Etienne St-Louis

Using the age-adjusted Charlson comorbidity index to predict outcomes in emergency general surgery.

BACKGROUND We evaluated the role of the Charlson age-comorbidity index (CACI), a weighted comorbidity index that reflects cumulative increased likelihood of 1-year mortality, in predicting perioperative outcomes in an emergency general surgery population at a large Canadian teaching hospital. METHODS A retrospective chart review of emergency general surgery admissions in 2010 was conducted. Patients who had surgery were identified. Mode of surgery and CACI were recorded, as well as measures of outcome, including 30-day mortality and intensive care unit (ICU) admission. A multivariate stepwise logistic regression model was created to assess the effect of age-adjusted Charlson comorbidity index on postoperative outcomes while controlling for the effect of possible confounders. The prediction ability of CACI for mortality was assessed using receiver operating characteristic analyses considering the area under the curve and its 95% confidence intervals (CIs). RESULTS Of the 529 admissions to general surgery from the emergency department, 257 patients underwent a surgical intervention. The CACI scores ranged from 0 to 16. We described a total of 11 deaths (4.3%) and 30 ICU admissions (11.7%). CACI was associated with an increased risk of 30-day mortality (adjusted odds ratio,1.39; 95% CI, 1.11–1.73; p = 0.0034). Receiver operating characteristic analysis was consistent with high accuracy of CACI for mortality prediction alone, resulting in area under the curve or c statistic of 0.90 (95% CI, 0.84–0.95). CACI was similar in predicting mortality to a multivariate model. CACI was also found to be associated with ICU admission (adjusted odds ratio, 1.17; 95% CI, 1.01–1.37; p < 0.0382). CACI is not as good a predictor for ICU admission when compared with the multivariate model. CONCLUSION We have shown that the CACI is a valid tool for 30-day mortality prediction in the context of emergency general surgery. LEVEL OF EVIDENCE Prognostic study, level III.

The Global Initiative for Children's Surgery: Optimal Resources for Improving Care

Abstract Background The Lancet Commission on Global Surgery reported that 5 billion people lack access to safe, affordable surgical care. The majority of these people live in low‐resource settings, where up to 50% of the population is children. The Disease Control Priorities (Debas HTP, Donkor A, Gawande DT, Jamison ME, Kruk, and Mock CN, editors. Essential Surgery. Disease Control Priorities. Third Edition, vol 1. Essential Surgery. Washington, DC: World Bank; 2015) on surgery included guidelines for the improvement of access to surgical care; however, these lack detail for childrens surgery. Aim To produce guidance for low‐ and middle‐income countries (LMICs) on the resources required for childrens surgery at each level of hospital care. Methods The Global Initiative for Childrens Surgery (GICS) held an inaugural meeting at the Royal College of Surgeons in London in May 2016, with 52 surgical providers from 21 countries, including 27 providers from 18 LMICs. Delegates engaged in working groups over 2 days to prioritize needs and solutions for optimizing childrens surgical care; these were categorized into infrastructure, service delivery, training, and research. At a second GICS meeting in Washington in October 2016, 94 surgical care providers, half from LMICs, defined the optimal resources required at primary, secondary, tertiary, and national referral level through a series of working group engagements. Results Consensus solutions for optimizing childrens surgical care included the following:Establishing standards and integrating them into national surgical plans.Each country should have at least one childrens hospital.Designate, facilitate, and support regional training hubs covering allchildrens surgical specialties.Establish regional research support centers. An “Optimal Resources” document was produced detailing the facilities and resources required at each level of care. Conclusion The Optimal Resources document has been produced by surgical providers from LMICs who have the greatest insight into the needs and priorities in their population. The document will be refined further through online GICS Working Groups and the World Health Organization for broad application to ensure all children have timely access to safe surgical care.

Systematic review and need assessment of pediatric trauma outcome benchmarking tools for low-resource settings

IntroductionTrauma is a leading cause of mortality and disability in children worldwide. The World Health Organization reports that 95% of all childhood injury deaths occur in Low–Middle-Income Countries (LMIC). Injury scores have been developed to facilitate risk stratification, clinical decision making, and research. Trauma registries in LMIC depend on adapted trauma scores that do not rely on investigations that require unavailable material or human resources. We sought to review and assess the existing trauma scores used in pediatric patients. Our objective is to determine their wideness of use, validity, setting of use, outcome measures, and criticisms. We believe that there is a need for an adapted trauma score developed specifically for pediatric patients in low-resource settings.Materials and methodsA systematic review of the literature was conducted to identify and compare existing injury scores used in pediatric patients. We constructed a search strategy in collaboration with a senior hospital librarian. Multiple databases were searched, including Embase, Medline, and the Cochrane Central Register of Controlled Trials. Articles were selected based on predefined inclusion criteria by two reviewers and underwent qualitative analysis.ResultsThe scores identified are suboptimal for use in pediatric patients in low-resource settings due to various factors, including reliance on precise anatomic diagnosis, physiologic parameters maladapted to pediatric patients, or laboratory data with inconsistent accessibility in LMIC.ConclusionAn important gap exists in our ability to simply and reliably estimate injury severity in pediatric patients and predict their associated probability of outcomes in settings, where resources are limited. An ideal score should be easy to calculate using point-of-care data that are readily available in LMIC, and can be easily adapted to the specific physiologic variations of different age groups.

Development and validation of a new pediatric resuscitation and trauma outcome (PRESTO) model using the U.S. National Trauma Data Bank

BACKGROUNDnThere is a need for a pediatric trauma outcomes benchmarking model that is adapted for Low-and-Middle-Income Countries (LMICs). We used the National-Trauma-Data-Bank (NTDB) and applied constraints specific to resource-poor environments to develop and validate an LMIC-specific pediatric trauma score.nnnMETHODSnWe selected a sample of pediatric trauma patients aged 0-14years in the NTDB from 2007 to 2012. Primary outcome was in-hospital death. Logistic regression was used to create the Pediatric Resuscitation and Trauma Outcome (PRESTO) score, which includes only low-tech predictor variables - those easily obtainable at point-of-care. Internal validation was performed using 10-fold cross-validation. External validation compared PRESTO to TRISS using ROC analyses.nnnRESULTSnAmong 651,030 patients, there were 64% males. Median age was 7. In-hospital mortality-rate was 1.2%. Mean TRISS predicted mortality was 0.04% (range 0%-43%). Independent predictors included in PRESTO (p<0.01) were age, blood pressure, neurologic status, need for supplemental oxygen, pulse, and oxygen saturation. The sensitivity and specificity of PRESTO were 95.7% and 94.0%. The resulting model had an AUC of 0.98 compared to 0.89 for TRISS.nnnCONCLUSIONnPRESTO satisfies the requirements of low-resource settings and is inherently adapted to children, allowing for benchmarking and eventual quality improvement initiatives. Further research is necessary for in-situ validation using prospectively collected LMIC data.nnnLEVEL OF EVIDENCEnLevel III - Case-Control (Prognostic) Study.

Optimizing the assessment of pediatric injury severity in low-resource settings: Consensus generation through a modified Delphi analysis

INTRODUCTIONnAlthough a plethora of pediatric injury severity scoring systems is available, many of them present important challenges and limitations in the low resource setting. Our aim is to generate consensus among a group of experts regarding the optimal parameters, outcomes, and methods of estimating injury severity for pediatric trauma patients in low resource settings.nnnMATERIALS AND METHODSnA systematic review of the literature was conducted to identify and compare existing injury scores used in pediatric patients. Qualitative data was extracted from the systematic review, including scoring parameters, settings and outcomes. In order to establish consensus regarding which of these elements are most adapted to pediatric patients in low-resource settings, they were subjected to a modified Delphi survey for external validation. The Delphi process is a structured communication technique that relies on a panel of experts to develop a systematic, interactive consensus method. We invited a group of 38 experts, including adult and pediatric surgeons, emergency physicians and anesthesiologists trauma team leaders from a level 1 trauma center in Montreal, Canada, and a pediatric referral trauma hospital in Santiago, Chile to participate in two successive rounds of our survey.nnnRESULTSnConsensus was reached regarding various features of an ideal pediatric trauma score. Specifically, our experts agreed pediatric trauma scoring tool should differ from its adult counterpart, that it can be derived from point of care data available at first assessment, that blood pressure is an important variable to include in a predictive model for pediatric trauma outcomes, that blood pressure is a late but specific marker of shock in pediatric patients, that pulse rate is a more sensitive marker of hemodynamic instability than blood pressure, that an assessment of airway status should be included as a predictive variable for pediatric trauma outcomes, that the AVPU classification of neurologic status is simple and reliable in the acute setting, and more so than GCS at all ages.nnnCONCLUSIONnTherefore, we conclude that an opportunity exists to develop a new pediatric trauma score, combining the above consensus-generating ideas, that would be best adapted for use in low-resource settings.

Out-of-Pocket and Catastrophic Expenses Incurred by Seeking Pediatric and Adult Surgical Care at a Public, Tertiary Care Centre in Uganda

BackgroundSurgical care is critical to establish effective healthcare systems in low- and middle-income countries, yet the unmet need for surgical conditions is as high as 65% in Ugandan children. Financial burden and geographical distance are common barriers to help-seeking in adult populations and are unmeasured in the pediatric population. We thus measured out-of-pocket (OOP) expenses and distance traveled for pediatric surgical care in a tertiary hospital in Mbarara, Uganda, as compared to adult surgical and pediatric medical patients.MethodsPatients admitted to pediatric surgical (nu2009=u200920), pediatric medical (nu2009=u200918) and adult surgical (nu2009=u200918) wards were interviewed upon discharge over a period ofxa03xa0weeks. Patient and caregiver-reported expenses incurred for the present illness included prior/future care needed, and travel distance/cost. The prevalence of catastrophic expenses (≥10% of annual income) was calculated and spending patterns compared between wards.ResultsThirty-five percent of pediatric medical patients, 45% of pediatric surgical patients and 55% of adult surgical patients incurred catastrophic expenses. Pediatric surgical patients paid more for their current treatment (pu2009<u2009u20090.01)—specifically medications (pu2009<u2009u20090.01) and tests (pu2009<u2009u20090.01)—than pediatric medical patients, and comparable costs to adults. Adult patients paid more for treatment prior to the hospital (pu2009=u20090.04) and miscellaneous expenses (e.g., food while admitted) (pu2009=u20090.02). Patients in all wards traveled comparable distances.ConclusionsSeeking healthcare at a publicly funded hospital is financially catastrophic for almost half of patients. Out-of-stock supplies and broken equipment make surgical care particularly vulnerable to OOP expenses because analgesics, anaesthesia and preoperative imaging are prerequisites to care.

Strategies for successful trauma registry implementation in low- and middle-income countries—protocol for a systematic review

BackgroundThe benefits of trauma registries have been well described. The crucial data they provide may guide injury prevention strategies, inform resource allocation, and support advocacy and policy. This has been shown to reduce trauma-related mortality in various settings. Trauma remains a leading cause of mortality in low- and middle-income countries (LMICs). However, the implementation of trauma registries in LMICs can be challenging due to lack of funding, specialized personnel, and infrastructure. This study explores strategies for successful trauma registry implementation in LMICs.MethodsThe protocol was registered a priori (CRD42017058586). A peer-reviewed search strategy of multiple databases will be developed with a senior librarian. As per PRISMA guidelines, first screen of references based on abstract and title and subsequent full-text review will be conducted by two independent reviewers. Disagreements that cannot be resolved by discussion between reviewers shall be arbitrated by the principal investigator. Data extraction will be performed using a pre-defined data extraction sheet. Finally, bibliographies of included articles will be hand-searched. Studies of any design will be included if they describe or review development and implementation of a trauma registry in LMICs. No language or period restrictions will be applied. Summary statistics and qualitative meta-narrative analyses will be performed.DiscussionThe significant burden of trauma in LMIC environments presents unique challenges and limitations. Adapted strategies for deployment and maintenance of sustainable trauma registries are needed. Our methodology will systematically identify recommendations and strategies for successful trauma registry implementation in LMICs and describe threats and barriers to this endeavor.Systematic review registrationThe protocol was registered on the PROSPERO international prospective register of systematic reviews (CRD42017058586).

Vacuum Bell Treatment of Pectus Excavatum: an Early North American Experience

PURPOSEnConservative treatment of pectus excavatum with a vacuum bell device may be an attractive alternative to surgical repair. We describe an early North American experience with this device.nnnMETHODSnProspectively maintained chest wall clinic registries from two institutions were reviewed to identify pectus excavatum patients ≤21u202fyears treated with the vacuum bell from 2013 to 2017. Multivariate linear regression was used to compare mean improvements in deformity-depth and Haller Index between groups of patients based on age and usage metrics (hours/day and days/week).nnnRESULTSnThirty-one patients with a median age of 14u202fyears received treatment with the device. Mean follow-up duration was 18u202fmonths. Median depth and Haller Index at treatment onset were 2.3u202fcm and 3.9, respectively. Improvements in deformity-depth were superior with device usage >2u202fh/day (pu202f<u202f0.01) and daily use (pu202f<u202f0.01). After adjusting for compliance, younger age of treatment onset was associated with greater improvement in Haller Index but not deformity depth.nnnCONCLUSIONnOur prospective early North American experience found the vacuum bell to be a potential alternative to surgical treatment for pectus excavatum. Longer usage periods in a daily frequency are associated with best results.nnnTYPE OF STUDYnTreatment study; case series with no comparison group.nnnLEVEL OF EVIDENCEnLevel IV.

Experience with peritoneal thermal injury during subcutaneous endoscopically assisted ligation for pediatric inguinal hernia

BACKGROUNDnSubcutaneous endoscopically-assisted ligation (SEAL) for pediatric inguinal hernia repair has gained in popularity although variations in techniques exist. Peritoneal scarring by thermal injury has been described as an adjunct. We explored the hypothesized inverse-correlation between peritoneal scarring and recurrence after SEAL.nnnMETHODSnWe conducted a single-center retrospective review of all patients <18years old undergoing SEAL between 2010 and 2016 (REB-20172727). Demographics and outcomes were investigated. Univariate and multivariable logistic regressions were performed to evaluate the association between peritoneal scarring and recurrence.nnnRESULTSnWe identified 272 patients. Median age was 3years, 35% were female, and 19% were born premature. Median follow-up was 30months, ≥1 visit/patient. Bilaterality was noted in 35%. There were no reported cases of metachronous hernia, vas injury, testicular atrophy or chronic pain, and recurrence rate was 4.6%. Prematurity, unilateral repair, incarceration, and suture-type (Ti-Cron® vs. Ethibond®) had significant correlation with recurrence on univariate analysis (p<0.25). Surgeon experience did not. Peritoneal scarring, performed in 195 cases (72%), was not predictive of recurrence (adjusted OR=0.87, p=0.830) on multivariable analysis.nnnCONCLUSIONnThe rate of complications with SEAL compares favorably to published data. Thermal injury was not associated with improved recurrence rates. The benefits of peritoneal scarring may not outweigh the risks.nnnLEVEL OF EVIDENCEnIII - Retrospective Case-Control Study.

Gastrocutaneous fistulae in children — A systematic review and meta-analysis of epidemiology and treatment options

BACKGROUNDnGastrostomy tubes are a common adjunct to the care of vulnerable pediatric patients. This study systematically evaluates the epidemiology and risk-factors for gastrocutaneous fistulae (GCF) after gastrostomy removal in children and reviews treatment options focusing on nonoperative management (NOM).nnnMETHODSnAfter protocol registration (CRD-42017059565), multiple databases were searched. Studies describing epidemiology in children and GCF treatment at any age were included. Critical appraisal was performed (MINORS risk-of-bias assessment tool). One-sided meta-analysis was executed to estimate efficacy of therapeutic adjuncts using a random-effects model.nnnRESULTSnSixteen articles evaluating pediatric GCF were identified. 44% defined GCF as persistence >1month which occurred in 31±7% of cases. Risk factors for pediatric GCF include age at gastrostomy, timing of removal, open technique, and fundoplication. Mean MINORS score was 0.60±0.16. Seventeen additional studies were identified reporting 142 patients undergoing NOM (endoscopic, systemic, and local therapies), and one pediatric comparative study was identified. Overall aggregate proportion of GCF closure after any NOM is 77% (80% success rate in local/systemic therapies; 75% success rate in endoscopic approaches). No adverse events were reported.nnnCONCLUSIONnPersistent GCF complicates the management of gastrostomies in 1/3 of children with predictable risk factors. Several treatment options exist that obviate the need for general anesthesia. Their efficacy is unclear. Further prospective investigations are clearly warranted.nnnLEVEL OF EVIDENCEnIII - Systematic Review and Meta-Analysis Based on Retrospective Case Control Studies.