonite compound (ZEO-treated). The wound was circular, full-thickness, and 2 cm in diameter. At the end of the 12th day, six animals from each group were randomly selected and terminated. The remaining rats were terminated after 21 days. Just after scarification, skin samples were excised and sent for stereological evaluation. Results. The results showed a significant difference between the two groups regarding the length density of the blood vessels and diameter of the large and small vessels on the 12th day after the wound was inflicted. Besides, volume density of both the dermis and collagen bundles was reduced by 25% in the ZEO-treated rats in comparison to the NS-treated animals after 21 days. Conclusions. One-time topical usage of zeolite–bentonite haemostatic powder on an animal skin wound might negatively affect the healing process through vasoconstriction and inhibition of neoangiogenesis.
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Rajabian MH, Ghorabi GH, Geramizadeh B, Sameni S, Ayatollahi M. Evaluation of bone marrow derived mesenchymal stem cells for full-thickness wound healing in comparison to tissue engineered chitosan scaffold in rabbit. Tissue Cell 2016; 49:112-121. [PMID: 27865438 DOI: 10.1016/j.tice.2016.11.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 10/30/2016] [Accepted: 11/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Chronic wounds present a major challenge in modern medicine. Even under optimal conditions, the healing process may lead to scarring and fibrosis. The ability of mesenchymal stem cells (MSCs) to differentiate into other cell types makes these cells an attractive therapeutic tool for cell transplantation. Both tissue-engineered construct and MSC therapy are among the current wound healing procedures and potential care. Chitosan has been widely applied in tissue engineering because of its biocompatibility and biodegradability. AIM The aim of the current work was to compare the efficiency of MSCs and chitosan dressing, alone or in combination treatment on wound healing. METHODS This study was conducted on 15 rabbits, which were randomly divided in 3 groups based on the type of treatment with MSCs, chitosan dressing and combination of both. A full-thickness skin defect was excised from the right and left side of the back of each animals. Defects on right sides were filled with treatments and left side defects were left as control. Evaluation of the therapeutic effectiveness was performed through a variety of clinical and microscopical evaluations and measurements of the process of wound healing on days 7, 14, 21, and 28. Histological evaluation of wound healing was classified by different scoring systems. RESULTS The data indicated that wounds treated with bone marrow derived MSC had enhanced cellularity and better epidermal regeneration. During the early stages of wound healing, the closure rate of bone marrow derived MSC-treated wounds were significantly higher than other treatments (P<0.05). Although the MSCs in the wound edges enhance the healing of the full-thickness wound, the healing process of chitosan treatment was slower than the control group. CONCLUSION This study revealed advanced granulation tissue formation and epithelialization in wounds treated with MSCs, and may suggests this treatment as an effective applicant in wound healing process. Chitosan scaffold dressings, whether alone or in combination with MSCs, have worsened the wound healing as compared to the control group.
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Affiliation(s)
| | | | - Bita Geramizadeh
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Safoura Sameni
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Biochemistry, Shiraz Branch, Islamic Azad University, Shiraz, Iran.
| | - Maryam Ayatollahi
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Stem Cell Institute for Cell Therapy & Regenerative Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
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Travan A, Scognamiglio F, Borgogna M, Marsich E, Donati I, Tarusha L, Grassi M, Paoletti S. Hyaluronan delivery by polymer demixing in polysaccharide-based hydrogels and membranes for biomedical applications. Carbohydr Polym 2016; 150:408-18. [DOI: 10.1016/j.carbpol.2016.03.088] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/14/2016] [Accepted: 03/29/2016] [Indexed: 02/08/2023]
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van Oostendorp SE, Tan ECTH, Geeraedts LMG. Prehospital control of life-threatening truncal and junctional haemorrhage is the ultimate challenge in optimizing trauma care; a review of treatment options and their applicability in the civilian trauma setting. Scand J Trauma Resusc Emerg Med 2016; 24:110. [PMID: 27623805 PMCID: PMC5022193 DOI: 10.1186/s13049-016-0301-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 09/01/2016] [Indexed: 01/15/2023] Open
Abstract
Introduction Exsanguination following trauma is potentially preventable. Extremity tourniquets have been successfully implemented in military and civilian prehospital care. Prehospital control of bleeding from the torso and junctional area’s remains challenging but offers a great potential to improve survival rates. This review aims to provide an overview of potential treatment options in both clinical as preclinical state of research on truncal and junctional bleeding. Since many options have been developed for application in the military primarily, translation to the civilian situation is discussed. Methods Medline (via Pubmed) and Embase were searched to identify known and potential prehospital treatment options. Search terms were|: haemorrhage/hemorrhage, exsanguination, junctional, truncal, intra-abdominal, intrathoracic, intervention, haemostasis/hemostasis, prehospital, en route, junctional tourniquet, REBOA, resuscitative thoracotomy, emergency thoracotomy, pelvic binder, pelvic sheet, circumferential. Treatment options were listed per anatomical site: axilla, groin, thorax, abdomen and pelvis Also, the available evidence was graded in (pre) clinical stadia of research. Results Identified treatment options were wound clamps, injectable haemostatic sponges, pelvic circumferential stabilizers, resuscitative thoracotomy, resuscitative endovascular balloon occlusion of the aorta (REBOA), intra-abdominal gas insufflation, intra-abdominal self-expanding foam, junctional and truncal tourniquets. A total of 70 papers on these aforementioned options was retrieved. No clinical reports on injectable haemostatic sponges, intra-abdominal insufflation or self-expanding foam injections and one type of junctional tourniquets were available. Conclusion Options to stop truncal and junctional traumatic haemorrhage in the prehospital arena are evolving and may offer a potentially great survival advantage. Because of differences in injury pattern, time to definitive care, different prehospital scenario’s and level of proficiency of care providers; successful translation of various military applications to the civilian situation has to be awaited. Overall, the level of evidence on the retrieved adjuncts is extremely low.
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Affiliation(s)
- S E van Oostendorp
- Department of Trauma Surgery, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - E C T H Tan
- Department of Trauma Surgery and Helicopter Emergency Medical Service, Radboud University Medical Center, Nijmegen, The Netherlands.,Royal Netherlands Army, Utrecht, The Netherlands
| | - L M G Geeraedts
- Department of Trauma Surgery, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
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Assessment of trauma patients. Int J Orthop Trauma Nurs 2016; 21:21-30. [DOI: 10.1016/j.ijotn.2015.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/06/2015] [Accepted: 10/12/2015] [Indexed: 11/17/2022]
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Khoshmohabat H, Paydar S, Kazemi HM, Dalfardi B. Overview of Agents Used for Emergency Hemostasis. Trauma Mon 2016; 21:e26023. [PMID: 27218055 PMCID: PMC4869418 DOI: 10.5812/traumamon.26023] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 04/19/2015] [Accepted: 05/25/2015] [Indexed: 12/12/2022] Open
Abstract
CONTEXT In today's modern world, despite the multiple advances made in the field of medicine, hemorrhagic shock is still the main cause of battlefield mortality and the second most prevalent cause of mortality in civilian trauma. Hemostatic agents can play a key role in establishing hemostasis in prehospital situations and preventing hemorrhage-associated death. In this respect, this article aims to review different aspects of known hemostatic agents. EVIDENCE ACQUISITION A comprehensive search of the academic scientific databases for relevant keywords was conducted; relevant articles were compiled and assessed. RESULTS Hemostatic agents can establish hemostasis by means of different mechanisms, including concentrating coagulation factors, adhesion to the tissues, in which traumatic hemorrhage occurred, and delivering procoagulant factors to the hemorrhage site. Presently, these hemostatics have been significantly improved with regard to efficacy and in adverse consequences, resulting from their use. Several hemostatic dressings have been developed to the degree that they have received FDA approval and are being used practically on the battlefield. In addition, there are currently several case reports on the use of such hemostatics in the hospital setting, in conditions where commonly known approaches fail to stop life-threatening bleeding. CONCLUSIONS The use of hemostatic dressings and agents is one of the main advancements achieved in recent decades. However, it can be claimed that the ideal hemostatic has not been recognized yet; therefore, this topic needs to be brought into focus and further addressed.
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Affiliation(s)
- Hadi Khoshmohabat
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Shahram Paydar
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Department of General Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | | | - Behnam Dalfardi
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding author: Behnam Dalfardi, Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, IR Iran. Tel: +98-9132483359, Fax: +98-7136254206, E-mail:
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Abstract
Although most extremity hemorrhage from trauma can be controlled with direct pressure and/or pressure dressings, the occasional uncontrolled hemorrhage can be life threatening. Tools that may be able to control such life-threatening extremity hemorrhage include hemostatic dressings, tourniquets, and several new devices that have recently become available. Hemostatic dressings, a relatively new concept, incorporate materials that increase coagulation into a dressing that is applied directly to the wound. Although the use of tourniquets has a long history, recent military conflicts have provided numerous studies that supported and refined their use. The novel extremity hemorrhage control devices effectively control bleeding in one of several ways: direct compression, arterial compression above the level of injury, and sealing the wounds’ edges, creating a hematoma.
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Affiliation(s)
- Michael W. Day
- Michael W. Day is a trauma clinical practice specialist at Northeast Georgia Medical Center in Gainesville, Georgia
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40
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Chan LW, Kim CH, Wang X, Pun SH, White NJ, Kim TH. PolySTAT-modified chitosan gauzes for improved hemostasis in external hemorrhage. Acta Biomater 2016; 31:178-185. [PMID: 26593785 DOI: 10.1016/j.actbio.2015.11.017] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/26/2015] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Abstract
Positively-charged chitosan gauzes stop bleeding from wounds by electrostatically interacting with negatively-charged cell membranes of erythrocytes to cause erythrocyte agglutination and by sealing wounds through tissue adhesion. In the following work, nonwoven chitosan gauze was impregnated with PolySTAT, a synthetic polymer that enhances coagulation by cross-linking fibrin, to generate PolySTAT/chitosan gauzes with improved hemostatic efficacy. When comparing nonwoven chitosan and PolySTAT/chitosan to a commercially-available chitosan-containing gauze (Celox® Rapid), no appreciable differences were observed in fiber size, morphology, and pore size. However, PolySTAT/chitosan demonstrated more rapid blood absorption compared to Celox® Rapid. In a rat model of femoral artery injury, PolySTAT/chitosan gauzes reduced blood loss and improved survival rate compared to non-hemostatic controls and Celox® Rapid. While Celox® Rapid had stronger adherence to tissues compared to PolySTAT/chitosan gauzes, blood loss was greater due to hematoma formation under the Celox® dressing. Animals treated with PolySTAT/chitosan gauzes required less saline infusion to restore and maintain blood pressure above the target blood pressure (60mmHg) while other treatment groups required more saline due to continued bleeding from the wound. These results suggest that PolySTAT/chitosan gauzes are able to improve blood clotting and withstand increasing arterial pressure with the addition of a fibrin cross-linking hemostatic mechanism. STATEMENT OF SIGNIFICANCE Blood loss remains one of the leading causes of death after traumatic injury in civilian populations and on the battlefield. Advanced biomaterials that interact with blood components and/or accelerate the clotting process to form a hemostatic plug are necessary to staunch bleeding after injury. Chitosan-based gauzes, which stop bleeding by causing red blood cell aggregation, are currently used on the battlefield and have shown variable performance under high pressure arterial blood flow in animal studies, suggesting that red blood cell aggregates require further mechanical stabilization for more reliable performance. In this work, we investigate the binding and cross-linking of fibrin, a major component in blood clots, on chitosan gauze fiber surfaces to structurally reinforce red blood cell aggregates.
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Pourshahrestani S, Zeimaran E, Djordjevic I, Kadri NA, Towler MR. Inorganic hemostats: The state-of-the-art and recent advances. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2016; 58:1255-68. [DOI: 10.1016/j.msec.2015.09.008] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 09/03/2015] [Indexed: 11/30/2022]
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Abstract
Pre-hospital care is emergency medical care given to patients before arrival in hospital after activation of emergency medical services. It traditionally incorporated a breadth of care from bystander resuscitation to statutory emergency medical services treatment and transfer. New concepts of care including community paramedicine, novel roles such as emergency care practitioners, and physician delivered pre-hospital emergency medicine are re-defining the scope of pre-hospital care. For severely ill or injured patients, acting quickly in the pre-hospital period is crucial with decisions and interventions greatly affecting outcomes. The transfer of skills and procedures from hospital care to pre-hospital medicine enables early advanced care across a range of disciplines. The variety of possible pathologies, challenges of environmental factors, and hazardous situations requires management that is tailored to the patient's clinical need and setting. Pre-hospital clinicians should be generalists with a broad understanding of medical, surgical, and trauma pathologies, who will often work from locally developed standard operating procedures, but who are able to revert to core principles. Pre-hospital emergency medicine consists of not only clinical care, but also logistics, rescue competencies, and scene management skills (especially in major incidents, which have their own set of management principles). Traditionally, research into the hyper-acute phase (the first hour) of disease has been difficult, largely because physicians are rarely present and issues of consent, transport expediency, and resourcing of research. However, the pre-hospital phase is acknowledged as a crucial period, when irreversible pathology and secondary injury to neuronal and cardiac tissue can be prevented. The development of pre-hospital emergency medicine into a sub-specialty in its own right should bring focus to this period of care.
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Affiliation(s)
- Mark H Wilson
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK; St Mary's Major Trauma Centre, Imperial College, London, UK.
| | - Karel Habig
- Greater Sydney HEMS Service, Sydney, Australia
| | | | - Amy Hughes
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK
| | - Gareth Davies
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, London, UK
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Panteli M, Pountos I, Giannoudis PV. Pharmacological adjuncts to stop bleeding: options and effectiveness. Eur J Trauma Emerg Surg 2015; 42:303-10. [PMID: 26660675 PMCID: PMC4886148 DOI: 10.1007/s00068-015-0613-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 11/29/2022]
Abstract
Severe trauma and massive haemorrhage represent the leading cause of death and disability in patients under the age of 45 years in the developed world. Even though much advancement has been made in our understanding of the pathophysiology and management of trauma, outcomes from massive haemorrhage remain poor. This can be partially explained by the development of coagulopathy, acidosis and hypothermia, a pathological process collectively known as the “lethal triad” of trauma. A number of pharmacological adjuncts have been utilised to stop bleeding, with a wide variation in the safety and efficacy profiles. Antifibrinolytic agents in particular, act by inhibiting the conversion of plasminogen to plasmin, therefore decreasing the degree of fibrinolysis. Tranexamic acid, the most commonly used antifibrinolytic agent, has been successfully incorporated into most trauma management protocols effectively reducing mortality and morbidity following trauma. In this review, we discuss the current literature with regard to the management of haemorrhage following trauma, with a special reference to the use of pharmacological adjuncts. Novel insights, concepts and treatment modalities are also discussed.
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Affiliation(s)
- M Panteli
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.
| | - I Pountos
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK
| | - P V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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Abstract
PURPOSE OF REVIEW Death from exsanguinating hemorrhage remains a priority in the management of combat casualties and civilian trauma patients with truncal and junctional injuries. Appropriate use of hemostatic agents and dressings in the prehospital setting may allow for earlier control and an improved survival rate. RECENT FINDINGS Third-generation chitosan-based hemostatic agents and dressings appear to be equally efficacious to the dressing currently deployed by the US military forces in the management of hemorrhage not amenable to tourniquet placement. Unfortunately, a lack of clinical trials places a heavy reliance on anecdotal reports and laboratory studies in agent selection and application. SUMMARY Efficacy of currently available hemostatic agents and dressings appears to have plateaued in recent years although new agents and delivery mechanisms under development may improve control in cases of severe hemorrhage.
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Derkenne C, Demaison X, Martinez JY, David JS. Apports de la médecine de l’avant militaire en situation préhospitalière civile. ANNALES FRANCAISES DE MEDECINE D URGENCE 2015. [DOI: 10.1007/s13341-015-0569-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Khoshmohabat H, Dalfardi B, Dehghanian A, Rasouli HR, Mortazavi SMJ, Paydar S. The effect of CoolClot hemostatic agent on skin wound healing in rats. J Surg Res 2015; 200:732-7. [PMID: 26363805 DOI: 10.1016/j.jss.2015.08.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/06/2015] [Accepted: 08/14/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND Hemostatic agents can play a key role in controlling severe hemorrhage after trauma. Previously, some criteria have been defined for improving the quality of these products; one of them is that the hemostat causes no further tissue injury. CoolClot is a recently introduced hemostatic agent that its effects on wound healing have not yet been examined, which this study aims to address. MATERIALS AND METHODS Thirty-four adult male Sprague-Dawley rats were assigned randomly to two groups (n = 17): a study group where CoolClot hemostatic agent was applied on their wounds, and a control group whose wounds were washed only with sterile saline. The rats underwent dorsal full-thickness skin excisional wounds (20 mm diameter). On day 12 after wounding, seven rats were chosen in a random manner from each of the groups of study and control, and their skin biopsies from the wound sites were sent for histologic examination. Skin samples of the remaining rats in each group were taken on the 21st d after wound creation. Wound healing was also monitored photographically. In addition, wound surface temperature after wounding, and the application of CoolClot was recorded. RESULTS There was no significant difference between the groups of study and control regarding the examined histopathologic parameters. The maximum increase in wound surface temperature was 1.56°C. CONCLUSIONS One-time topical usage of CoolClot has no significant negative effect on the wound healing process. In addition, no significant increase in wound surface temperature will occur after the application of this agent.
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Affiliation(s)
- Hadi Khoshmohabat
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Behnam Dalfardi
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran; Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Amirreza Dehghanian
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran; Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Rasouli
- Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Javad Mortazavi
- Medical Physics Department, School of Medicine, Ionizing and Non-ionizing Radiation Protection Research Center (INIRPRC), Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Paydar
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran; Department of General Surgery, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Navarro A, Brooks A. Use of local pro-coagulant haemostatic agents for intra-cavity control of haemorrhage after trauma. Eur J Trauma Emerg Surg 2014; 41:493-500. [PMID: 26037982 DOI: 10.1007/s00068-014-0441-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 07/28/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Uncontrolled haemorrhage as a result of trauma remains a significant surgical challenge, accounting for approximately 25-40% of trauma-related mortality. A wide range of local internal haemostatic agents have been developed to help achieve intra-cavity control of bleeding, with choice of agent influenced by the circumstances and nature of the haemorrhage. Trauma patients are frequently coagulopathic, so products that incorporate pro-coagulant technology and thereby act independently of the clotting cascade may be more effective in these settings. A range of products that utilise thrombin and fibrinogen to promote local haemostasis at intra-cavity bleeding points are available or in development, including fibrin glues (e.g. Tisseel®/Tissucol® and Evicel®/Crosseal®/Quixil®), fibrin sealant patches (e.g. TachoSil®) and products based on a gelatin-thrombin haemostatic matrix (e.g. FloSeal®). MATERIALS AND METHODS This systematic review was performed to assess all peer-reviewed evidence of product efficacy. RESULTS Fibrin sealant patches have shown haemostatic efficacy in a variety of surgical procedures and appear to offer practical advantages over liquid fibrin glues. Existing evidence suggests that patch products enable delivery of pro-coagulants to defined areas with less chance of dilution and/or displacement by blood flow, but they require a pressure buttress for a suitable amount of time to achieve good results after trauma. CONCLUSIONS Our experience, supported by other reports in the literature, suggests the use of such fibrin patches may provide an effective option in helping to control haemorrhage after trauma. However, there is a general paucity of clinical data for intra-cavity haemostatic agent use, with the majority of data being based on animal models and case reports. Further clinical evidence, ideally including comparative studies between different agents, would be beneficial in helping guide surgeon choice to the most appropriate products to use in trauma settings.
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Affiliation(s)
- A Navarro
- Hepatobiliary Surgery and Major Trauma, Nottingham University Hospitals NHS Trust and East Midlands Major Trauma Centre, Nottingham, UK.
| | - A Brooks
- Hepatobiliary Surgery and Major Trauma, Nottingham University Hospitals NHS Trust and East Midlands Major Trauma Centre, Nottingham, UK
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