Mohammad Asim

The therapeutic challenges of degloving soft-tissue injuries.

Background: Degloving soft-tissue injuries are serious and debilitating conditions. Deciding on the most appropriate treatment is often difficult. However, their impact on patients’ outcomes is frequently underestimated. Objectives: We aimed to study the incidence, clinical presentation, management and outcome of degloving soft-tissue injuries. Materials and Methods: We conducted a narrative traditional review using the key words; degloving injury and soft-tissue injuries through search engines PubMed, Science Direct, and Scopus. Results: There are several therapeutic options for treating degloving soft-tissue injuries; however, no evidence-based guidelines have been published on how to manage degloving soft-tissue injuries, although numerous articles outline the management of such injuries. Conclusion: Degloving soft-tissue injuries are underreported and potentially devastating. They require early recognition, and early management. A multidisciplinary approach is usually needed to ensure the effective rehabilitation of these patients.

The laboratory risk indicator for necrotizing fasciitis (LRINEC) scoring: the diagnostic and potential prognostic role

BackgroundNecrotizing fasciitis (NF) is a devastating soft tissue infection associated with potentially poor outcomes. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score has been introduced as a diagnostic tool for NF. We aimed to evaluate the prognostic value of LRINEC scoring in NF patients.MethodsA retrospective analysis was conducted for patients who were admitted with NF between 2000 and 2013. Based on LRINEC points, patients were classified into (Group 1: LRINECu2009<u20096 and Group 2: LRINECu2009≥u20096). The 2 groups were analyzed and compared. Primary outcomes were hospital length of stay, septic shock and hospital death.ResultsA total of 294 NF cases were identified with a mean age 50.9u2009±u200915xa0years. When compared to Group1, patients in Group 2 were 5xa0years older (pu2009=u20090.009), more likely to have diabetes mellitus (61 vs 41%, pu2009<u20090.001), Pseudomonas aeruginosa infection (pu2009=u20090.004), greater Sequential Organ Failure Assessment (SOFA) score (11.5u2009±u20093 vs 8u2009±u20092, pu2009=u20090.001), and prolonged intensive care (median 7 vs 5xa0days) and hospital length of stay (22 vs 11xa0days, pu2009=u20090.001). Septic shock (37 vs. 15%, pu2009=u20090.001) and mortality (28.8 vs. 15.0%, pu2009=u20090.005) were also significantly higher in Group 2 patients. Using Receiver operating curve, cutoff LRINEC point for mortality was 8.5 with area under the curve of 0.64. Pearson correlation analysis showed a significant correlation between LRINEC and SOFA scorings (ru2009=u20090.51, pu2009<u20090.002).DiscussionEarly diagnosis, simplified risk stratification and on-time management are vital to achieve better outcomes in patients with NF.ConclusionsBeside its diagnostic role, LRINEC scoring could predict worse hospital outcomes in patients with NF and simply identify the high-risk patients. However, further prospective studies are needed to support this finding.

Traumatic Subarachnoid Hemorrhage Due To Motor Vehicle Crash Versus Fall From Height: A 4-Year Epidemiologic Study

BACKGROUNDnTraumatic brain injury (TBI) is a common cause of morbidity and mortality worldwide. It is difficult to estimate the real incidence of traumatic subarachnoid hemorrhage (TSAH). Although TSAH after trauma is associated with poor prognoses, the impact of mechanism of injury (MOI) and the pathophysiology remains unknown. We hypothesized that outcome of TSAH caused by motor vehicle crash (MVC) or fall from height (FFH) varies based on the MOI.nnnMETHODSnData were collected retrospectively from a prospectively created database registry in the section of Trauma Surgery at Hamad General Hospital between January 2008 and July 2012. All patients presented with head trauma and TSAH were included. Patient data included age, gender, nationality, mechanism of injury, injury severity score (ISS), types of head injuries, and associated injuries. Ventilator days, intensive care unit length of stay, pneumonia, and mortality were also studied.nnnRESULTSnA total of 1665 patients with TBI were identified, of them 403 had TSAH with a mean age of 35 ± 15 years. Of them 93% were male patients and 86% were expatriates. MVC (53%) and FFH (35%) were the major mechanisms of injury. The overall mean ISS and head abbreviated injury score were 19 ± 10.6 and 3.4 ± 0.96, respectively. Patients in MVC group sustained severe TSAH, had significantly greater head abbreviated injury score (3.5 ± 0.9 vs. 3.2 ± 0.9; P = 0.009) and ISS (21.6 ± 10.6 vs. 15.9 ± 9.5; P = 0.001), and lower scene Glasgow coma scale (10.8 ± 4.8 vs. 13.2 ± 3.4; P = 0.001) compared with the FFH group. In addition, the MVC group sustained more intraventricular hemorrhage (4.7 vs. 0.7; P = 0.001) and diffuse axonal injury (4.2 vs. 2.9; P = 0.001). In contrast, extradural hemorrhage (14.3% vs. 11.6%; P = 0.008) was higher in the FFH group. Lower extremities (14% vs. 4.3%; P = 0.004) injury was mainly associated with the MVC group. The overall mortality was 19 % among patients with TSAH. The mortality rate was higher in the MVC group when compared with the FFH group (24% vs. 10%; P = 0.001). In both groups, ISS and Glasgow coma scale at the scene were independent predictors of mortality.nnnCONCLUSIONSnPatients with TSAH have a higher mortality rate. In this population, MVCs are associated with a 3-fold increased risk of mortality. Therefore, prevention of MVC and fall can reduce the incidence and severity of TBI in Qatar.

Blunt traumatic injury in the Arab Middle Eastern populations.

Background: Trauma represents a global public health concern with an estimated 5 million deaths annually. Moreover, the incidence of blunt traumatic injuries (BTI) particularly road traffic accidents (RTAs) and workplace-related injuries are rising throughout the world-wide. Objectives: We aimed to review the epidemiology and prevention of BTI, in the Arab Middle East. Materials and Methods: A traditional narrative literature review was carried out using PubMed, MEDLINE and EMBASE search engines. We used the keywords “traumatic injuries”, “blunt” “epidemiology”, “Arab Middle East” between December 1972 and March 2013. Results: The most common mechanisms of BTI in our region are RTAs, falls from height, struck by heavy objects and pedestrian motor vehicle trauma crashes. The rate of RTA and occupational injuries are markedly increased in the region due to rapid industrial development, extreme climatic conditions and unfamiliar working environment. However, lack of reliable information on these unintentional injuries is mainly responsible for the underestimation of this trauma burden. This knowledge deficit shields the extent of the problem from policy makers, leading to continued fatalities. These preventable injuries in turn add to the overall financial burden on the society through loss of productivity and greater need of medical and welfare services. Conclusion: In the Arab Middle East, population-based studies on the incidence, mechanism of injury, prevention and outcome of BTI are not well-documented. Therefore, region-specific BTI studies would strengthen surveillance to better understand the burden of these injuries in the region.

Underutilization of occupant restraint systems in motor vehicle injury crashes: a quantitative analysis from Qatar

ABSTRACT Introduction: Restraint systems (seat belts and airbags) are important tools that improve vehicle occupant safety during motor vehicle crashes (MVCs). We aimed to identify the pattern and impact of the utilization of passenger restraint systems on the outcomes of MVC victims in Qatar. Methods: A retrospective study was conducted for all admitted patients who sustained MVC-related injuries between March 2011 and March 2014 inclusive. Results: Out of 2,730 road traffic injury cases, 1,830 (67%) sustained MVC-related injuries, of whom 88% were young males, 70% were expatriates, and 53% were drivers. The use of seat belts and airbags was documented in 26 and 2.5% of cases, respectively. Unrestrained passengers had greater injury severity scores, longer hospital stays, and higher rates of pneumonia and mortality compared to restrained passengers (P = .001 for all). There were 311 (17%) ejected cases. Seat belt use was significantly lower and the mortality rate was 3-fold higher in the ejected group compared to the nonejected group (P = .001). The overall mortality was 8.3%. On multivariate regression analysis, predictors of not using a seat belt were being a front seat passenger, driver, or Qatari national and young age. Unrestrained males had a 3-fold increase in mortality in comparison to unrestrained females. The risk of severe injury (relative risk [RR] = 1.82, 95% confidence interval [CI], 1.49–2.26, P = .001) and death (RR = 4.13, 95% CI, 2.31–7.38, P = .001) was significantly greater among unrestrained passengers. Conclusion: The nonuse of seat belts is associated with worse outcomes during MVCs in Qatar. Our study highlights the lower rate of seat belt compliance in young car occupants that results in more severe injuries, longer hospital stays, and higher mortality rates. Therefore, we recommend more effective seat belt awareness and education campaigns, the enforcement of current seat belt laws, their extension to all vehicle occupants, and the adoption of proven interventions that will assure sustained behavioral changes toward improvements in seat belt use in Qatar.

Pedestrians: the daily underestimated victims on the road

Traffic-related pedestrian injuries (TRPI) are vulnerable to road users. In this study, we aimed to evaluate the demographic pattern of injury and outcome of TRPI. Patients with TRPI admitted between November 2007 and March 2010 to the only level 1 trauma centre in Qatar were included. A retrospective analysis was based on medical records and Emergency Medical Services run sheets. The spreadsheet included demographic data and pre-hospital transport, service admissions and injuries by system and mortality. Of 4077 patients who were admitted, 420 (10.3%) had TRPI. The mode of transportation included ambulances (91%), private vehicles (6%) and helicopters (3%). The direct dispositions were trauma intensive care units (38%), surgical wards (42%) and operating rooms (17%). Patients were classified according to Injury Severity Score (1–8 in 28%, 9–15 in 25%, 16–24 in 20% and 25–75 in 17% cases). Multisystem injuries were most characteristic. Of 804 injures, injury of extremities was predominant followed by head, thorax and abdomen. The overall mortality was 8%. Pedestrian injuries are a significant cause of serious trauma in Qatar. Motor vehicle/pedestrian interface contributes to this ongoing public health problem. Reducing pedestrian trauma requires recognition of the problem and implementing programmes to mitigate these largely preventable injuries.

Characteristics, Management, and Outcomes of Surgically Treated Arteriovenous Fistula Aneurysm in Patients on Regular Hemodialysis

BACKGROUNDnTo investigate the clinical characteristics, surgical interventions, and outcomes of arteriovenous fistula (AVF) aneurysms, we retrospectively analyzed patients on regular hemodialysis (HD).nnnMETHODSnWe conducted a cohort study of all patients with HD access who presented with AVF aneurysms and underwent operative procedures over a 11-year period. Patients demographics, comorbidities, vascular access characteristics, management of aneurysms, complications, and outcomes were analyzed.nnnRESULTSnOf the 700 end-stage renal failure patients, 530 patients were maintained on HD (130xa0through PermCath and 400 through AV access in terms of AVF and arteriovenous graft). We identified 129 patients who developed AV aneurysms, and 40 of them required surgical interventions (24 men and 16 women) with a mean age of 58xa0±xa014.6xa0years. The 40 patients who developed AVF aneurysms underwent 43 surgical interventions. The majority of aneurysms were presented with thinning and ulceration (82.5%) of the overlying skin. Thirty-four patients had true aneurysms and 6 had pseudoaneurysms. The aneurysmal AVF comprised 26 brachiocephalic fistulas, 9 radiocephalic fistulas, 3 brachial artery grafts, 1 ulnar-basilic fistula, and 1 Fem-Fem graft at presentation. Patients were treated mainly with ligation (13; 32.5%), excision and repair with graft interposition (15; 37.5%) or vein interposition (11; 27.5%), and end-to-end AVF (1;xa02.5%). The median follow-up postsurgery duration was 53xa0months (range 1-192) andxa0thexa0median duration from fistula creation to the surgical intervention was 52xa0months (range 4-182). On follow-up, 34 patients continued on HD, while 5 underwent renal transplantation and 1 shifted to peritoneal dialysis. The overall all-cause mortality rate was 37.5% and the leadingxa0causes of mortality were sepsis/pneumonia (60%), myocardial infarction, and heart failure (40%).nnnCONCLUSIONSnIn HD patients, the rate of AVF aneurysmal formation is high with a significant rate of morbidity and mortality. Therefore, timely and appropriate evaluation and surgical intervention are crucial.

Diagnostic implications of computed tomography pulmonary angiography in patients with pulmonary embolism

Introduction: Pulmonary embolism (PE) is a serious cardiovascular and pulmonary complication worldwide. We aimed to assess the implications of different computed tomography pulmonary angiography (CTPA) parameters in patients with acute PE. Methods: A retrospective observational study to include patients presented with clinical suspicious of PE who underwent CTPA was conducted. Patients demographics, clinical presentation, risk factors, laboratory investigations, management, and outcome were analyzed. Computed tomography findings included clot burden (Qanadli score [QS]) and right ventricular dysfunction (RVD) parameters. Results: A total of 45 patients with radiologically confirmed diagnosis of PE were included in the study; of these patients, 8 (17.8%) died during the hospital course. Patients who died were 13 years older than those who survived, and the mortality rate was significantly higher in patients with cancer. The two groups were comparable for cardiovascular parameters. The mean clot burden (QS) was 19.5 ± 11.3 points and 53% of patients had QS >18 points. Obesity (52.4% vs. 12.5%; P = 0.01), hypertension (54.4% vs. 23.8%; P= 0.03), and median D-dimer levels (7.8 vs. 3.4; P = 0.03) were significantly higher in patients with QS >18. Among right ventricular (RV) dysfunction parameters, only higher RV/left ventricular (LV) ratio (P = 0.001) and bowing of interventricular septum (P = 0.001) were associated with higher QS. A significant positive correlation was found between RV short axis (r = 0.499, P = 0.001), RV/LV ratio (r = 0.592, P = 0.001), and pulmonary artery (PA) diameter (r = 0.301, P = 0.04) with the PA clot burden. Receiver operating characteristic curve for clot burden showed a cutoff value of 17.5 points to accurately predict RV dysfunction. Conclusions: Clot burden >18 is associated with RV dysfunction in patients with acute PE. Echocardiography and RVD parameters showed no correlation with in-hospital deaths. CTPA has clinicoradiological implications for risk stratification in PE patients. As the sample size is small, our findings warrant further larger prospective studies.

Clinical Presentation, Management, and Outcomes of Deep Vein Thrombosis Based on Doppler Ultrasonography Examination

We studied the frequency, clinical presentation, and outcomes of deep vein thrombosis (DVT). Serial Doppler ultrasonography was performed between 2008 and 2013 for 6420 patients with suspected DVT. Diagnosis was confirmed in 662 (10.3%) participants (mean age: 50 ± 17 years; 51% females). Obesity, diabetes mellitus, and malignancy were reported in 47%, 28%, and 16%, respectively. Abnormal protein C, protein S, factor V Leiden, or antithrombin III were found in 9%, 7%, 3.8%, and 4%, respectively. Left, right, and both legs were involved in 55%, 37%, and 8%, respectively. Common femoral, popliteal, and posterior tibial veins were affected in 48.5%, 72%, and 71%, respectively. Postthrombotic syndrome, pulmonary embolism, and death were reported in 50%, 12.2%, and 15% of cases, respectively. Kaplan-Meier survival curves and Cox regression analysis showed that gender had no impact on mortality during follow-up; however, age (>50 years) was associated with greater risk of death (hazard ratio: 6.54; 95% confidence interval: 3.2-13.3). These findings will improve our understanding of the various risk factors and help develop institutional guidelines for the management of patients with DVT.

Traffic-related pedestrian injuries amongst expatriate workers in Qatar: a need for cross-cultural injury prevention programme

Qatar is a rapidly developing country in which expatriate workers constitute the majority of population. Also, Qatar is an example of right-sided road driving convention (RDC) country. The aim of our study is to analyse the traffic-related pedestrian injuries (TRPI) amongst expatriates in relation to RDC. A retrospective analysis of prospectively collected data of TRPI patients who were admitted to the only Level I trauma centre in Qatar between 2009 and 2011 was performed. Demographics, country of origin, time of injury, injury severity score (ISS), RDC, morbidity and mortality were analysed. Of the 4997 injured patients, 601 (12%) were pedestrians. Of these, 92% were expatriates. The mean age was 31.8 ± 17 and 64% of them were 18–45 years old. Mean ISS was higher in those who were injured on weekends (15.4 ± 10) in comparison to working days (13.5 ± 10) (p = 0.04). The overall mortality was 15%. Sixty-seven percent of those who died were from left RDC countries. Expatriate workers, originally from left RDC countries are disproportionately affected by TRPI. This group of injured patients requires focused injury prevention programmes that are culture and language appropriate.