Syed Nabeel Zafar

Phenytoin versus Leviteracetam for Seizure Prophylaxis after brain injury - a meta analysis

BackgroundCurrent standard therapy for seizure prophylaxis in Neuro-surgical patients involves the use of Phenytoin (PHY). However, a new drug Levetiracetam (LEV) is emerging as an alternate treatment choice. We aimed to conduct a meta-analysis to compare these two drugs in patients with brain injury.MethodsAn electronic search was performed in using Pubmed, Embase, and CENTRAL. We included studies that compared the use of LEV vs. PHY for seizure prophylaxis for brain injured patients (Traumatic brain injury, intracranial hemorrhage, intracranial neoplasms, and craniotomy). Data of all eligible studies was extracted on to a standardized abstraction sheet. Data about baseline population characteristics, type of intervention, study design and outcome was extracted. Our primary outcome was seizures.ResultsThe literature search identified 2489 unduplicated papers. Of these 2456 papers were excluded by reading the abstracts and titles. Another 25 papers were excluded after reading their complete text. We selected 8 papers which comprised of 2 RCTs and 6 observational studies. The pooled estimate’s Odds Ratio 1.12 (95% CI = 0.34, 3.64) demonstrated no superiority of either drug at preventing the occurrence of early seizures. In a subset analysis of studies in which follow up for seizures lasted either 3 or 7 days, the effect estimate remained insignificant with an odds ratio of 0.96 (95% CI = 0.34, 2.76). Similarly, 2 trials reporting seizure incidence at 6 months also had insignificant pooled results while comparing drug efficacy. The pooled odds ratio was 0.96 (95% CI = 0.24, 3.79).ConclusionsLevetiracetam and Phenytoin demonstrate equal efficacy in seizure prevention after brain injury. However, very few randomized controlled trials (RCTs) on the subject were found. Further evidence through a high quality RCT is highly recommended.

Cranioplasty after decompressive craniectomy: An institutional audit and analysis of factors related to complications

Background: Although a relatively simple procedure, cranioplasties have been associated with high complication rates. Keeping this in perspective, we aimed to determine the factors associated with immediate and long-term complications of cranioplasties at our institution. Methods: A retrospective review of patient records was carried out for patients having undergone reconstructive cranioplasties at our institution during the last 10 years (2001-2010). All case notes, records, and investigations were reviewed and the data were recorded in a predesigned questionnaire. Complications were recorded along with existing comorbids and measures taken for their prevention and management. Univariate and multivariate logistic regression analysis was performed to determine possible predictors of complications. Results: A total of 96 patients with a mean age of 33 + 15 years were included in the study. Of the sample, 76% (n = 73) had no comorbids. The leading primary pathology was blunt traumatic brain injuries in 46% (n = 44), followed by cerebrovascular incidents in 24% (n = 23), penetrating traumatic brain injuries in 12% (n = 11), and tumors in 10% (n = 10) of cases, with 41% (n = 39) of patients requiring multiple craniotomies. In a mean follow-up of 386 ± 615 days, complications were noted in 36.5% (n = 35) of the patients. Twenty six percent of patients (n = 25) had minor complications which included breakthrough seizures (15.6%, n = 15), subgaleal collections (3.1%, n = 3), and superficial wound infections (3.1%, n = 3), whereas major complications (10.4% n = 10) included hydrocephalus (3.1%, n = 3), transient neurological deficits (3.1%, n = 3), and osteomyelitis (2.1%, n = 2). Univariate and multivariate analysis revealed External Ventricular Drain (EVD) placement and parietal flaps to be associated with complications. This could be explained by the fact that the patients requiring EVD usually have relatively severe head injuries, increasing the possibility of hydrocephalus. Conclusion: We have found a higher risk of complications of cranioplasty in patients who had EVD placement and removal prior to their constructive surgery. We however did not find any association between risks of complications in any other studied variable. We also did not find any association between intraoperative placement of subgaleal drains and postoperative risk of subgaleal fluid collections. Overall, our results are comparable with other reported series on cranioplasties.

National estimates of predictors of outcomes for emergency general surgery.

BACKGROUND Identifying predictors of mortality and surgical complications has led to outcome improvements for a variety of surgical conditions. However, similar work has yet to be done for factors affecting outcomes of emergency general surgery (EGS). The objective of this study was to determine the predictors of in-hospital complications and mortality among EGS patients. METHODS The Nationwide Inpatient Sample (2003–2011) was queried for patients with conditions encompassing EGS as determined by the American Association for Surgery of Trauma, categorizing them into predefined EGS groups using DRG International Classification of Diseases—9th Rev.—Clinical Modification codes. Primary outcomes considered included incidence of a major complication (pneumonia, pulmonary emboli, urinary tract infections, myocardial infarctions, sepsis, or septic shock) and in-hospital mortality. Separate multivariate logistic regression analyses for complications and mortality were performed to identify risk factors of either outcome from the following domains: patient demographics (age, sex, insurance type, race, and income quartile), comorbidities, and hospital characteristics (location, teaching status, and bed size). RESULTS This study included 6,712,151 discharge records, weighted to represent 32,910,446 visits for EGS conditions. Mean age was 58.50 (19.74) years; slightly more than half (54.66%) were female. Uninsured patients were more likely to die (odds ratio,1.25; 95% confidence interval, 1.20–1.30), whereas patients in the highest income quartile had the least likelihood of mortality (odds ratio, 0.86; 95% confidence interval, 0.84–0.87). Old age was an independent predictor of mortality for all EGS subdiagnoses. The overall mortality rate was 1.76%; the overall complication rate was 10.03%. Of the patients who died, 62% experienced at least one major complication. Patients requiring resuscitation had the highest likelihood of mortality followed by patients with vascular disease and hepatic disease. CONCLUSION Death patterns of EGS patients were discerned using an administrative data set. Understanding patterns of mortality and complications derived from studies such as this could improve hospital benchmarking for EGS, akin to trauma surgery’s previous success. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Prevalence and predictors of depression among an elderly population of Pakistan

Objective: To assess the magnitude and risk factors of the problem of depression in an elderly population of Pakistan. Method: A cross-sectional study was conducted using a sample of 402 people aged 65 and above visiting the Community Health Center of the Aga Khan University, Karachi. Questionnaire based interviews were conducted for data collection and the 15-Item Geriatric Depression Scale was used to screen for depression. Univariate and multivariate logistic regression analyses were performed to identify factors associated with depression. Results: Of the 402 participants; 69.7% (95% CI = ±4.5%) were men, 76.4% (95% CI = ±4.2%) were currently married, 36.8% (95% CI = ±5%) had received 11 or more years of education and 24.4% (95% CI = ±4.2%) were employed. The mean age was 70.57 years (SD = ±5.414 years). The prevalence of depression was found to be 22.9% (95% CI = ±4.1%) and multiple logistic regression analysis indicated that higher number of daily medications (p-value = 0.03), total number of health problems (p-value = 0.002), financial problems (p-value < 0.001), urinary incontinence (p-value = 0.08) and inadequately fulfilled spiritual needs (p-value = 0.067) were significantly associated with depressive symptoms. Conclusion: We have identified several risk factors for depression in the elderly which need to be taken into account by practicing family physicians and health care workers.

Optimal Time for Early Laparoscopic Cholecystectomy for Acute Cholecystitis

IMPORTANCE There is growing evidence in support of performing early laparoscopic cholecystectomy (LC) for acute cholecystitis. However, the definition of early LC varies from 0 through 10 days depending on the research protocol. The optimum time to perform early LC is still unclear. OBJECTIVES To determine whether outcomes after early LC for acute cholecystitis vary depending on time from presentation to surgery and to determine the optimum time to perform LC for acute cholecystitis. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective review of prospectively collected data from the Nationwide Inpatient Sample (NIS) for 2005 through 2009. The population-based sample included 95,523 adults (18 years and older) who underwent LC within 10 days of presentation for acute cholecystitis. INTERVENTIONS Patients were categorized and analyzed in 2 ways based on length of time from presentation to surgery. First, patients were categorized into 3 groups: 0 through 1 day, 2 through 5 days, and 6 through 10 days. Second, we compared outcomes for each incremental preoperative day (days 0-5). MAIN OUTCOMES AND MEASURES Outcomes of interest were mortality, length of stay, complications, and cost. Propensity score matching and generalized linear modeling were used. The hypothesis being tested was formulated after data collection was complete. RESULTS A total of 95,523 patients were selected. After matching the 3 groups based on propensity scores, patients who underwent surgery during days 2 through 5 and days 6 through 10 had increasingly worse outcomes when compared with those undergoing surgery on days 0 through 1. The odds of mortality were 1.26 (95% CI, 1.00-1.58) and 1.93 (95% CI, 1.38-2.68), and the odds of postoperative infections were 0.88 (95% CI, 0.69-1.12) and 1.53 (95% CI, 1.05-2.23) for days 2 through 5 and days 6 through 10, respectively. Adjusted mean hospital cost increased from

Hospital-based trauma quality improvement initiatives: first step toward improving trauma outcomes in the developing world.

8974 (days 0-1) to

Developing best practices to study trauma outcomes in large databases: an evidence-based approach to determine the best mortality risk adjustment model.

17,745 (days 6-10). Analysis by each incremental day revealed the optimal time of surgery to be within the first 48 hours of presentation. CONCLUSIONS AND RELEVANCE Laparoscopic cholecystectomy performed within 2 days of presentation of acute cholecystitis yielded the best outcomes and lowest costs. Although causality could not be established, delaying LC was associated with more complications, higher mortality, and higher costs.

Comparative effectiveness of inhospital trauma resuscitation at a French trauma center and matched patients treated in the United States

BACKGROUND Injuries remain a leading cause of death in the developing world. Whereas new investments are welcome, quality improvement (QI) at the currently available trauma care facilities is essential. The objective of this study was to determine the effect and long-term sustainability of trauma QI initiatives on in-hospital mortality and complications at a large tertiary hospital in a developing country. METHODS In 2002, a specialized trauma team was formed (members trained using advanced trauma life support), and a western style trauma program established including a registry and quality assurance program. Patients from 1998 onward were entered in to this registry, enabling a preimplementation and postimplementation study. Adults (>15 years) with blunt or penetrating trauma were analyzed. The main outcomes of interest were (1) in-hospital mortality and (2) occurrence of any complication. Multiple logistic regression was performed to assess the impact of formalized trauma care on outcomes, controlling for covariates reaching significance in the bivariate analyses. RESULTS A total of 1,227 patient records were analyzed. Patient demographics and injury characteristics are described in Table 1. Overall in-hospital mortality rate was 6.4%, and the complication rate was 11.1%. On multivariate analysis, patients admitted during the trauma service years were 4.9 times less likely to die (95% confidence interval, 1.77–13.57) and 2.60 times (odds ratio; 95% confidence interval, 1.29–5.21) less likely to have a complication compared with those treated in the pretrauma service years. CONCLUSION Despite significant delays in hospital transit and lack of prehospital trauma care, hospital level implementation of trauma QI program greatly decreases mortality and complication rates in the developing world. LEVEL OF EVIDENCE Care management study, level IV.

Epidemiology of Eye-Related Emergency Department Visits

BACKGROUND The National Trauma Data Bank (NTDB) is an invaluable resource to study trauma outcomes. Recent evidence suggests the existence of great variability in covariate handling and inclusion in multivariable analyses using NTDB, leading to differences in the quality of published studies and potentially in benchmarking trauma centers. Our objectives were to identify the best possible mortality risk adjustment model (RAM) and to define the minimum number of covariates required to adequately predict trauma mortality in the NTDB. METHODS Analysis of NTDB 2009 was performed to identify the best RAM for trauma mortality. For each plausible NTDB covariate, univariate logistic regression was performed, and the area under the receiver operating characteristics curve (AUROC, with 95% confidence interval [CI]) was calculated. Covariates with p < 0.01 and an AUROC of 0.6 of greater or with strong previous evidence were included in the subsequent multivariate logistic regression analyses. Manual backward selection was then used to identify the most parsimonious RAM with a similar AUROC (overlapping 95% CI). Similar analyses were performed for penetrating and severely injured patient subsets. All models were validated using NTDB 2010. RESULTS A total of 630,307 patients from NTDB 2009 were analyzed. A total of 16 of 106 NTDB covariates tested on univariate analyses were selected for inclusion in the initial multivariate model. The best RAM included only six covariates (age, hypotension, pulse, total Glasgow Coma Scale [GCS] score, Injury Severity Score [ISS], and a need for ventilator use) yet still demonstrated excellent discrimination between survivors and nonsurvivors (AUROC, 0.9578; 95% CI, 0.9565–0.9590). In addition, this model was validated on 665,138 patients included in NTDB 2010 (AUROC, 0.9577; 95% CI, 0.9564–0.9589). Similar results were obtained for the subset analyses. CONCLUSION This quantitative synthesis proposes a framework and a set of covariates for studying trauma mortality outcomes. Such analytic standardization may prove critical in implementing best practices aimed at improving the quality and consistency of NTDB-based research. LEVEL OF EVIDENCE Prognostic study, level III.

Outcomes after emergency general surgery at teaching versus nonteaching hospitals.

Objective:The objective of this paper is to compare mortality outcomes between patients treated at a trauma center in France and matched patients in the United States. Background:Although trauma systems in France and the United States differ significantly in prehospital and inhospital management, previous comparisons have been challenged by the lack of comparable data. Methods:Coarsened exact matching identified matching patients between a single center trauma database from Lyon, France, and the National Trauma Data Bank (NTDB) of the United States. Moderate to severely injured [injury severity score (ISS) > 8] adult patients (age ≥ 16) presenting alive to level 1 trauma centers from 2002 to 2005 with blunt or penetrating injuries were included. After matching patients, multivariate regression analyses were performed to determine difference in mortality between patients in Lyon and the NTDB. Results:A total of 1043 significantly injured patients were presented to the Lyon center. Matching eligible patients with complete records were sought from 219,985 patients in the NTDB. The unadjusted odds of mortality at the Lyon center was 2.5 times higher than that of the NTDB [95% confidence interval (CI) = 2.18–2.98]. However, the Lyon center received patients with higher ISS, lower Glasgow Coma Score (GCS), and lower systolic blood pressure (SBP) (all P < 0.001). After 1:1 matching, 858 patient pairs were produced, and the odds of mortality became equivalent [odds ratio (OR) = 1.3, 95% CI = 0.91–1.73]. Similar results were found in multiple subset analyses. Conclusions:Trauma patients admitted to a single French trauma center had an equal chance of survival compared with similarly injured patients treated at US trauma centers.