How to No Longer Take Things Personally


How to No Longer Take Things Personally

“Don’t take anything personally. Nothing others do is because of you. What others say and do is a projection of their own reality, their own dream. When you are immune to the opinions and actions of others, you won’t be the victim of needless suffering.” ~ Don Miguel Ruiz

We live in a world where people aren’t always nice to one another. Where people use unkind and unloving words to talk to, and about, each other. And because I believe that there is always a better way to deal with negativity, and with those people who spread out these negative vibes, I decided to write this blog post on How to No Longer Take Things Personally and live in peace and harmony.

Enjoy :)

1. It’s not about you, it’s about them.

“But it is not what I am saying that is hurting you; it is that you have wounds that I touch by what I have said. You are hurting yourself. There is no way I can take this personally.” ~ Don Miguel Ruiz

Most people are very unconscious of their own unconsciousness, projecting their own darkness, their own pain and internal struggles onto those around them. Failing to realize that what’s on the outside isn’t the problem, but rather what’s on the inside. And that most of the things people say and do, have little, or nothing, to do with the people they are “describing”, but a lot to do with who they themselves are, and the internal struggles they are facing.

The words that come out of a person’s mouth, their actions and behaviors reveal the many things that are hidden deep within a person’s heart.  Their words don’t describe the people they are “attacking”, nor do they reveal who others are. But rather they reveal the pain, the suffering, the darkness and the many wounds that are present within them. They reveal the pain that’s present in their hearts. And that is why is so important not to take things personally, and to always remember that it’s not about you, it’s about them.

2. Don’t give it too much attention.

Thoughts have power, creative power. And since there are no idle thoughts ( for every thought you think creates a belief, belief that you will later on craft your reality on), it’s very important for you not to dwell upon the negativity that comes out of people’s mouths. It’s very important for you not to give too much attention to the negative things people say or do. For these things have the power to poison your heart, your mind, your body and your life.

“People tend to be generous when sharing their nonsense, fear, and ignorance. And while they seem quite eager to feed you their negativity, please remember that sometimes the diet we need to be on is a spiritual and emotional one. Be cautious with what you feed your mind and soul. Fuel yourself with positivity and let that fuel propel you into positive action.” ~ Steve Maraboli

3. Just be yourself.

Bernard Baruch said it best with these words: “Be who you are and say what you feel, because those who mind don’t matter and those who matter don’t mind.”

Always do the things you feel in your heart that you are meant to do, and don’t give too much thought about what others might have to say about you. Never make other people’s opinions of you more important than your own opinion of yourself. Keep in mind that your job here on this Earth is to be true to yourself. To honor your heart and Soul, and to walk on the path life needs you to walk upon, not on the many paths other people might think you should walk upon. If certain people don’t agree with the way you live your life, that’s their problem, not yours. 

4. What other people think of you is none of your business.

In The Tao Te Ching (500BC), a work many consider the wisest book ever written, there is a great line that goes like this: “Care about people’s approval and you will be their prisoner.” And the truth of the matter is that once you care about what others think of you, and once you start chasing after their validation and approval, taking everything other people say and do personally, you immediately become their prisoner and their slave… Don’t allow them to put you in that position. Remind yourself constantly that what people think or say about you, is none of your business. And that their negativity has little or nothing to do with you, but a lot to do with who they themsleves are.

5. It’s not worth your time and energy.

It’s incredible how much we care about what other people think of us. And how much time and energy we are willing to waste trying to understand why certain people don’t like us. And why they choose to talk and behave to us, and about us, in ways that aren’t always friendly and loving. Instead of focusing on those who love and cherish us, and instead of feeding our hearts and souls with the love and kindness we receive from these people, we choose to dwell upon the negativity of those who don’t like us. Failing to realize that by doing so, not only we are wasting our precious time and energy, but we are also poisoning our minds, bodies and souls, which by the way, it’s just not worth it.

6. People give what they have in their hearts to give.

I really believe that we are all born with this innate need to give. To offer to those around us that which we have in our hearts to offer. Those people who are at peace and whose hearts are filled with love, kindness and compassion, give love to everyone they come in contact with. They give joy, laughter, peace and happiness. While those people who are in distress, and whose hearts are wounded because of the many challenges, trials and painful experiences they have gone through, they give fear, pain and a lot of negativity. Because that’s what they have to offer at the moment… People give that which they have in their hearts to give, nothing less and nothing more.

With that being said,“Can anyone be justified in responding with anger to a brother’s plea for help? No response can be appropriate except the willingness to give it to him, for this and only this is what he is asking for. Offer him anything else, and you are assuming the right to attack his reality by interpreting it as you see fit. Perhaps the danger of this to your own mind is not yet fully apparent. If you believe that an appeal for help is something else you will react to something else. Your response will therefore be inappropriate to reality as it is, but not to your perception of it.” ~ ACIM 

7. Never confuse the behavior with the person.

We all know that children are born pure and innocent, and that all they have to offer is their unfailing love. But as they grow older, and as they start experiencing life through the filters of the many beliefs and limitations they adopt from those around them, their innocence starts to fade. And if in the beginning they looked at life and everyone around them with eyes of love, welcoming the whole world in their pure and loving hearts, as they grew older, and as they advanced through life, they learned that it was unsafe to live life that way. Thus, the love that they once held in their pure and innocent hearts is slowly but surely being replaced with a lot of fear. Fear that “forces” them to act in unkind and unloving ways, creating a lot of pain and suffering for themselves and for those around them… 

Don’t take it personally. Don’t make their pain your pain. Don’t make their darkness your darkness. Help them if you can, by giving them your love, compassion and understanding, and by helping them understand that love is their true nature, while fear is nothing but an illusion. And if that’s something you can’t do, make sure you don’t feed their pain by reacting in unkind and unloving way, and by confusing the behavior with the person, for that would only create more suffering into their lives, and into your own life.

8. Guard your heart, for everything you do flows from it.

No matter what anyone might say to you, and about you, and no matter how much negativity people might try to bring into your life through their actions and behaviors, never allow the pain that might be created to make you hate. Never allow resentment to pour through your system, continuing to poison your heart long after you have been “bitten by the snake.” Keep your heart pure, free from negativity, hate and resentment. For everything you do flows from your heart.

9. Let Love forgive.

“Fear condemns and love forgives. Forgiveness thus undoes what fear has produced.” ~ ACIM

When I was a little kid, whenever me and my siblings would argue or get into a fight, at the end of it all, I would often run to my mom and complain about the mean things my siblings said or did to me. And my mom would always tell me the same thing: “If you are the bigger you will forgive and let go…”

Even though most of us believe that forgiveness is an act of weakness, the truth of the matter is that forgiveness is an act of strength not of weakness. You don’t forgive because you are weak but because you are strong enough to realize that only by giving up on resentment you will be happy…. And the bigger person always forgives. Not necessarily because they think that the other person deserves it, but because they know that they themselves do. Because they know that forgives cleanses the mind and purifies the hearts of all the negativity that might have gotten into our system because of all the hurtful things that might have been said and done. Keeping our hearts open and allowing life’s many gifts to shower us and to continue to make us feel nourished, loved, cared for and appreciated.

10. Set peace of mind as your highest goal.

Turn your back to those things that aren’t meant to bring you peace, joy and happiness into your life, and constantly focus onto those things that fill your heart with love. Set peace of mind as your highest goal in life and let nothing and no one interfere with that. Let nothing and no one disturb your inner peace. Whenever you are faced with a difficult person or situation, ask yourself: “How can I handle this situation in a way that will not disturb my inner peace?” And make sure you only act in ways that will help you maintain a state of inner peace and tranquility.

Why do you think it’s so challenging for people not to take things personally, constantly chasing after people’s approval and validation? You can share your insights in the comment section below :)

Don’t Stop Worrying About Cholesterol .


Despite what recent reports say, no responsible health professional thinks we should return to the era of unrestrained consumption of french fries and pizza

We still need to worry about cholesterol.

SA Forum is an invited essay from experts on topical issues in science and technology.

Recently Americans heard some fantastic-sounding news: A federally appointed panel of experts announced that we can stop worrying about cholesterol. Even more surprising, the news is true—sort of.

Every five years the U.S. Department of Health and Human Services is legally required to publish a new revision of a government document called the Dietary Guidelines for Americans. Its purpose is to help set a course for the country’s future food and nutrition policies. To ensure that the book’s advice will be as accurate and up-to-date as possible, a special Dietary Guidelines Advisory Committee (DGAC) has been established to read and summarize the latest research on a wide array of topics, ranging from dietary patterns to food sustainability. Nevertheless, parts of the guidelines have remained essentially the same. For one thing, every edition since the first one has advised Americans to consume less cholesterol.

Until now, that is. The 2015 Dietary Guidelines are still being drafted and won’t be published until later this year. But the advisory committee’s latest 571-page report (pdf) has already made headlines by pointedly dropping the usual call for a reduction in dietary cholesterol: “Previously, the Dietary Guidelines for Americansrecommended that cholesterol intake be limited to no more than 300 milligrams per day. The 2015 DGAC will not bring forward this recommendation because available evidence shows no appreciable relationship between consumption of dietary cholesterol and serum cholesterol, consistent with the conclusions of the AHA/ACC [American Heart Association/American College of Cardiology] report.”

And in light of the public uproar over the committee’s shift on dietary cholesterol, it’s also worth mentioning that the DGAC report stands by previous guidelines’ recommendations for Americans to minimize their consumption of saturated fat. These days that substance, rather than dietary cholesterol, appears to be the big threat to America’s cardiovascular health. The answer is not merely to avoid saturated fat; it’s also to steer clear of refined carbohydrates, like sugar and white bread. Instead, the report says (along with the AHA and others) we need to replace those calories that come from saturated fat with polyunsaturated fats. As described in the committee’s report, a heart-healthy diet for active American adults is rich in vegetables, fruit, whole grains, seafood, legumes and nuts; moderate in low- and nonfat dairy products and alcohol (among adults); lower in red and processed meat; and particularly low in sugar-sweetened foods and beverages and refined grains.

Beyond confirming such well-established medical wisdom, the committee’s chief assignment was to help compile the necessary research for the guidelines’ authors, not to take over the actual writing. At this point there’s no telling what the finished version of the 2015 guidelines will say, whether about cholesterol consumption or about any other aspect of the American diet. In any case, it should be remembered that the guidelines are primarily a tool for policy makers. They were never designed to be a nutritional protocol for the treatment of high-risk individuals. The hope is only that each new edition will help to make America a healthier country.

Whoa, scientists have captured the first ever picture of thunder


When it comes to thunderstorms, lightning tends to steal the show, dazzling everyone with its spectacular displays, and overshadowing the powerful long-distance rumbles that accompany the atmospheric energy release.

But now a team of scientists working at the Southwest Research Institute in the US has captured the world’s first detailed image of thunder, and it looks even more incredible than we ever imagined.

The image was created using acoustic wave maps, which were based on recordings from a range of microphones positioned around an artificially generated lightning strike.

Because sound waves from higher elevations take longer to travel to the microphones, these recordings allowed the scientists to visualise how the claps and rumbles emitted during a storm move in space.

ts_thunder-briefUniversity of Florida, Florida Institute of Technology, Southwest Research Institute

To understand how thunder works, you first need to understand lightning, which is created by electrical charges moving either within a cloud, or between the cloud and the surface of the Earth. As this charge travels, it heats up the surrounding air, triggering the dramatic release of energy, which causes thunder.

To map the process, the researchers shot a long, Kevlar-coated copper wire into an electrically charged cloud, as you can see in the Science News video below. The result is an impressive lighting strike and resulting thunder, captured by 15 ultra-sensitive microphones positioned 95 metres from the strike point.

The researchers found that the thunder was louder when more current flowed through the lightning, a discovery that could one day help scientists use thunder to work out how much energy is being conducted through lightning. This could potentially be useful if we work out how to harness the energy from lightning.

The results of the research (and this spectacular image) were presented at the meeting of the American Geophysical Union on May 5. Watch your back, lightning, who’s the show pony now?

 

Thunder large inbodywatch the video. URL: https://youtu.be/qLcxnFVwQf0

 

The New Science On Old Age: 10 Ways To Live Longer


the pinnacle of health

Balancing good foods, physical activity, a positive view on life, and love can help you live longer, according to studies. 

The average human lifetime has been increasing steadily over the course of centuries, as we’ve found ways to improve medicine, sanitation, safety, work conditions, and overall self-awareness, at least in first world countries. Today, the average life expectancy at birth is about 68.5 years for males and 73.5 years for females — but plenty of people are living well past 80 and even 90. What’s the best way to ensure you’ll live longer? Below are 10 tips to keep in mind.

Manage Stress

When you’re stressed out, you’re more likely to get sick due to a compromised immune system. You’re also more likely to see bags under your eyes turn into wrinkles, or grey hairs peek out amid your natural color. When you’re stressed, fatigue is an everyday feeling, and you having fun seems like a distant memory of your college days.

Then there’s all the research that shows that chronic stress can contribute to heart problems, diabetes, obesity, cancer, asthma, depression, and even Alzheimer’s. The reason why stress can have such a huge impact on our bodies is because it shortens telomeres, the protective caps at the end of chromosomes, which are associated with health and longevity. When telomere length is compromised, our cells age faster.

But here’s the thing: You don’t have to be miserable. Learning to cope with stressful events, depression, or anxiety can make a huge difference on your health and longevity. Slowing down can benefit you even on a cellular level; it prevents them from aging and dying sooner, and can stop your telomeres from shortening.

“[S]tressful events can accelerate immune cell aging in adults, even in the short period of one year,” said Dr. Eli Puterman, an author of a study on stress. “Exciting, though, is that these results further suggest that keeping active, and eating and sleeping well during periods of high stress are particularly important to attenuate the accelerated aging of our immune cells.”

Exercise

What’s the single best thing you can do for your health? Exercise. A recent study found that working out and staying active reduces the risk of pretty much every single chronic disease out there — from cancer to obesity. Exercise lowers symptoms in knee arthritis patients by 47 percent, dementia and Alzheimer’s by 50 percent, diabetes by 58 percent, and anxiety by 48 percent. Feeling stressed and fatigued? Go for a run; it will do you wonders. Studies have shown that more intense exercise is better for you than mild to moderate, but any amount of walking or standing will help.

Don’t Smoke

Smoking can lead to lung cancer, heart disease, skin problems, teeth impairment, and accelerated aging. According to the CDC, overall mortality for male and female smokers in the U.S. is up to three times higher than for non-smokers; cigarette smoke accounts for one of every five deaths each year. For every month or year you quit, you add more years onto your life.

Don’t Do Hard Drugs Or Drink Too Much

Another no-brainer is to stay away from hard drugs like heroin or cocaine (marijuana is a different story; some research shows it may actually be good for you, especially in reducing anxiety and relieving headaches). Drug overdoses and drug-related deaths are pretty high up on the list of causes of death in the U.S., particularly among young people. On that note, becoming an alcoholic will wreak havoc on your liver and other organs, as well as your brain and mental health.

Think Young!

Feeling young can make you young — at least that’s what one recent JAMA Internal Medicine study from the University College London found. The researchers learned that people who felt three or more years younger than they were actually had a lower death rate than people who felt their own age or more than a year older. These results are pretty fascinating, and they’re inspiration for us to not worry about turning one year older; it’s what’s inside that counts!

Avoid A Sedentary Lifestyle

Sitting all day is just as bad as smoking. You can, however, fight this by getting a half-hour workout in daily, using a standing desk at work, taking walks on your lunch break, and getting up every few minutes to stretch and move around. Watch this video to see more of how sitting affects your body and brain.

As you get older, it’s even more important to be physically active. Doing things like cleaning, washing dishes, gardening, or walking will cut your risk of heart disease, diabetes, and depression.

Good Foods (Mediterranean Diet)

An easy way to eat well is to follow a Mediterranean Diet, which is rich in heart-healthy fish like salmon, protein-packed nuts, and scores of vegetables. Research has shown over and over that sticking to this food regimen could make you live longer, along with providing you with health benefits like protection against heart disease and Alzheimer’s.

Eating well doesn’t have to mean eating bland, boring foods like raw vegetables. It can mean washing down whole grain pastas, seafood, bread and olive oil, and eggplant parmesan with glasses of wine. Europeans like the French and Greeks are notorious for eating well but staying skinny — and it’s because they eat everything in moderation.

Be A Student For Life

Don’t fall into the trap that as you grow older, your mind gets fuzzier and your memory is shot. Instead, change up your boring daily routine to add something new. Go to lectures, museums, and read challenging books to keep your mind sharp. Learn a new language. Travel someplace new. Keeping your mind young and sharp has actually been shown to help you live longer.

Keep Close Friends

It’s true: Loneliness and social isolation can be harmful to your mental, emotional, and even physical health, while having a close network of friends around can do you good. One recent study published this year found thatloneliness could lead to an early death at the same rate that obesity does. Having social support can reduce your stress levels, risk of suicide, and depression. Especially in the modern day and age when people communicate solely through digital means and live alone, staying in touch with your friends is important.

Stay positive!

Finding a purpose in your life will help you live longer, according to a 2014 study. Whether you’re in college, working, or retired, making goals for yourself and challenging yourself is going to improve your outlook on life, which will make you happier and keep you healthier. At the end of the day, it’s all about being positive, focusing on the good things, and never giving up. So next time you’re feeling lost and stuck, make some short-term and long-term goals for yourself. Then take the steps to achieve them. Having a sense of purpose will increase your productivity and positivity and help you feel better about yourself, reducing stress in the meantime.

New medicine could help diabetics save Rs 10,000 per year.


A new anti-diabetes drug from the ‘gliptin’ family soon to be launched in India promises to lower treatment cost for patients by 55-60%.

The launch of ‘Teneligliptin’ by Mumbai-based Glenmark Pharma under Ziten and Zita Plus brands at an affordable price could prove to be a game-changer with savings of over Rs 10,000 per year for diabetics. Treatment cost for the debilitating disease which gradually attacks and weakens all body organs may come down further over months, with possibly more domestic companies entering the market, experts said.

Teneligliptin, a third-generation oral anti-diabetic drug manufactured by Glenmark, has received regulatory approval and is priced aggressively at nearly Rs 20 for a day’s therapy (Rs 7,263 per year). As against this, all gliptins being sold in the market are priced around Rs 45 for a day, taking the cost of treatment for patients to nearly Rs 16,500 per year. (See chart)

Most gliptins launched by MNCs in the country are currently imported. While manufacturing the drug entirely in the country, the pharma company has sought to connect its innovation to the Narendra Modi government’s ‘Make in India’ programme.

Diabetes is fast gaining the status of a potential epidemic in India with over 67 million individuals currently diagnosed with the disease (source: IDF 2014), while there is a huge undiagnosed diabetes population estimated around 35.4 million.

The economic burden of diabetes is high in India as most patients pay out of their pocket for treatment due to the lack of medical reimbursement. The cost of treatment includes consultation, investigations, drugs and monitoring, and, due to the nature of the disease, the complications related to the disease may increase it substantially.

Due to the high cost of therapy, patients from the lower socio-economic class tend to neglect it, or at times are forced to take loans, mortgage or sell property.

Though the new class of drugs, gliptins (also called DPP-4 inhibitors), are increasingly emerging as a highly popular therapy, it is prescribed to only one in 10 diabetics in cities. Doctors say the price, particularly for economically-constrained patients, has always been an area of concern.

“Cost of conventional treatment of diabetes is often prohibitive for most Indians; and addition of newer drugs (gliptins, SGLT-2 inhibitors), often needed to control blood sugar and prevent complications, makes it higher. In this respect, any drug of new category (gliptins) at half the price of available drugs of similar category is welcome in India,” said Dr Anoop Misra, chairman Fortis-C-DOC Hospital for Diabetes.

Overall, the oral anti-diabetic market in which Teneligliptin is the new entrant, is valued at approximately Rs 4,800 crore, increasing at 19% per annum (source: ORG-IMS MAT April 2015), while the gliptin family is at Rs 1,200 crore, growing at 27%.

However, since the molecule has not been used extensively right now, its safety data needs more scrutiny, doctors say. “In general, gliptins tend to do well in Indians as we eat more carbohydrates and need lower doses. But we need more safety and outcome data on Teneligliptin coming from India,” said Dr Shashank Joshi, endocrinologist and diabetologist.

The drug, originally developed by Mitsubishi Tanabe Pharma, is approved for use mainly in Japan and Korea, and will be available in the country soon, said a Glenmark official. The company received approval from DCGI after conducting clinical trials on the molecule for over two years in India, he added.

Globally, a recent study has dissipated a cloud that had been hanging over one of the gliptins, where it was found that there was no cardiovascular problems like heart failure associated with the use of these drugs, including Merck’s Januvia.

Tranexamic Acid’s Potentially Bright Future Relies on Collaborative Data .


TXA
EMS agencies using tranexamic acid (TXA) believe it can improve survival as a part of an organized trauma system. Photos Mark Voyles and David Howerton

Jeffrey M. Goodloe, MD, NRP, FACEP & Ryan Gerecht, MD, CMTE

Have you heard of tranexamic acid, or TXA for short? If you work with multisystem trauma patients, you likely recognize its growing adoption in EMS and trauma center protocols for hemorrhagic shock.

In April 2013, JEMS featured an article introducing TXA to many EMTs and paramedics.1 It acknowledged TXA as a medication used for decades in cardiovascular surgery and focused on two groundbreaking studies supporting its use for trauma patients in need of significant blood transfusion. The article also discussed how TXA combats significant hemorrhage by functioning as an antifibrinolytic, though more current studies indicate that how TXA helps our patients is likely more complex, giving us more than antifibrinolytic action alone.2

Two Key Studies

The two key studies discussed are still the most relevant for EMS use of TXA. The Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage 2 (CRASH-2) study stands as the largest TXA study, including over 20,000 adult trauma patients at 274 hospitals in 40 countries.3 If you haven’t heard much about it, it’s likely because no hospitals in the United States and only one in Canada were involved in any part of it. Nevertheless, agencies adopting TXA as a local standard of care commonly use the CRASH-2 enrollment criteria as their indications—trauma patients must have clinical assessment consistent with significant external or internal hemorrhage and tachycardia greater than 110 beats per minute, systolic blood pressure less than 90 mmHg, or both vital sign abnormalities.

CRASH-2 helped identify patients in which TXA made a real difference in their survival outcome. Factoring all causes of death, 16% of patients who didn’t get TXA died, compared with 14.5% of patients who did get TXA. This is statistically significant when applied over thousands of patients. Of those who died primarily due to bleeding, 5.7% weren’t given TXA, but only 4.9% of deaths occurred among those who received TXA—a relative 15% improvement in survival. Of note, these survival benefits were most evident when TXA was administered within three hours of injury, and more so when administered within the first hour post-injury.4

Although TXA alone isn’t the decision-maker between life and death in seriously injured and bleeding patients, it’s important to realize it can improve survival as a part of an organized trauma system that includes early notification and EMS response, accurate and efficient scene and transport care, appropriate triage to a trauma center, and continuity of that care in the ED, operating suite and ICU. Because survival becomes difficult in so many of these critical patients, TXA deserves serious consideration in local and regional standards of care.

One major point to remember whenever we reflect on the CRASH-2 study is that all the patients who received TXA first received it in the hospital. Although the time delay from injury to TXA administration was often within 1–2 hours, that’s still a remarkable difference from the time it takes for paramedics to routinely arrive at the patient’s side in large, urban EMS systems.

The second major TXA study, Military Application of Tranexamic Acid in Trauma Emergency Resuscitation study, or MATTERs, helped demonstrate TXA could be effective when given outside the hospital. Much smaller in the number of patients involved—though the sample size was still nearly 900—MATTERs showed an even greater benefit to TXA in trauma patients thought to require massive blood transfusion, with 28.1% mortality being reduced nearly 50% to 14.4%.5

The CRASH-2 and MATTER studies are largely to credit for sparking enthusiasm for TXA use in EMS in the U.S. over past two years. Despite several agencies adopting TXA into their trauma protocols, there has yet to be large-scale U.S. civilian EMS-based study. There are several reasons for this.

First, not all interventions are studied in detail and submitted to medical journals in formal writings of impact findings.

Secondly, even when such study is performed, there’s often a lag between study enrollment, analysis and publication that can stretch far beyond two years.

Lastly, the numbers of patients must be high enough for any study to have widespread adoptability and garner a consensus that it has merit. A report of a single patient may stimulate a bit of interest here and there, but rarely has widespread standard of care ever been linked to a single patient experience. And although 10 patients—or, even better, 50—are more than one in simple math, they’re not functionally much different when it comes to analyzing meaningful cause and effect in an intervention, especially something in a very dynamic, complex clinical situation such as traumatic hemorrhagic shock.

TXA
TXA has a half-life of about two hours, maintaining antifibrinolytic action in some tissues for up to 17 hours and in the blood for approximately 7–8 hours.

The USA TXA Experience

Despite the lack of a U.S. civilian EMS-based study on TXA, many encouraging commonalities can be seen among EMS agencies that have adopted TXA over these past two years:

>> Collaboration with local trauma surgeons and trauma systems;

>> Ability for paramedics to accurately identify patients who meet CRASH-2 or very similar criteria; and

>> Although there aren’t widespread claims of “miracle cures” by TXA, there are also no widespread concerns of TXA-linked thromboembolic complications, such as pulmonary embolism, deep venous thrombosis, acute myocardial infarction or stroke.

The American College of Emergency Physicians out-of-hospital severe hemorrhage control policy statement even states that systems should consider the use of TXA. Encouragingly, the trauma-related interest in TXA has spawned interest in how TXA might help serious nontraumatic hemorrhage, such as gastrointestinal bleeding, intracerebral bleeding and even epistaxis.6–8

Roadmap to TXA

The processes utilized both in metropolitan Cincinnati and metropolitan Oklahoma City and Tulsa, Okla., can serve as a useful map in going from TXA pondering to reliable, accurate and coordinated TXA administration.

Both systems use committed physician medical oversight capabilities, specifically the Academy of Medicine of Southwest Ohio Prehospital Protocol Committee and the Medical Control Board for the EMS System for Metropolitan Oklahoma City and Tulsa, respectively. These deliberative bodies foster healthy debate and dialogue when determining if procedures or medications are appropriate for the needs of patients served.

They also serve as conduits for critically important input from the medical community, and consulted with trauma centers, trauma surgeons, emergency physicians and surgical intensivists when these agencies were considering TXA. Through such collaboration, evidenced-based treatment protocols and educational resources were developed.

Both agencies’ protocols allow and encourage paramedics to initiate TXA administration when indicated, regardless of how close they are to a trauma center. This acknowledges the critical role EMS plays in the continuum of care for the severely injured. Furthermore, it recognizes the complex patient care logistics and inherent task saturation that can occur in a busy trauma center, thus potentially delaying hospital-based administration of TXA.

Both protocols use CRASH-2 and MATTERs dosing in adult trauma patients. This is 1 g of TXA mixed in at least 100 mL normal saline or lactated Ringer’s and given IV or intraosseously (IO) over 10 minutes. Of note, neither protocol directs the EMS initiation of the second 1 g dose (this is an 8-hour continuous infusion). This is based partially on relatively short transport times, but primarily on pharmacokinetics.

Clinical and research pharmacists at the University of Cincinnati College of Medicine highlight the fact TXA has a half-life of about two hours, maintaining antifibrinolytic action in some tissues for up to 17 hours and in the blood for approximately 7–8 hours.9 Thus, based on customary EMS patient course of care times, the continuous TXA infusion is deferred to the receiving trauma center. In some trauma center protocols, this can allow for laboratory testing to determine if additional TXA is needed after the prehospital bolus.

Furthermore, it simplifies logistics for EMS providers with multiple other management priorities and potential interventions to perform during transport.

Recognizing the challenging, dynamic nature of traumatic hemorrhagic shock care, both EMS systems developed patient eligibility checklists to confirm TXA is indicated. The checklist used in Cincinnati is nicely organized and serves as a great example list. (See Table 1, p. 32.)

table 1The CRASH-2 study noted time matters, and future studies could further validate this point. The difference in time of evaluation for TXA could largely explain why metropolitan Oklahoma City and Tulsa—a 100-paramedic ambulance EMS system that serves two major metropolitan areas—has used TXA only 10 times from April 1, 2013, until Jan. 15, 2015, while Cincinnati—a three-helicopter system serving a region that includes everything from urban to super-rural settings—administered TXA nearly 50 times since November 2013. In short, it may well be that large, urban EMS systems are able to respond to suspected hemorrhagic trauma patients so quickly that patients have yet to compensate with tachycardia or begin to decompensate, evidenced by declining systolic blood pressures.

Patient eligibility checklists help crews to quickly confirm that TXA is indicated for a patient.
Patient eligibility checklists help crews to quickly confirm that TXA is indicated for a patient.

Expanding TXA Use

We believe TXA will find future use in patient types not typically treated with it. There’s a growing body of literature—both expert opinion and clinical trial types—that supports the use of TXA in pediatric trauma patients. One study focusing on pediatric injury involving 766 patients aged 18 years or younger, looked specifically at the 66 (9%) patients who received TXA.10 These patients often had severe abdominal or extremity injury. Even though the TXA patients had greater injury severity, hypotension, acidosis and coagulopathy than the patients who didn’t get TXA, they had improved survival. Given the benefits shown in adults, this finding may not come as a surprise; however, this evidence can serve as the basis for the next generation of EMS TXA protocols. The EMS System for Metropolitan Oklahoma City and Tulsa is now promoting TXA administrations in serious, suspected hemorrhagic shock trauma patients age 10 or above.

The decision for EMS administration of TXA to suspected or confirmed pregnant patients will vary from system to system. TXA is known to pass through the placenta and appear in umbilical cord blood at a concentration level nearly equal to that found in the mother’s blood.10 As an FDA pregnancy category B, there are no adequate and well-controlled studies of TXA in pregnant women to date. Metropolitan Cincinnati likely has the safest and most effective position at present: EMS avoids TXA in women who are known or suspected to be pregnant with a fetus of viable gestational age (defined as at least 24 weeks). These women may receive TXA at the receiving trauma center if indicated by laboratory assessment there. For those severely injured women who are pregnant with a pre-viable fetus, EMS does administer TXA per the standard Southwest Ohio protocol.

Conclusion

This remains an exciting time for EMS and the applicability of TXA in our practices of medicine. In the absence of a large-scale U.S. civilian EMS-based study, the minority of EMS systems that have adopted TXA should analyze their use of it. Are the right patients—at least the ones we believe to be right—getting TXA? Is it being administered correctly? What are the outcomes after the patients arrive at the trauma center? Small numbers of patients will likely not yield firm conclusions, but perhaps multiple systems can pool their findings into a multicenter study.

For any EMS agency, whether already utilizing TXA or considering doing so, we believe the most important things to recognize are how critically important careful review of the evidence-based literature and collaboration with your local subject matter experts are to the overall success of your efforts. We do have useful and relatively clear peer-reviewed scientific writings that support TXA and specifically its use in EMS. But there are still many questions to answer and different interpretations of the literature regarding a variety of clinical and logistical aspects of its administration. Enthusiasm, accurate patient assessment and a true continuum of effective emergency care, from citizen recognition to definitive surgical care, will undoubtedly continue to advance our trauma care capabilities and successes.

Jeffrey M. Goodloe, MD, NRP, FACEP, is medical director for the Medical Control Board, providing physician oversight for the EMS System for Metropolitan Oklahoma City and Tulsa, Okla., which includes the Emergency Medical Services Authority, Oklahoma City Fire Department, Tulsa Fire Department and over 20 suburban fire departments. He’s professor and chief of the EMS Section of the Department of Emergency Medicine at the University of Oklahoma School of Community Medicine in Tulsa. He started in EMS in 1988 as an EMT-B and has never quit learning about the challenges and privileges of being in a dynamic practice of EMS medicine. He’s a member of the JEMS Editorial Board and can be reached at jeffrey-goodloe@ouhsc.edu.

Ryan Gerecht, MD, CMTE, started his career in EMS as an EMT over 10 years ago. Today he’s an EMS fellow in the Department of Emergency Medicine at the University of Cincinnati, an EMS physician with the Cincinnati Fire Department, a flight physician with University of Cincinnati Air Care, and the associate medical director for Colerain Township Department of Fire and EMS. He’s the inaugural NAEMSP/Physio-Control EMS medicine medical director fellow and a member of the JEMS Editorial Board. Contact him at gerechrn@ucmail.uc.edu.

References

1. Goodloe JM, Howerton DS, McAnallen D, et al. TXA: A difference maker for trauma patients. JEMS. 2013;38(4):60–65.

2. Roberts I, Prieto-Merino D, Manno D. Mechanism of action of tranexamic acid in bleeding trauma patients: Sn exploratory analysis of data from the CRASH-2 trial. Crit Care. 2014;18(6):685.

3. CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): A randomized placebo controlled trial. Lancet. 2010; 376(9734):23–32.

4. CRASH-2 collaborators, Roberts I, Shakur H, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: An exploratory analysis of the CRASH-2 randomized controlled trial. Lancet. 2011;377(9771):1096–1101.

5. Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg. 2012;147(2):113–119.

6. Bennett C, Klingenberg SL, Langholz E, et al. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2014;11:CD006640.

7. Sprigg N, Renton CJ, Dineen RA, et al. Tranexamic acid for spontaneous intracerebral hemorrhage: A randomized controlled pilot trial. J Stroke Cerebrovasc Dis. 2014;23(6):1312–1318.

8. Zahed R, Moharamzadeh P, Alizadeharasi S, et al. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: A randomized controlled trial. Am J Emerg Med. 2013;31(9):1389–1392.

9. U.S. Food and Drug Administration Safety Information. (January 2011.) Cyklokapron (tranexamic acid) injection prescribing information. NDA 19-281/S-030. Retrieved Feb. 13, 2015, from http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/019281s030lbl.pdf.

10. Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: The pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852–858.

Nonalcoholic Fatty Liver Disease: A Systematic Review


Importance  Nonalcoholic fatty liver disease and its subtype nonalcoholic steatohepatitis affect approximately 30% and 5%, respectively, of the US population. In patients with nonalcoholic steatohepatitis, half of deaths are due to cardiovascular disease and malignancy, yet awareness of this remains low. Cirrhosis, the third leading cause of death in patients with nonalcoholic fatty liver disease, is predicted to become the most common indication for liver transplantation.

Objectives  To illustrate how to identify patients with nonalcoholic fatty liver disease at greatest risk of nonalcoholic steatohepatitis and cirrhosis; to discuss the role and limitations of current diagnostics and liver biopsy to diagnose nonalcoholic steatohepatitis; and to provide an outline for the management of patients across the spectrum of nonalcoholic fatty liver disease.

Evidence Review  PubMed was queried for published articles through February 28, 2015, using the search terms NAFLD and cirrhosis, mortality, biomarkers, and treatment. A total of 88 references were selected, including 16 randomized clinical trials, 44 cohort or case-control studies, 6 population-based studies, and 7 meta-analyses.

Findings  Sixty-six percent of patients older than 50 years with diabetes or obesity are thought to have nonalcoholic steatohepatitis with advanced fibrosis. Even though the ability to identify the nonalcoholic steatohepatitis subtype within those with nonalcoholic fatty liver disease still requires liver biopsy, biomarkers to detect advanced fibrosis are increasingly reliable. Lifestyle modification is the foundation of treatment for patients with nonalcoholic steatosis. Available treatments with proven benefit include vitamin E, pioglitazone, and obeticholic acid; however, the effect size is modest (<50%) and none is approved by the US Food and Drug Administration. The association between nonalcoholic steatohepatitis and cardiovascular disease is clear, though causality remains to be proven in well-controlled prospective studies. The incidence of nonalcoholic fatty liver disease–related hepatocellular carcinoma is increasing and up to 50% of cases may occur in the absence of cirrhosis.

Conclusions and Relevance  Between 75 million and 100 million individuals in the United States are estimated to have nonalcoholic fatty liver disease and its potential morbidity extends beyond the liver. It is important that primary care physicians, endocrinologists, and other specialists be aware of the scope and long-term effects of the disease. Early identification of patients with nonalcoholic steatohepatitis may help improve patient outcomes through treatment intervention, including transplantation for those with decompensated cirrhosis.

Philae comet lander wakes up – BBC News


The European Space Agency (Esa) says its comet lander, Philae, has woken up and contacted Earth.

Philae, the first spacecraft to land on a comet, was dropped on to the surface of Comet 67P by its mothership, Rosetta, last November.

It worked for 60 hours before its solar-powered battery ran flat.

The comet has since moved nearer to the Sun and Philae has enough power to work again, says the BBC’s science correspondent Jonathan Amos.

An account linked to the probe tweeted the message, “Hello Earth! Can you hear me?”

On its blog, Esa said Philae had contacted Earth, via Rosetta, for 85 seconds on Saturday in the first contact since going into hibernation in November.

Tweet from Philae Lander
Tweet from ESA Rosetta Mission

“Philae is doing very well. It has an operating temperature of -35C and has 24 watts available,” said Philae project manager, Dr Stephan Ulamec.

Scientists say they now waiting for the next contact.

‘Comet hitchhiker’

Esa’s senior scientific advisor, Prof Mark McCaughrean, told the BBC: “It’s been a long seven months, and to be quite honest we weren’t sure it would happen – there are a lot of very happy people around Europe at the moment.”

Philae was carrying large amounts of data that scientists hoped to download once it made contact again, he said.

“I think we’re optimistic now that it’s awake that we’ll have several months of scientific data to pore over,” he added.

Media captionMonica Grady says she hugged a taxi driver when she learned the lander had woken up
File photo: Comet 67P/CG, acquired by the Rolis instrument on the Philae lander during descent from a distance of approximately 3 km (1.86 miles), 12 November 2014
The lander snapped this photo of the comet during its descent last year

This is one of the most astonishing moments in space exploration and the grins on the faces of the scientists and engineers are totally justified, says BBC science editor David Shukman.

For the first time, we will have a hitchhiker riding on a comet and describing what happens to a comet as it heats up on its journey through space, he adds.

‘Building blocks of life’

Philae is designed to analyse the ice and rocky fragments that make up the comet.

Prof Monica Grady from the Open University told the BBC that scientists now hoped to be able to carry out experiments to see whether comets were the source of life on Earth.

Comets contained a lot of water and carbon, and “these are the same sorts of molecules responsible for getting life going,” she said.

“What we’re trying to find out is whether the building blocks of life, in terms of water and carbon-bearing molecules, were actually delivered to Earth from comets.”

Grey line

Analysis: Jonathan Amos, BBC science correspondent

Comet 67P landscape
Philae will provide valuable information about the landscape of comet 67P

When Philae first sent back images of its landing location, researchers could see it was in a dark ditch. The Sun was obscured by a high wall, limiting the amount of light that could reach the robot’s solar panels.

Scientists knew they only had a limited amount of time – about 60 hours – to gather data before the robot’s battery ran flat.

But the calculations also indicated that Philae’s mission might not be over for good when the juice did eventually run dry. The comet is currently moving in towards the Sun, and the intensity of light falling on Philae, engineers suggested, could be sufficient in time to re-boot the machine.

And so it has proved. Scientists must now hope they can get enough power into Philae to carry out a full range of experiments.

One ambition not fulfilled before the robot went to sleep was to try to drill into the comet, to examine its chemical make-up. One attempt was made last year, and it failed. A second attempt will now become a priority.

 

The Rosetta probe took 10 years to reach 67P, and the lander – about the size of a washing-machine – bounced at least a kilometre when it touched down.

Before it lost power, Philae sent back images of its surroundings that showed it was in a dark location with high walls blocking sunlight from reaching its solar panels.

Its exact location on the duck-shaped comet has since been a mystery.

Esa had a good idea of where it was likely to be, down to a few tens of metres, but could not get Rosetta close enough to the comet to acquire conclusive pictures.

Continued radio contact should now allow precise coordinates to be determined, correspondents say.

Comet 67P is currently 205 million km (127 million miles) from the Sun, and getting closer.

It is due in August to get as close as 186 million km, before then sweeping back out into the outer Solar System.

As it nears the sun, the comet will warm and its ices will melt.

This process will throw out a huge shroud of gas and dust, and if Philae can continue to keep working it will provide scientists with an extraordinary view of what is happening right at the surface of 67P.

HIV ‘Can-Opener’ Molecule Exposes Virus’s Most Vulnerable Parts; What It Means For Vaccine Development


While testing a recently developed molecule, JP-III-48, on samples from HIV-positive patients, researchers at the University of Montreal in Canada observed something groundbreaking. The molecule had the ability to open up HIV “like a flower.” Although this finding is still in its early stages, the team hopes it may set the foundation for new preventive HIV measures and even possibly a way to eliminate the virus from those already infected.

Part of the reason why scientists find it so difficult to create a vaccine for HIV is that the virus has a unique way of evading the immune system. Although the host creates antibodies against HIV, without a way to physically reach the virus, it is difficult for the human body to mount an effective immune response against it. A recent study, now published in the Proceedings of the National Academy of Sciences, suggests a way around HIV’s defenses.

The virus is similar to a tightly sealed can. Figuring out a way to “open” HIV would allow antibodies to reach the most vulnerable parts of the virus and eliminate infection.

Harvard and University of Pennsylvania researchers developed JP-III-48, but Montreal researchers were the first to successfully test it on HIV-positive patients. The molecule imitates CD4, a protein located on the surface of T lymphocytes. CD4 acts as a doorway to the T cell and allows HIV to enter and infect. It was in the Montreal study that the researchers added JP-III-48 to the serum of patients infected with HIV-1 (the most common form of HIV) and witnessed the flower-opening effect.

“Adding the small molecule forces the viral envelop to open like a flower,” lead author of the study, Jonathan Richard, explained in a press release. The molecule forces the virus to expose parts which are recognized by the host’s antibodies. The antibodies then create a sort of bridge with some cells in the immune system and form an attack. “The antibodies that are naturally present after the infection can then target the infected cells so they are killed by the immune system,” Richard added.

So far, JP-III-48’s effect on HIV has only been observed in serum taken from HIV-positive patients, but the researchers hope to soon test this “can opener” molecule on primates with a simian version of the virus.

The researchers speculate that this discovery could have huge potential in research into developing a vaccine against HIV. Another factor that makes HIV so difficult to fight is that even if the virus is completely eradicated from the body, traces of it still remain dormant in HIV “resevoirs,” waiting to return once treatments cease. The team believes that the “can opener” molecule can play a role in overcoming this defense. If scientists can develop a way to “shock” the HIV traces out of hiding, then they can be killed using the “can opener” molecule and already present antibodies.

%d bloggers like this: