Trauma-induced coagulopathy (TIC) is a recently described condition which traditionally has been diagnosed by the common coagulation tests (CCTs) such as prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), platelet count, and fibrinogen levels. The varying sensitivity and specificity of these CCTs have led trauma coagulation researchers and clinicians to use Viscoelastic Tests (VET) such as Thromboelastography (TEG) to provide Targeted Thromboelastographic Hemostatic and Adjunctive Therapy (TTHAT) in a goal directed fashion to those trauma patients in need of hemostatic resuscitation. This review describes the utility of VETs, in particular, TEG, to provide TTHAT in trauma and acquired non-trauma-induced coagulopathy.Keywords: Thromboelastography, point-of-care, acquired coagulopathy, blood component therapy, systemic hemostatic agents, trauma-induced coagulopathy, hemostatic resuscitation, tranexamic acid, targeted pharmacologic therapy. TRAUMA INDUCED COAGULOPATHY AND AC-QUIRED COAGULOPATHY IntroductionCoagulopathy is found in approximately 25% of severely injured trauma patients on admission to the emergency department (ED). Patients with Trauma-Induced Coagulopathy (TIC) are at a higher risk for increased transfusion requirements and death compared to those without TIC [1][2][3][4][5]. The etiology of TIC has been a matter of speculation. Trauma induced disturbances of compensatory activation of activated protein C (APC), hypofibrinogenemia, Tissue Factor (TF) release, coagulation factor consumption and dilution, platelet dysfunction, and fibrinolysis have been cited as possible causes of TIC [1][2][3][4][5][6][7][8][9]. In addition, it has been argued by Gando and others that TIC is a variant of disseminated intravascular coagulation [10,11]. Most recently, Dobson et al. have described the etiology of TIC in relation to four paradigms of hemostatic derangement which are: 1) the DIC/ consumption/ fibrinolysis hypothesis 2) the activated protein-C hypothesis 3) the glycocalyx hypothesis and 4) the "fibrinogencentric" hypothesis. These hypotheses are not mutually exclusive. It is necessary to refer to this theoretical aspect of

aPKC is highly expressed and activated in cancers of epithelial origin. aPKC is sufficient to disrupt apical-basal polarity and overcome contact inhibition of epithelial cell growth to promote a transformed phenotype by deregulating Hippo/Yap signaling.

This article discusses the importance and effectiveness of viscoelastic hemostatic assays (VHAs) in assessing hemostatic competence and guiding blood component therapy (BCT) in patients with postpartum hemorrhage (PPH). In recent years, VHAs such as thromboelastography and rotational thromboelastometry have increasingly been used to guide BCT, hemostatic adjunctive therapy and prohemostatic agents in PPH. The three pillars of identifying hemostatic competence include clinical observation, common coagulation tests, and VHAs. VHAs are advantageous because they assess the cumulative contribution of all components of the blood throughout the entire formation of a clot, have fast turnaround times, and are point-of-care tests that can be followed serially. Despite these advantages, VHAs are underused due to poor understanding of correct technique and result interpretation, a paucity of widespread standardization, and a lack of large clinical trials. These VHAs can also be used in cases of uterine atony, preeclampsia, acute fatty liver of pregnancy, amniotic fluid embolism, placental abruption, genital tract trauma, surgical trauma, and inherited and prepartum acquired coagulopathies. There exists an immediate need for a point-of-care test that can equip obstetricians with rapid results on developing coagulopathic states. The use of VHAs in predicting and treating PPH, although in an incipient state, can fulfill this need.

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Purpose: To describe experience with an outpatient interventional radiology (IR) vein practice with respect to internal referrals, external referrals, self-referrals, and downstream patient retention into the affiliated parent hospital system. Materials and Methods: An IRB-approved single institution retrospective review of outpatient visits at a newly established IR outpatient clinic was performed between June 2009 and December 2012. Demographic data, type of referral (obtained through a standard questionnaire during the intake process), prior contact with the affiliated parent hospital system and subsequent continuation of care within the hospital system were examined. Results: Between the establishment of this outpatient IR clinic in June 2009 and December 2012, there was a total of 2404 patient visits. Of these, 743 (30.9%) were new patient visits for the evaluation of venous disease. 634 (85.3%) of the new patients were female and 109 (14.7%) were male, with an average age of 53 years old. 248 (33.4%) new patient visits were from internal referrals affiliated with the clinic's parent hospital system. 495 (66.6%) visits were from external referrals. This included outside practitioners (306 visits, 61.8%) who in part were reached through health fair expos, and patient selfreferrals (189, 38.2%) which were attributed to advertising/ marketing (144, 64.5%), friends (6, 3.2%), internet research (5, 2.6%), and "other" (34, 18%). 229 (46.3%) of the 495 externally referred patients had no prior contact with the affiliated parent hospital system (e.g., antecedent clinic visits, diagnostic testing, etc.). Of these, 50 (21.8%) went on to receive further medical care unrelated to their IR clinic visit in the parent hospital system. Conclusion: External referrals are essential to building a robust outpatient IR clinical practice. While some of these referrals are obtained from consumer marketing, out of network external physician referrers comprise the majority and are a key target in the referring community. Conversion and retention of these externally referred new IR patients generates positive downstream effects for the parent hospital system and may support the establishment of these clinics.

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