Human cadaver blood transfusion: perspectives on its utility in conflict zones

Karl landsteiner and his major contributions to haematology

Blood Transfusion-Induced Immunomodulation

This article briefly reviews the evolution of medical support during wars and conflicts from ancient to modern times and discusses the effect warfare has had on the development of civilian health care and emergency medical services (EMS). Medical breakthroughs and discoveries made of necessity during military conflicts have developed into new paradigms of medical care, including novel programs of triage and health assessment, emergency battlefield treatment and stabilization, anesthesia, and other surgical and emergency procedures. The critical role of organizations that provide proper emergency care to help the sick and injured both on the battlefield and in the civilian world is also highlighted.

Ninety years ago Alexander Fleming (later to discover penicillin) jointly wrote a description of the use of indirect transfusions of citrated blood at a World War 1 (WW1) base hospital. It was the longest series yet to be published, incorporating what was then a novel procedure for treating war casualties. Returning to civilian life Fleming, a qualified surgeon and bacteriologist, chose a different career path, and not until the wars of the late 1930s were the advances in transfusion in WW1 fully incorporated into the management of trauma and haemorrhage. Like penicillin, the benefits of indirect transfusion were only slowly realised.

The distribution of military conflicts duration, the calculation of their average and median duration and the forecast of conflicts in future have been conducted based on the statistical analysis of most military conflicts in the XX–XXI centuries (up to the end of 2016). The unpredictability of military conflicts duration and useless of their accurate forecast have been grounded. The portion of periods when military conflicts occurred in the USSR and Russia during ХХ–ХХI centuries has been determined. The dynamics of military expenditure trends and its share in the GDP of the USA and Russia have been analyzed. The tendency to the GDP slowdown associated with the participation in military conflicts has been observed. The trend to increase military expenditures has also been revealed. The forecast of absolute values, GDP growth trends and military expenditures of Russia and the USA has been made using autoregression and trend models. The conception to create a special military fund to accumulate recourses to insure a country from different risks in current and future military campaigns has been suggested. The structure of expenditures on military campaigns has been analyzed. The examples of high costs of a country participation in military conflicts and full-scale wars in the case study of the USA have been given. The influence of military expenditures on an economic growth in a country has been studied based on the criticism of the “broken windows” effect. The positive effect to increase military expenditures on the social-economic development of a country to strengthen the security and to transfer military developments to a civil sector has been observed. The necessity to manage GDP dynamics due to military expenditures increase has been grounded. The future researches will concern the size of a special military fund and the speed of its increase. Keywords military conflict, expenditures, duration, a model, autoregression, resources, forecast, economic growth, GDP, fund, the expected duration, the broken windows theory.

Blood transfusion pioneers Blood transfusion has been part of medical treatments for centuries. Physicians performed ‘bloodletting’ to prevent or cure a whole range of illnesses and diseases until they realized blood’s essential role in preserving life. The first human–human blood transfusion reported dates back to 1818. Before that, transfusion attempts using animal blood from various species failed tragic ally. Despite the use of human blood, transfusions were not tolerated by all recipients and fatal reactions were common [1]. This phenomena remained a mystery for many years until the turn of the 20th century when Karl Landsteiner discovered the ABO blood group system. He was the first to provide a scientific basis for donor–recipient compati­ bility. Many discoveries that followed brought change to the practice of transfusion medicine. Albert Hustin was the first to add citrate to avoid blood coagulation during sampling in 1916. This simple solution stopped the need for arm–arm transfusion, which saved thou­ sands of soldiers during World War I and this advance led to the creation of the first blood­ collecting center by Arnault Tzanck (Paris, France in 1928). For all those years, blood transfusion improved the quality of life with thanks to ABO typing, which greatly reduced serious adverse reactions. However, incompatibility still remained a problem for a small portion of recipients until 1940, when Karl Landsteiner and Alexander Wiener made one more impor­ tant discovery – the RhD antigen, named after the Rhesus monkeys they used for their experi­ ments. From then onwards, blood transfusion became safe for everyone. Since these pioneers’ work, the practice of blood transfusion has evolved. The International Society of Blood Transfusion (Amsterdam, The Netherlands) recognizes 30 blood groups com­ prising over 300 antigens. Blood components are now separated to fulfill specific medical needs, automated apparatus to collect these products are used and all blood donations are tested for transmissible diseases.

During recent years, so rapid and remarkable have been the developments in the field of dermatology, so vitally has progress been influenced by discoveries in kindred sciences, that by no group of medical men can more benefit be obtained from annual meetings than by dermatologists. For we bring to these meetings the results of labor in crowded clinical laboratories and conclusions reached after accurate diagnoses and employment of therapeutic means in countless cases. To exchange personal experiences we come from the shores of the Pacific to the coast of the Atlantic, drawn together by that powerful tie—common interest in a profession whose advance depends entirely on investigations of science. So far-reaching is interest in this world-wide profession that it spans the ocean, and brings from the mother country our highly esteemed colleague—Dr. J. M. H. MacLeod, a clinician of marked skill, an author of international reputation, a lecturer whose instruction

Пам’ять про Першу світову війну у монументальному мистецтві Польщі

Whole blood transfusion is a practical option to counter the lack of supply and lack of clotting factors.Supplying blood to the battlefront has been an ever-growing challenge since its inception in the First World War, when blood collection and transfusions came of age. During the early phases of Operation Iraqi Freedom, blood supplies were difficult to acquire and maintain because of the dynamic and austere environment of the battlefield. To ensure adequate supplies to meet patients’ needs during emergency situations, some units collected and transfused whole blood.During the initial phases of Operation Iraqi Freedom (Spring 2003), our forward surgical team (FST) received our first call that medical evacuation helicopters were bringing in several severely wounded casualties. Unknown to us at that time, this experience would also be our first time of collecting whole blood.The fall of the Berlin Wall brought many changes, including the way the US Army would fight future battles. For many years, the Cold War had provided the US Armed Forces a single enemy, and only a linear concept of fighting a war. Military planners soon realized that the post–Cold War battlefield would be characterized by quick-moving military operations in which mobility, flexibility, and geographically extended lines of communication would be key elements to success.1 In order to support the changing battlefield, the FST concept was developed in 1987, leading to a significant change in how the Army Medical Corps delivers wartime health care. The concept of the FST is based on research from earlier conflicts that indicated that hemorrhage was the most common cause of preventable mortality.1 The earlier experiences showed that the faster a casualty was treated and stabilized, the more mortality and long-term morbidity were reduced. Operation Iraqi Freedom is the first large-scale test of the Army’s new concept of placing surgical assets close to the fighting and potentially right in the heat of battle.An FST consists of a 20-person team that can provide around-the-clock surgical and postoperative care for up to 30 patients in a 72-hour period without resupply2 (Figure 1). Typical surgical candidates for a FST include patients with major chest or abdominal wounds, uncontrolled or continuous hemorrhage, severe shock, airway compromise, and closed head injuries with progressively deteriorating levels of consciousness.1 The section breakdown and team organization are described in more detail in the TableT1.Mobility is critical to the success of an FST, so limitations must be set on supplies, blood, and equipment. Increasing the weight of an item or the space it requires will directly increase the overall size of the FST and slow the team’s movement. The time frame for FST operations (48–72 hours) and the limitation in supplies demand efficiency and frequent resupply. Blood storage is confined to a compact portable refrigerator (Figure 2). The refrigerator can hold approximately 50 units of PRBCs, an amount that is adequate for our 72-hour mission but leaves little room for multiple mass transfusions. Therapy with blood components is often not possible, and an FST cannot afford the extra room to carry platelets, fresh-frozen plasma, or cry-oprecipitate.3,4 Managing storage limitations, maintaining blood at required temperatures (outdoor daytime temperatures often exceed 49ºC [120ºF]), ensuring shelf life, and coordinating resupply caused major difficulties for our blood bank in addition to the normal complications associated with maintaining stored blood.5Indications for the use of fresh whole blood (FWB) have been reported. Jevtic et al6 described using autotransfusion to supplement limited blood supply for treatment of massive hemothorax during high-intensity combat in the territories of the former Yugoslavia during 1991 and 1992. During the war in Croatia in the early 1990s, Horzic et al3 noted the importance of transfusion services during wartime to ensure that adequate amounts of whole blood are readily available. FWB has been used within the military community during significant conflicts when subcomponents such as platelets and frozen components were not available.7 In Somalia, FWB was used after the entire supply of PRBCs was used,8 and in the first Gulf War, FWB was used when platelet supplies were exhausted.7During combat operations, limitations and restrictions in blood products affect the decision of when to use blood and/or how much blood to use for the situation at hand. Each medical unit must decide how to augment its blood supply in crisis situations when immediate resupply is not an option. Use of FWB is a practical option in these extreme situations, and each soldier deployed is a source of whole blood.Recognized shortfalls of blood and/or blood components have been a wartime reality, and health care providers have needed to adapt. The principle of walking blood banks is not new; it has been documented in the literature and is an effective alternative to stored blood.4 Medical units have typed and screened assigned personnel before deployment to further augment the units’ own organic blood supply. The screening process used by the FST for this emergency blood requirement relies on donors’ answers to screening questions and the predeployment processing system. Predeployment processing is a screening evaluation completed on all military personnel before they are deployed to ensure that they are healthy enough to deploy, have received all required vaccinations, are free from communicable diseases, and have proper blood-typing documentation. For example, the screening prevents deployment of soldiers who have a positive test for infection with human immunodeficiency virus or have other communicable diseases. Hepatitis vaccinations are a requirement for all medical personnel. Prescreening before FWB donation confirmed each donor’s general state of health, verified blood type, and completion of all required immunizations.Walking blood banks require no refrigeration and can provide a wide variety of blood types. When the need arises for additional blood, this prearranged walking blood bank offers ready access to FWB; prescreened donors require only a rapid recertification before blood is donated.4 However, this type of walking blood bank has a major drawback for the FST. Donation of blood can affect some donors physically, and these donors would require time to recover, a luxury an FST cannot afford with limited personnel and 24-hour operations.Upon receiving word from the primary general surgeon that FWB was needed, we notified personnel in the base camp that a soldier was in urgent need of blood. Within minutes, a line of nearly a dozen soldiers had formed. Our blood donation collection system consisted of a primary container with 63 mL of a solution of the anticoagulant citrate phosphate dextrose and a satellite container with 100 mL of Optisol brand preservative solution for red blood cells (Terumo Medical Corp, Tokyo, Japan). We did not use the satellite container, which is used for collecting plasma and cryoprecipitate. With the primary container, approximately 450 mL of blood can be collected. The collection system includes all the required tubing and needles for collection. Blood was collected from an antecubital vein, while the collection container was gently rocked, until the container was full. During this process, additional samples were collected for further testing of the blood for hepatitis B and C viruses, human immunodeficiency virus, syphilis, and human T-cell lymphotropic viruses I and II; a donor tracking system should be in place to locate donors if indicated.9 After collection, the blood was immediately given to the staff caring for the patient for immediate infusion. The blood was run through a rapid fluid infuser by using blood tubing, and each unit of blood was followed by 250 mL of normal saline intravenous solution. The time from questioning of the first donor soldier to bedside delivery of the first unit of FWB was less than 20 minutes.In the most severely injured casualties, preventing the lethal triad of hypothermia, acidosis, and coagulopathy is paramount.10 FWB can be a key component in the reversal of the effects of this triad. Treatment with FWB can reverse dilutional coagulopathy associated with transfusing large amounts of preserved red blood cells.11Whole blood and PRBCs differ markedly. Type O whole blood has benefits in correcting coagulopathy that may offset the inherent risks of giving FWB. FWB is readily available, can increase both red cell mass and plasma volume, and contains clotting factors, which were critical for the patient described in the case study and are not otherwise available.12 Levels of coagulation factors II, V, VII, IX, X, XII, and XIII and fibrinogen are well preserved in stored whole blood.13 In total, 1 unit of PRBCs (335 mL) plus 1 unit of platelets (50 mL) plus 1 unit of fresh-frozen plasma (275 mL) provide 660 mL of fluid with a hematocrit of 0.29, 88 000 platelets, and 65% coagulation factor activity. In contrast, 1 unit of FWB (500 mL) has a hematocrit of 0. 33 to 0.43, 130 000 to 350 000 platelets, and 86% coagulation factor activity.14Whole blood transfusions are a tried and proven concept.4,7,9,15,16 The systemic effects—improved intravascular volume, decreased or limited third spacing, enhanced oxygen carrying capacity, and replenishment of coagulation factors—all prove the effectiveness of this therapy.15 Replacement solely with crystalloids and PRBCs may aggravate coagulopathy further. Experience in treating the severely wounded in Operation Iraqi Freedom has indicated that patients may already have coagulopathy upon admission to an FST.10,17 Anecdotal evidence10 from health care personnel who treated trauma patients in Iraq suggests that decreased crystalloid use in the first 24 hours results in less postoperative edema and may improve ventilation and decrease duration of mechanical ventilation. During the situation discussed in this article, treatment with FWB provided the only possible solution available at the time to reverse the coagulopathy experienced by the patient.Whole blood transfusion should be considered as an option for treatment of patients with unresponsive hypovolemic shock or coagulopathy during war or during shortages of blood components in a domestic disaster. With planning, appropriate supplies, and access to a walking blood bank, whole blood transfusion can be a safe and rapid alternative in times of critical blood shortages. Use of whole blood has played an important role in the history of war and treating wounded soldiers; its use should still be considered relevant, especially for replacing clotting components that are not readily available in a combat theater of operations.The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

The concept for this paper originated from my work with the diary of American World War II soldier Vernon Goetz. I have been working with the diary and its artifacts in Goucher’s Special Collections since the fall of 2013 with Professor Tina Sheller. In Professor Sheller’s Historic Preservation 311 course entitled “Public History: Theory and Practice” we focused on the documents that were found inside of the diary. I was assigned three leaflets from the diary to use as a basis for my research into the United States government’s use of psychological warfare during World War II. As I began my research, I became fascinated with the different messages that were used to influence the attitudes and actions of Americans and Germans and with the techniques used to completely surround both groups with these messages. Throughout this paper I explored the origins and methods of the United States government’s propaganda campaigns that were used to gain support from Americans and weaken German forces.

Seventy years earlier, the Battle of Stalingrad ended, changing the course of the European theatre of the Second World War. As the researcher of this project, I now stood in southern Russia, inside the siege boundary of this pivotal turning point during the war. My direct, subjective perception of this ruinscape, of geographical and meteorological extremes, juxtaposed with my long-held fascination with the narrative and representation of combat spectacle of the Stalingrad combat film canon. These sources fed the desire to reconstruct the spatiality of encircled defendable spaces and make-shift urban battlements on the threshold of combat, from a merging of two sources: the documentation of the historical event as a decaying landscape of ruin and the recreation of these events as cinema. This exegesis investigates the perception of these liminal spaces through the lens of autoethnography. The research analyses the narrative state and ambiguous potentialities of the non-combat scenes from a tangible craft-based production design point of view. Attention is focused on the morbid scenic design of the geographical panorama, ruined architecture and extreme meteorology of these in-between battlefield microcosms; the visual state of environmental conditions translated into stages suspended on the threshold of combat violence. It examines how these combine to shape the interpretive nuances of the liminal miseen- scene comparative to the macrocosm of combat. The architectural landscape of the urban battlefield becomes perceptually invisible inside the spectacle of modern warfare. This architecture of warfare, originating from the frontline event, is re-discovered inside the architecture of the combat film. Acknowledging that there are inherent political overtones to the study of military warfare, this research is purely concerned with the on-screen architecture of the liminal scene mise-en-scene in the Stalingrad canon and how this can be reconstructed and transformed into stop motion animation. The purpose is to offer a new reading of the staging qualities of this production design as threedimensional craft. This production design explores the spatial through the tangible, translating a personal experience of actual battlefield spaces into a scale-model. The restaging of this architectural landscape of ruin, is re-directed by interpretation into a re-constructed image, through deep mapping, that is then translated into the three-dimensions of a tangible film set design. Reconfigured through the stagecraft of stop motion animation, the ruinscape reappears in the miniature and is transitioned and re-produced as a system of production design.

The article is a review of the scientific reference edition “Prisoners of War of the First World War: Interfund Name Index to the metric books of churches of the Omsk region (1914-1920)”, prepared by a team of eight employees of the Historical Archive of the Omsk region. The book was published in December 2023, and its presentation to the general scientific community took place on February 1, 2024 in the Center for the Study of the History of the Civil War of the Historical Archive of the Omsk Region. The basis for the preparation of the scientific and reference edition is a continuous study of act records of metric books of churches of four world confessions, operating in the Omsk region at that time. The argument in favor of this choice was the fact that the records of dozens of Orthodox churches, churches, kirchas and synagogues have been preserved in the Historical Archive of the Omsk Region. The name index is a brief biographical information with search data on prisoners of war who appeared in 1914-1920 on the territory of the modern Omsk region. The preface to the publication by the authoritative historian D. I. Petin contains the historiography of the study of prisoners of war of the early twentieth century in Siberia, an analytical review of published materials with generalized statistical data, a description of the methodology of compiling the index and actually represents an independent study on the problem of prisoners of war of the First World War in the Omsk region. Military-historical anthropology with elements of imagology and local history became the theoretical basis for the analytical comprehension of the book novelty. The principles of historicism, scientific approach in depicting historical phenomena and rationalization of archival business gave grounds to refer this publication not only to the sphere of professional historical interest, but also to the demanded reference publications of search character in the field of historical biography and practical genealogy. The review presents the significance of the interfond index for historical research on the problems of prisoners of war during the First World War, descendants of foreigners searching for their ancestors, and in general for the preservation of historical memory of the tragic pages of world history. The merits of this publication as a research project aimed at publishing a representative set of sources on the history of prisoners of war in the Omsk region during the period of social cataclysms are highlighted.

We review the effects of war on HIV and STI transmission and critically appraise short- and medium-term approaches to prevention. Our intent is to stimulate thinking about the potential for increased HIV/STI transmission in current and future armed conflicts with particular reference to Afghanistan and to encourage timely interventions to prevent a worsening HIV epidemic in Central and South Asia. (excerpt)

The Dutch were not just passive bystanders of the war. They reflected on the nature and consequences of modern warfare and on the position of their country in the world. Their responses to and reflections on the war were influenced by the neutral position of the Netherlands. While reservations about military violence were dominant in popular reactions, people were extremely interested in the details of modern warfare. After the war, commemoration initially focused on the mobilisation and neutrality. In the 1920s the pacifist memory of the war as mass suffering in an allegedly senseless conflict prevailed until the Second World War.

British strategy in 1939 had been based on the belief that Britain could not provide a large army to fight on the continent; instead, she would make her contribution in other areas. Of these, one of the most significant was a rather nebulous but nonetheless important aspect of strategy known as economic warfare. This idea was originally based on the belief that Germany’s ultimate defeat in the First World War had been due to the success of blockade, and during the 1930s it had been expanded to include such other means of pressure as strategic bombing, sabotage and psychological warfare. By the outbreak of the Second World War the theory had become highly attractive to many and, in the opinion of one commentator, was seen as ‘the primary instrument of war’ and ‘the mainstay of official strategy’. This position could only be reinforced as Britain’s European allies were overrun, for without their armies there was little choice other than to adopt unconventional methods of waging war.