Ronald Denis

Trauma care regionalization: a process-outcome evaluation.

BACKGROUND Regionalization of trauma care services in our region was initiated in 1993 with the designation of four tertiary trauma centers. The process continued in 1995 with the implementation of patient triage and transfer protocols. Since 1995, the network of trauma care has been expanded with the designation of 33 secondary, 30 primary, and 32 stabilization trauma centers. In addition, during this period emergency medical personnel have been trained to assess and triage trauma victims within minimal prehospital time. The objective of the present study was to evaluate the impact of trauma care regionalization on the mortality of major trauma patients. METHODS This was a prospective study in which patients were entered at the time of injury and were followed to discharge from the acute-care hospital. The patients were identified from the Quebec Trauma Registry, a review of the records of acute-care hospitals that treat trauma, and records of the emergency medical services in the region. The study sample consisted of all patients fulfilling the criteria of a major trauma, defined as death, or Injury Severity Score (ISS) > 12, or Pre-Hospital Index > 3, or two or more injuries with Abbreviated Injury Scale scores > 2, or hospital stay of more than 3 days. Data collection took place between April 1, 1993, and March 31, 1998. During this period, four distinct phases of trauma care regionalization were defined: pre-regionalization (phase 0), initiation (phase I), intermediate (phase II), and advanced (phase III). RESULTS A total of 12,208 patients were entered into the study cohort, and they were approximately evenly distributed over the 6 years of the study. During the study period, there was a decline in the mean age of patients from 54 to 46 years, whereas the male/female ratio remained constant at 2:1. There was also an increase in the mean ISS, from 25.5 to 27.5. The proportion of patients injured in motor vehicle collisions increased from less than 45% to more than 50% (p < 0.001). The mortality rate during the phases of regionalization were: phase 0, 52%; phase I, 32%; phase II, 19%; and phase III, 18%. These differences were clinically important and statistically significant (p < 0.0001). Stratified analysis showed a significant decline in mortality among patients with ISS between 12 and 49. The change in mortality for patients with fatal injuries (ISS > or = 50) was not significant. During the study period, the mean prehospital time decreased significantly, from 62 to 44 minutes. The mean time to admission after arrival at the hospital decreased from 151 to 128 minutes (p < 0.001). The latter decrease was primarily attributable to changes at the tertiary centers. The proportion of patients with ISS between 12 and 24 and between 25 and 49 who were treated at tertiary centers increased from 56 to 82% and from 36 to 84%, respectively (p < 0.001). Compared with the secondary and primary centers, throughout the course of the study the mortality rate in the secondary and tertiary centers showed a consistent decline (p < 0.001). In addition, the mortality rate in the tertiary centers remained consistently lower (p < 0.001). The results of multivariate analyses showed that after adjusting for injury severity and patient age, the primary factors contributing to the reduced mortality were treatment at a tertiary center, reduced prehospital time, and direct transport from the scene to tertiary centers. CONCLUSION This study produced empirical evidence that the integration of trauma care services into a regionalized system reduces mortality. The results showed that tertiary trauma centers and reduced prehospital times are the essential components of an efficient trauma care system.

Direct transport to tertiary trauma centers versus transfer from lower level facilities: impact on mortality and morbidity among patients with major trauma

BACKGROUND The purpose of the study was to compare the outcome of severely injured patients who were transported directly to a Level I, tertiary trauma center with those who were transferred after being first transported to less specialized hospitals. METHODS The data were based on all patients treated at three tertiary trauma centers in Quebec between April 1, 1993, and December 31, 1995. There were 1,608 patients (37%) transferred and 2,756 patients (63%) transported directly. RESULTS The mean age of the patients was approximately 45 years, and more than 60% were males. The predominant mechanisms of injury were falls and motor vehicle crashes. The transfer and direct transport groups were similar with respect to age, gender, and mechanism of injury. Body regions injured were also similar with the exception of head or neck injuries (transfer, 56%; direct, 28%; p < 0.0001). The mean Injury Severity Score was 14, the mean Pre-Hospital Index score was 5.5, and the mean Revised Trauma Score was 7.5. The two groups were similar with respect to these injury severity measures. The primary outcome of interest was mortality described as overall death rate, death rate in the emergency room, and death rate after admission. Other outcomes studied were hospital length of stay and duration of treatment in an intensive care unit. When compared with the direct transport group, transferred patients were at increased risk for overall mortality (transfer, 8.9%; direct, 4.8%; odds ratio, 1.96; 95% confidence interval (CI) = 1.53-2.50), emergency room mortality (transfer, 3.4%; direct, 1.2%; odds ratio, 2.96; 95% CI = 1.90-4.6), and mortality after admission (transfer, 5.5%; direct, 3.6%; odds ratio, 1.57; 95% CI = 1.17-2.11). All of these differences were statistically significant (p < 0.003). Stratified and multiple logistic regression analysis did not alter these results and failed to identify a patient subgroup for which transfer was associated with a reduced risk of mortality. After adjusting for patient age, Injury Severity Score, and presence of injuries to the head or neck and extremities, transferred patients stayed significantly longer in the hospital and the intensive care unit as indicated by the mean length of stay (transfer, 16.0 days; direct, 13.2 days; p = 0.02) and the mean intensive care unit stay (transfer, 2.0 days; direct, 0.95 days; p = 0.001). CONCLUSION The results of this study have shown that transportation of severely injured patients from the scene directly to Level I trauma centers is associated with a reduction in mortality and morbidity. Further studies are required for the evaluation of transport protocols for rural trauma. Economic and cost-effectiveness considerations of patient triage are also essential.

Multicenter Canadian Study of Prehospital Trauma Care

ObjectiveTo evaluate whether the type of on-site care a trauma patient receives affects outcome. Summary Background DataThe controversy regarding the prehospital care of trauma patients between Advanced Life Support (ALS) and Basic Life Support (BLS) is ongoing. Due to this unresolved controversy, as well as historical, cultural, and political factors, there are significant variations with respect to the type of prehospital care available for trauma patients. MethodsThis prospective cohort study compared three types of prehospital trauma care systems: Montreal, where physicians provide ALS (MD-ALS); Toronto, where paramedics provide ALS (PMD-ALS); and Quebec City, where emergency medical technicians provide BLS only (EMT-BLS). The study took advantage of this variation to evaluate the association between the type of on-site care and mortality in patients with major life-threatening injuries. All patients were treated at highly specialized tertiary (level I) trauma hospitals. The main outcome measure was death as a result of injury. Follow-up was to hospital discharge. ResultsThe overall mortality rates by type of on-site personnel were physicians 35%, paramedics 24%, and EMTs 18%. For patients with major but survivable trauma, the overall mortality rates were physicians 32%, paramedics 28%, and EMTs 26%. The overall mortality rate of patients receiving only BLS at the scene was 18% compared to 29% for patients receiving ALS. For the subgroup of patients with major but survivable injuries, the mortality rates were 30% for ALS and 26% for BLS. The adjusted increased risk for mortality in patients receiving ALS at the scene was 21%. ConclusionsIn urban centers with highly specialized level I trauma centers, there is no benefit in having on-site ALS for the prehospital management of trauma patients.

Ineffectiveness of on-site intravenous lines: is prehospital time the culprit?

The purpose of the present study was to test the association between on-site intravenous fluid replacement and mortality in patients with severe trauma. The effect of prehospital time on this association was also evaluated. The design was that of an observational quasi-experimental study comparing 217 patients who had on-site intravenous fluid replacement (IV group) with an equal number of matched patients for whom this intervention was not performed (no-IV group). The patients were individually matched on their Prehospital Index obtained at the scene and were included in the study if they had an on-site Prehospital Index score > 3 and were transported alive to the hospital. The outcome measure of interest was mortality because of injury. The patients in the IV group had a significantly lower mean age (37 vs. 45 years; p < 0.001) and higher incidence of injuries to the head or neck (46 vs. 32%; p = 0.004), chest (34 vs. 17%; p < 0.001), and abdomen (28 vs. 12%; p < 0.001). The IV group also had a higher proportion of patients injured by motor vehicle crashes (41 vs. 27%; p = 0.003), firearms (9 vs. 2%; p = 0.001), and stabbing (20 vs. 9%; p = 0.001). The rate of extremity injuries (38 vs. 59%; p < 0.001) and falls (12 vs. 40%; p < 0.001) was lower for the IV group. In addition, the mean Injury Severity Score was significantly higher for the IV group (15 vs. 9; p < 0.001). The mortality rates for the IV and no-IV groups were 23 and 6% (p < 0.001). Logistic regression analysis showed that after adjusting for patient age, gender, Injury Severity Score, mechanism of injury, and prehospital time, the use of on-site intravenous fluid replacement was associated with a significant increase in the risk of mortality (adjusted odds ratio = 2.3; 95% confidence interval = 1.02-5.28; p = 0.04). To further evaluate the effect of prehospital time on the association between on-site IV use and mortality, the analysis was repeated separately for the following time strata: 0 to 30 minutes, 31 to 60 minutes, and >60 minutes. The adjusted odds ratios (95% confidence interval) for these strata were 1.05 (0.08-14.53; p = 0.97), 3.38 (0.84-13.62; p = 0.08), and 8.40 (1.27-54.69; p = 0.03). These results show that for prehospital times of less than 30 minutes, the use of on-site intravenous fluid replacement provides no benefit, and that for longer times, this intervention is associated with significant increases in the risk of mortality. The results of this observational study have shown that the use of on-site intravenous fluid replacement is associated with an increase in mortality risk and that this association is exacerbated by, but is not solely the result of, increased prehospital times. Our findings are consistent with the hypothesis that early intravenous fluid replacement is harmful because it disrupts the normal physiologic response to severe bleeding. Although this evidence is against the implementation of on-site intravenous fluid replacement for severely injured patients, further studies including randomized controlled trials are required to provide a definitive answer to this question.

Relationship among subjective sleep complaints, headaches, and mood alterations following a mild traumatic brain injury.

BACKGROUND Sleep complaints (e.g., frequent awakenings, nightmares), headaches and mood alterations (e.g., feeling depressed, irritable) can appear following a mild traumatic brain injury (MTBI). The objective of this retrospective study was to assess the relationships between the above symptoms. Our hypothesis was that sleep complaints might be among the risk factors for the development of headaches and mood alterations. METHODS The consecutive charts of 443 patients (68.2% males vs. 31.8% female; mean age of 46.9 years) diagnosed with MTBI were reviewed for past medical history and above symptoms using the Rivermead post-concussion symptom assessment questionnaire and self-report. Data were retrieved in 2 time courses: 10 days and 6 weeks. RESULTS For the 2 time courses, the prevalence of subjective sleep complaints were 13.3% and 33.5%; headaches 46.8% and 39.3%; feeling depressed 9.5% and 20.4%; and feeling irritable 5.6% and 20.2%, respectively. Reports of sleep complaints at 6 weeks were 2.9 times (p=0.004) more likely if such a symptom was reported at 10 days. Moreover, the presence of sleep complaints at 10 days is associated with concomitant headaches, depressive symptoms, and feeling irritable by 2.3, 9.9, and 12.2 times (p=0.0001 and 0.014); and by 2.9, 6.3, and 4.8 times (p=0.0001) at 6 weeks, respectively. CONCLUSIONS Our results suggest that patients afflicted with sleep complaints are more likely to suffer from concomitant headaches, depressive symptoms, and irritability.

Is octreotide a new hope for enterocutaneous and external pancreatic fistulas closure

BACKGROUND Octreotide is a long-acting analogue of somatostatin that exhibits good subcutaneous absorption. It reduces gastrointestinal and pancreatic secretions as well as relaxes the intestinal musculature. It has been hypothesized that octreotide could decrease fistula output, thus facilitating fluid and electrolytes management and possibly hasten fistula closure. DATA SOURCES Relevant articles were identified from a MEDLINE search of the literature. Because of the scarcity of well-designed studies on the use of octreotide to promote enterocutaneous and pancreaticocutaneous fistulas closure, all case series and controlled trials were reviewed. CONCLUSIONS Octreotide as an adjuvant to standard fistula management diminishes fistula output, but its shortening of the time to fistula closure remains to be proven by well-designed comparative trials. For recent onset fistulas (less than 8 days old), octreotide does not seem better than the recommended management, including parenteral nutrition. Octreotide can effectively prevent postoperative complications and fistula formation in patients undergoing elective pancreatic resection.

Prospective randomized trial of barbed polyglyconate suture to facilitate vesico-urethral anastomosis during robot-assisted radical prostatectomy: Time reduction and cost benefit

Study Type – RCT (randomized trial)

Impact of deferred treatment of blunt diaphragmatic rupture: A 15-year experience in six trauma centers in Quebec

BACKGROUND The purpose of this study was to show that blunt diaphragmatic rupture does not require immediate emergency operation in the absence of other indications. METHODS We reviewed all patients with blunt diaphragmatic rupture admitted within 24 hours of injury to one of six university trauma centers providing trauma care for the province of Quebec from April 1, 1984, to March 31, 1999. Multivariate analysis of demographic profiles, severity indices, indications for operation, and preoperative delays was performed. RESULTS There were 160 patients (91 men and 69 women) with blunt diaphragmatic rupture. Mean age was 40.1 +/- 16.2 years. Mean Injury Severity Score was 26.9 +/- 11.5 and mortality was 14.4%. Patients undergoing emergency surgery for indications other than diaphragmatic rupture had a significantly higher Injury Severity Score than those undergoing surgery for repair of diaphragmatic rupture alone (34.7 +/- 10.7 vs. 22.0 +/- 9.0, p < 0.001). In patients undergoing surgery for diaphragmatic rupture alone, delay before repair of the diaphragmatic hernia did not lead to an increased mortality compared with patients undergoing immediate surgery (3.4% vs. 5.0%, p = NS). CONCLUSION Blunt diaphragmatic rupture in the absence of other surgical injuries carries low mortality. Operative repair of diaphragmatic rupture can be deferred without appreciable increased mortality if no other indication mandates immediate surgery.

Rapid EEG Activity during Sleep Dominates in Mild Traumatic Brain Injury Patients with Acute Pain

Chronic pain is a highly prevalent post-concussion symptom occurring in a majority of patients with mild traumatic brain injury (mTBI). About half of patients with mTBI report sleep-wake disturbances. It is known that pain can alter sleep quality in this population, but the interaction between pain and sleep is not fully understood. This study aimed to identify how pain affects subjective sleep (Pittsburgh Sleep Quality Index [PSQI]), sleep architecture, and quantitative electroencephalographic (qEEG) brain activity after mTBI. Twenty-four mTBI patients complaining of sleep-wake disturbances, with and without pain (8 and 16, respectively), were recruited 45 (±22.7) days post-trauma on average. Data were compared with those of 18 healthy controls (no sleep or pain complaints). The PSQI, sleep architecture, and qEEG activity were analyzed. Pain was assessed using questionnaires and a 100-mm visual analogue scale. Patients with mTBI reported three times poorer sleep quality than controls on the PSQI. Sleep architecture significantly differed between patients with mTBI and controls but was within normal range. Global qEEG showed lower delta (deep sleep) and higher beta and gamma power (arousal) at certain EEG derivations in patients with mTBI compared with controls (p<0.04). Patients with mTBI with pain, however, showed greater increase in rapid EEG frequency bands, mostly during REM sleep, and beta bands in non-REM sleep compared with patients with mTBI without pain and controls (p<0.001). Pain in patients with mTBI was associated with more rapid qEEG activity, mostly during REM sleep, suggesting that pain is associated with poor sleep and is a critical factor in managing post-concussion symptoms.

International prospective evaluation of scintimammography with 99mTechnetium sestamibi

BACKGROUND The purpose of this study is to evaluate the efficacy of scintimammography with (99m)Technetium-Sestamibi for the diagnosis of breast cancer. METHODS This was a multicenter prospective cohort clinical trial. A total of 1,734 women were enrolled of whom 1,243 had complete data upon study completion. RESULTS The mean +/- standard error age of the patients is 56 +/-12 years (with a range of 19 to 94). Mammographic results were classified by the Breast Imaging Reporting and Data System (BIRADS) as 199 (16%) BIRADS 5, 149 (12%) BIRADS 4, 199 (16%) BIRADS 3, and 696 (56%) BIRADS 2 or 1. Scintimammography was positive for 322 (26%) of the patients and negative for 921 (76%). Histopathology showed malignancy for 201 (16%) of the patients. Sensitivity and specificity of scintimammography was estimated 93% and 87% respectively. A positive predictive value (PPV) of 58% with a negative predictive value of 98% were calculated. CONCLUSIONS The present study suggests that scintimammography with (99m)Technetium-Sestamibi is highly accurate for the detection of breast cancer.