Sarvesh Logsetty

Clinical review: Canadian National Advisory Committee on Blood and Blood Products - Massive Transfusion Consensus Conference 2011: report of the panel

In June 2011 the Canadian National Advisory Committee on Blood and Blood Products sponsored an international consensus conference on transfusion and trauma. A panel of 10 experts and two external advisors reviewed the current medical literature and information presented at the conference by invited international speakers and attendees. The Consensus Panel addressed six specific questions on the topic of blood transfusion in trauma. The questions focused on: ratio-based blood resuscitation in trauma patients; the impact of survivorship bias in current research conclusions; the value of nonplasma coagulation products; the role of protocols for delivery of urgent transfusion; the merits of traditional laboratory monitoring compared with measures of clot viscoelasticity; and opportunities for future research. Key findings include a lack of evidence to support the use of 1:1:1 blood component ratios as the standard of care, the importance of early use of tranexamic acid, the expected value of an organized response plan, and the recommendation for an integrated approach that includes antifibrinolytics, rapid release of red blood cells, and a foundation ratio of blood components adjusted by results from either traditional coagulation tests or clot viscoelasticity or both. The present report is intended to provide guidance to practitioners, hospitals, and policy-makers.

The association between number and type of traumatic life experiences and physical conditions in a nationally representative sample

OBJECTIVE Posttraumatic stress disorder (PTSD) is significantly and positively associated with several physical conditions. We aimed to examine whether the nature and number of trauma(s) experienced may be related to physical conditions using a population-based sample. METHODS Data came from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (N=34,653; age 20 years and older). Participants indicated lifetime trauma experiences and physical conditions experienced over the past year. Multiple logistic regressions examined the association between type and number of trauma(s) and physical conditions. RESULTS After adjusting for sociodemographics, Axis I and II mental disorders, and all other trauma, injurious and witnessing trauma were significantly associated with all the assessed physical conditions. Psychological trauma was associated with cardiovascular and gastrointestinal diseases, diabetes and arthritis. Natural disaster/terrorism was associated with cardiovascular disease, gastrointestinal disease and arthritis only. Finally, combat-related trauma and other trauma were not positively associated with any physical condition. Our results also suggested a dose-response relationship between number of traumatic events and physical conditions. CONCLUSION These data suggest that the impact of certain types and number of traumas may differ with respect to their relationship with physical health problems independent of PTSD.

Protocol for the PREHAB study—Pre-operative Rehabilitation for reduction of Hospitalization After coronary Bypass and valvular surgery: a randomised controlled trial

Introduction Frailty is a geriatric syndrome characterised by reductions in muscle mass, strength, endurance and activity level. The frailty syndrome, prevalent in 25–50% of patients undergoing cardiac surgery, is associated with increased rates of mortality and major morbidity as well as function decline postoperatively. This trial will compare a preoperative, interdisciplinary exercise and health promotion intervention to current standard of care (StanC) for elective coronary artery bypass and valvular surgery patients for the purpose of determining if the intervention improves 3-month and 12-month clinical outcomes among a population of frail patients waiting for elective cardiac surgery. Methods and analysis This is a multicentre, randomised, open end point, controlled trial using assessor blinding and intent-to-treat analysis. Two-hundred and forty-four elective cardiac surgical patients will be recruited and randomised to receive either StanC or StanC plus an 8-week exercise and education intervention at a certified medical fitness facility. Patients will attend two weekly sessions and aerobic exercise will be prescribed at 40–60% of heart rate reserve. Data collection will occur at baseline, 1–2 weeks preoperatively, and at 3 and 12 months postoperatively. The primary outcome of the trial will be the proportion of patients requiring a hospital length of stay greater than 7 days. Potential impact of study The healthcare team is faced with an increasingly complex older adult patient population. As such, this trial aims to provide novel evidence supporting a health intervention to ensure that frail, older adult patients thrive after undergoing cardiac surgery. Ethics and dissemination Trial results will be published in peer-reviewed journals, and presented at national and international scientific meetings. The University of Manitoba Health Research Ethics Board has approved the study protocol V.1.3, dated 11 August 2014 (H2014:208). Trial registration number The trial has been registered on ClinicalTrials.gov, a registry and results database of privately and publicly funded clinical studies (NCT02219815).

Necrotizing fasciitis: a six-year experience.

Necrotizing fasciitis (NF) is a life-threatening infectious disease whose incidence has been on the rise. Commonly a consequence of group A beta-hemolytic Streptococcus infection, it results in high levels of morbidity and mortality. Diagnosis is difficult and treatment involves emergent surgical intervention and antibiotic therapy. The aim of this study is to examine the incidence of NF in Manitoba with the goal of observing whether there is a geographic variation in incidence and outcomes based on Regional Health Authorities (RHAs). This is a 6-year retrospective chart review of all NF patients who presented to the Health Sciences Center from 2004 to 2009. A total of 130 patients satisfied the inclusion criteria. The mean age was 47 ± 16 years. The most common comorbidities were diabetes (33.8%) and hypertension (33.1%). The overall mortality was 13.1% with advanced age being an independent risk factor (P < .05). Lower extremity was the most common location of infection (44.6%) and the most common causative organism was group A beta-hemolytic Streptococcus (63.9%). The type of infection (mono- vs. polymicrobial) was not found to affect length of stay, amputation rate, or mortality. There was no statistical difference in rate of amputations, length of stay, or mortality based on RHA. Incidence within the province, however, varied significantly based on RHA and ethnicity (P < .05). We determined that regardless of origin before admission, all our patients have equivalent prognosis. Burntwood RHA was found to have substantially higher incidence than the rest of the province, and higher incidence was established among the Aboriginal population.

The iTClamp Controls Junctional Bleeding in a Lethal Swine Exsanguination Model

Abstract Objective. Severe hemorrhage is a leading cause of death and difficult to control even by trained medical personnel. Current interventions have significant limitations in the prehospital setting; therefore, a need exists for a new and effective treatment. iTraumaCare has designed a temporary wound closure device, the iTClamp, which controls external hemorrhage from open wounds within compressible zones. The device approximates the wound edges, sealing the skin within a pressure bar, enabling creation of a hematoma and subsequent clot formation. The objective of this study is to test the effectiveness of the iTClamp to control external bleeding due to a major vascular injury to the groin in an in vivo swine model. Methods. Twenty Yorkshire-cross male swine were enrolled in this study. A complex groin injury was created by complete excision of the femoral artery and vein along with some surrounding muscle. The animals were divided into four treatment groups: control (no treatment), early iTClamp treatment, late iTClamp treatment, and standard gauze treatment. Survival rate, survival time, and blood loss were the primary endpoints. Physiologic parameters (heart rate, blood pressure, oxygen saturation) were monitored throughout the experiment and blood samples were collected to analyze partial thromboplastin time and fibrinogen. Results: All (100%) of the animals treated with the iTClamp lived through the end of the experiment, compared to 60% in standard gauze treated and 0% of untreated control animals (early and late iTClamp vs. control and standard gauze, Fishers exact, p = 0.003). Both the early iTClamp and late iTClamp treatment groups survived significantly longer than the untreated control pigs (Mann-Whitney U-test, p < 0.009). External blood loss was significantly lower in animals treated with the iTClamp (early) compared to no treatment (Mann-Whitney U-test, p < 0.008). There was no significant change in physiologic or hematologic parameters between treatment groups. Conclusions: The iTClamp showed statistically significant improvement in survival, survival time, and estimated blood loss when compared to no treatment. This proof-of-concept study demonstrates the potential of the iTClamp to control severe bleeding and prevent blood loss.

Bereavement after sibling death: a population-based longitudinal case-control study

The objective of this study was to examine mental disorders and treatment use among bereaved siblings in the general population. Siblings (N=7243) of all deceased children in the population of Manitoba, Canada who died between 1984 and 2009 were matched 1:3 to control siblings (N=21,729) who did not have a sibling die in the study period. Generalized estimating equations were used to compare the two sibling groups in the two years before and after the index childs death on physician‐diagnosed mental disorders and treatment utilization, with adjustment for confounding factors including pre‐existing mental illness. Analyses were stratified by age of the bereaved (<13 vs. 13+). Results revealed that, in the two years after the death of the child, bereaved siblings had significantly higher rates of mental disorders than control siblings, even after adjusting for pre‐existing mental illness. When comparing the effect of a childs death on younger versus older siblings, the rise in depression rates from pre‐death to post‐death was significantly higher for siblings aged under 13 (p<0.0001), increasing more than 7‐fold (adjusted relative rate, ARR=7.25, 95% CI: 3.65‐14.43). Bereaved siblings aged 13+ had substantial morbidity in the two years after the death: 25% were diagnosed with a mental disorder (vs. 17% of controls), and they had higher rates of almost all mental disorder outcomes compared to controls, including twice the rate of suicide attempts (ARR=2.01, 95% CI: 1.29‐3.12). Siblings in the bereaved cohort had higher rates of alcohol and drug use disorders already before the death of their sibling. In conclusion, the death of a child is associated with considerable mental disorder burden among surviving siblings. Pre‐existing health problems and social disadvantage do not fully account for the increase in mental disorder rates.

Mental health outcomes of burn: a longitudinal population-based study of adults hospitalized for burns

PURPOSE This study investigates the increased risk of mental health outcomes and health care utilization associated with burn with two year of follow-up using a longitudinal population-based matched cohort design. METHODS Adult burn survivors (n=157) were identified from a provincial burn registry and matched 1:5 with non-burn control subjects from the general population (matching variables age and gender). The prevalence of mental health outcomes and the rates of health care utilization between the groups were compared for the 2years pre and post index date using anonymously linked population-based administrative health care data. Rates were adjusted for age, gender and sociodemographic characteristics. RESULTS While the burn cohort had an increased prevalence of mental health problems after burn compared to the control cohort, the burn group also had an increased prevalence of pre-burn depression (16.6% vs 7.8%; p=0.0005) and substance use disorders (8.9% vs 3.2%; p=0.001) when compared to controls. Once the pre-existing prevalence of mental illness was taken into account there was no significant change in the prevalence of mental health problems when comparing the burn group to controls over time. CONCLUSIONS Although burns may not increase rates of mental health issues and health care utilization, burn survivors are a vulnerable group who already demonstrate increased rates of psychopathology and need for care. The present study highlights the importance of assessment and treatment of mental health outcomes in this population.

Evaluation of the iTClamp 50 in a human cadaver model of severe compressible bleeding.

BACKGROUND Uncontrolled hemorrhage is a significant cause of preventable death. The iTClamp 50 is a temporary wound closure device designed to control bleeding within seconds of an injury. This study evaluates the ability of the iTClamp to control compressible bleeding in a human cadaver model. METHODS Sterile water was pumped through the major arteries to mimic blood flow. Full-thickness, elliptical segments of skin were excised; arteriotomies or complete transections were performed on the major arteries in the thigh (distal femoral), groin (common femoral), neck (carotid), and arm (brachial). Scalp wounds were created by making a 4.4-cm linear incision to the level of the bone. Fluid losses from the wounds were compared with and without the iTClamp applied and with and without movement of the cadaver. Angiographic images of pressure-injected contrast were obtained of the neck and groin wounds. Hematoma volumes and needle penetration depth into the skin were measured. RESULTS In all wounds tested, application of the iTClamp significantly reduced fluid loss in all wounds studied (p < 0.05), and movement of the cadaver did not affect the function of the iTClamp. For example, in one groin wound, the average fluid loss during 1 minute was reduced from 728.4 ± 79.3 mL to 5.6 ± 3.4 mL. Distal flow was maintained during application of the iTClamp, as illustrated in angiographic images obtained of the iTClamp applied to the neck and groin wounds. The average needle penetration depth into the skin was 4.21 ± 0.02 mm; furthermore, the iTClamp did not cause any visible skin damage or skin tearing. CONCLUSION The iTClamp is effective at controlling fluid loss from open wounds within multiple compressible areas. The iTClamp does not occlude distal flow, and aside from small needle punctures, there was no other visible skin damage or skin tearing.

Validation of the quality of ultrasound imaging and competence (QUICk) score as an objective assessment tool for the FAST examination.

BACKGROUND The Focused Assessment with Sonography for Trauma (FAST) examination has become a valuable tool in trauma resuscitation. Despite the widespread use of FAST training among traumatologists, no evidence-based guidelines exist to support optimal training requirements or to provide quantitative objective assessments of imaging capabilities. Both Task-Specific Checklist (TSC) and Global Rating Scale (GRS) have been validated as objective skill assessment tools; we developed both types of scoring checklist and assessed them for construct validity with the FAST examination. METHODS Two scoring checklists, collectively termed the Quality of Ultrasound Imaging and Competence (QUICk) Score, were developed and subjected to a modified Delphi consensus process. Two cohorts of 12 novice and 12 expert sonographers performed the FAST examination and were evaluated by two experts according to the QUICk model. Total scores as well as anatomic subsets were compared via comparison of means, and logistic regression modeling was used to determine sensitivity and specificity. RESULTS Experts achieved significantly higher total scores than novices on both scoring systems (17.2 vs. 11.1 of 24, p < 0.01 TSC, 29.8 vs. 18.4 of 40, p < 0.01 GRS). Sensitivity (85.7% TSC, 92.9% GRS) and specificity (75.0% TSC, 91.7% GRS) as well as area under the receiver operating characteristic curve (89.9% TSC, 97.6% GRS) were consistent with a highly discriminant tool. CONCLUSION The QUICk Score is the first validated objective tool for assessment of the quality of FAST examination imaging. Use of this tool may be instrumental in developing an evidence-based minimum-performance standard and for assessing quality-improvement modifications in FAST examination training.

Zinc supplementation in burn patients.

Micronutrient supplementation is a common practice throughout many burn centers across North America; however, uncertainty pertaining to dose, duration, and side effects of such supplements persists. The authors prospectively collected data from 23 hospitalized patients with burn sizes ranging from 10 to 93% TBSA. Each patient received a daily multivitamin and mineral supplement, 50 mg zinc (Zn) daily, and 500 mg vitamin C twice daily. Supplements were administered orally or enterally. Albumin, prealbumin, C-reactive protein, serum Zn, and serum copper were measured weekly during hospital admission until levels were within normal reference range. Our study concluded that 50 mg daily dose of Zn resulted in normal serum levels in 19 of 23 patients at discharge; 50 mg Zn supplementation did not interfere with serum copper levels; and Zn supplements, regardless of administration route, did not result in gastrointestinal side effects.