Tanya L. Zakrison

Homeless people's trust and interactions with police and paramedics.

Although the health impact of patients’ trust in physicians has been well documented, less is known about the possible health effects of trust in police or paramedics. Homeless people frequently interact with police officers and paramedics, and these experiences may affect their health and future willingness to seek emergency assistance. We examined homeless people’s self-reported interactions with police and paramedics in Toronto, Canada, and their level of trust in these emergency service providers. In a sample of 160 shelter users, 61% had interacted with police in the last 12 months, and 37% had interacted with paramedics (P=.0001). The proportion of subjects who expressed willingness to call police in an emergency was significantly lower than those willing to call paramedics in an emergency (69% vs. 92%, P=.0001). On a Likert scale ranging from a minimum of 0 to a maximum of 5, trust levels were lower in police than in paramedics (median level 3 vs. 5, P=.0001). Among shelter users, 9% (95% confidence interval [CI], 5% to 14%) reported an assault by a police officer in the last year, and 0% (95% CI, 0% to 4%) reported an assault by a paramedic. These findings showed that homeless people have much lower levels of trust in police than paramedics. Reports of negative interactions with police are not uncommon, and homeless people’s perceptions of the police may pose a barrier to seeking emergency assistance. Further research is needed for objective characterization of homeless people’s interactions with police officers and the potential health implications of low levels of trust in the police.

The prevalence of psychological morbidity in West Bank Palestinian children.

Objective: To determine the prevalence of psychological morbidity among Palestinian children living in the southern Bethlehem District of the West Bank during July 2000. Methods: We undertook a descriptive study using the Rutter A2 (parent) Scale to determine psychological morbidity. This questionnaire comprises 31 questions that were answered by a parent of the 206 subject children (ages 6 to 13 years). We selected subjects based on a multistage, randomized selection of 8 Palestinian villages and their households in the southern region of Bethlehem, West Bank. We used the Gaza Socioeconomic Adversities Questionnaire to determine differences in economic status among families. Results: For all families interviewed, the father was employed, none were receiving financial assistance, and all but 1 owned their own house. The results of the Rutter A2 Scale revealed a rate of psychological morbidity (“caseness”) of 42.3% among Palestinian children. The rate for boys was 46.3% and for girls, 37.8%. Conclusions: The prevalence of psychological morbidity among Palestinian children in the West Bank was significantly higher (factor of 2; χ2 = 23.26, df 1, P < 0.001), relative to the level of psychological morbidity determined independently for children in Gaza during 2000. We predict that these rates will have increased substantially owing to the escalated violence that began in this region 2 months after we conducted our study. We further predict that children in Israeli settlements in the West Bank will also exhibit elevated levels of psychological morbidity, relative to their counterparts in Israel.

Effect of Body Mass Index on Treatment of Complicated Intra-Abdominal Infections in Hospitalized Adults: Comparison of Ertapenem with Piperacillin-Tazobactam

BACKGROUND Complicated intra-abdominal infections (cIAI) are a common problem in surgical practice. The effect of body mass index (BMI) on the outcome is poorly understood. We compared the association of BMI and type of antibiotic therapy for cIAI described in a previously published trial of ertapenem vs. piperacillin-tazobactam (Namias N, Solomkin JS, Jensen EH, et al. Randomized, multicenter, double-blind study of efficacy, safety, and tolerability of intravenous ertapenem versus piperacillin/tazobactam in treatment of complicated intra-abdominal infections in hospitalized adults. Surg Infect 2007;8:15-28). METHODS A post-hoc analysis was performed using data obtained from the published study. The effect of BMI and type of antibiotic used for therapy were calculated for clinically favorable outcomes at early follow-up assessment (EFA). RESULTS The 231 patients who were microbiologically evaluable at EFA were stratified by BMI (<30 or ≥30 kg/m(2)). Twelve patients were excluded because of missing BMI data, leaving 219 patients for analysis. There were some differences in baseline characteristics between patients with a BMI <30 kg/m(2), including the source of intra-abdominal infection (more appendicitis in BMI <30 group; p=0.01) and gender (more men in the BMI <30 group; p=0.03). There was no difference in cure rates between the groups (82.9% for BMI <30 kg/m(2) vs. 74.5% for those with BMI ≥30 kg/m(2); 8% difference in proportions, 95% confidence interval [CI] -5%, 25%). There was an 80% favorable clinical response to ertapenem in the BMI <30 group compared with an 81% favorable rate in the BMI ≥30 group (-1% difference in proportions; 95% CI -22%, 19%). This compared with an 86% favorable response rate to piperacillin-tazobactam in the BMI <30 group vs. a 65% favorable clinical response rate in the BMI ≥30 group (21% difference in proportions; 95% CI -1%, 47%). CONCLUSIONS There was no difference in the cure rate of patients with cIAI in the BMI <30 and BMI ≥30 kg/m(2) groups. There were no statistically significant differences in the likelihood of response to an antibiotic regimen. However, there was a nominally 21% lower cure rate in the high BMI group receiving piperacillin-tazobactam (86% vs. 65%; 21% difference in proportions; 95% CI -1%, 47%), whereas there was only a 1% difference in the cure rate between BMI groups in the patients receiving ertapenem. This difference may be related to gender and etiology of infection. Although limited by the small number of high BMI patients and post-hoc methodology, these results merit consideration of the design of future prospective antibiotic trials to include stratification for BMI and consideration of the effect of BMI on pharmacokinetics and pharmacodynamics.

Pediatric emergency department thoracotomy: A large case series and systematic review

BACKGROUND/PURPOSE The emergency department thoracotomy (EDT) is rarely utilized in children, and is thus difficult to identify survival factors. We reviewed our experience and performed a systematic review of reports of EDT in pediatric patients. METHODS Patients age ≤18 years who received an EDT from 1991 to 2012 at our institution and all published case series were reviewed. Data analyzed include age, sex, mechanism of injury (MOI), injury patterns, presence of vital signs (VS) or signs of life (SOL) in the field/ED, return of spontaneous circulation (ROSC), and survival. RESULTS A total of 252 patients were analyzed. 84% were male. 51% sustained penetrating injuries, and median age was 15 years. Upon arrival, 17% had VS, and 35% had SOL. After EDT, 30% experienced ROSC. The survival rate was 1.6% for blunt trauma, 10.2% for penetrating injuries, and 6.0% overall. CONCLUSION Survival of pediatric patients following EDT is comparable to recent analyses in adults. Children who sustain blunt injury and are without SOL have been uniformly unsalvageable. Children who sustain penetrating trauma and have SOL or are without SOL for a short time prior to arrival have been salvageable. There are no reported EDT survivors less than 14 years of age following blunt injury.

Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes

INTRODUCTION Timely hemorrhage control is paramount in trauma; however, a critical time interval from emergency department arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW. METHODS Data of adults (n = 309) with hypotension and GSW to the torso requiring immediate operation from January 2004 to September 2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring more than 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. Statistical significance was considered at p ⩽ 0.05. RESULTS The study population was aged 32 ± 12 years, 92% were male, Injury Severity Score was 24 ± 15, systolic blood pressure was 81 ± 29 mm Hg, Glasgow Coma Scale score was 13 ± 4. Overall mortality was 27%. Mean time to operation was 19 ± 13 minutes. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared with those who arrived in 10 minutes or less (HR, 1.89; 95% CI, 1.10–3.26; p = 0.02); this was also true in the severely hypotensive patients with systolic blood pressure of 70 mm Hg or less (HR, 2.67; 95% CI, 0.97–7.34; p = 0.05). The time associated with a 50% cumulative mortality was 16 minutes. CONCLUSIONS Delay to the operating room of more than 10 minutes increases the risk of mortality by almost threefold in hypotensive patients with GSW. Protocols should be designed to shorten time in the emergency department. Further prospective observational studies are required to validate these findings. LEVEL OF EVIDENCE Therapeutic study, level IV.

Lost information during the handover of critically injured trauma patients: a mixed-methods study

Background Clinical information may be lost during the transfer of critically injured trauma patients from the emergency department (ED) to the intensive care unit (ICU). The aim of this study was to investigate the causes and frequency of information discrepancies with handover and to explore solutions to improving information transfer. Methods A mixed-methods research approach was used at our level I trauma centre. Information discrepancies between the ED and the ICU were measured using chart audits. Descriptive, parametric and non-parametric statistics were applied, as appropriate. Six focus groups of 46 ED and ICU nurses and nine individual interviews of trauma team leaders were conducted to explore solutions to improve information transfer using thematic analysis. Results Chart audits demonstrated that injuries were missed in 24% of patients. Clinical information discrepancies occurred in 48% of patients. Patients with these discrepancies were more likely to have unknown medical histories (p<0.001) requiring information rescue (p<0.005). Close to one in three patients with information rescue had a change in clinical management (p<0.01). Participants identified challenges according to their disciplines, with some overlap. Physicians, in contrast to nurses, were perceived as less aware of interdisciplinary stress and their role regarding variability in handover. Standardising handover, increasing non-technical physician training and understanding unit cultures were proposed as solutions, with nurses as drivers of a culture of safety. Conclusion Trauma patient information was lost during handover from the ED to the ICU for multiple reasons. An interprofessional approach was proposed to improve handover through cross-unit familiarisation and use of communication tools is proposed. Going beyond traditional geographical and temporal boundaries was deemed important for improving patient safety during the ED to ICU handover.

Trauma in Canada: A Spirit of Equity & Collaboration

BackgroundThe delivery of equitable trauma care in Canada is not without challenges within our universal health care system. Notably, the tyranny of geography is intermittently at odds with adequate access for our rural, indigenous, and impoverished populations. Other differences exist when compared with neighbouring trauma systems, for example in the United States.MethodsAs a critical review, we chose to compare and critique the overall system of trauma organization and perceived societal expectations of a high-income, North American country (Canada) to assist with discussions on trauma systems for the future.ResultsTele-technology is providing some early solutions. Trauma systems and delivery of care in Canada differ from the United States due to our single-payer system, regionalization and universal provision. Care for injured Canadians has a long history of being multidisciplinary, with collaborative research programs. Canada also has a history of global surgical endeavours, beginning with Dr. Norman Bethune and his recognition of the political causes of trauma and continuing as a global public health concern for all.ConclusionsWhile challenges continue to exist for the provision of equitable trauma care in Canada, unique multidisciplinary, collaborative and technology-based solutions continue to be developed, both locally and globally, to address this critical public health issue.

Venous and arterial base deficits: do these agree in occult shock and in the elderly? A Bland-Altman analysis.

BACKGROUND Trauma centers are increasingly advocating the replacement of arterial blood gas measurements with venous blood gas measurements for simplification of base deficit (BD) determination. These values have never been demonstrated to agree in important trauma populations, such as for patients in occult shock (OS) or the elderly. The goal of this study was to investigate the level of agreement between venous and arterial BDs from blood gases in critically ill or injured patients, specifically in OS and the elderly. METHODS This is a retrospective, consecutive, cohort study using matched pairs of venous and arterial blood gases from patients admitted to the Trauma and Neurosurgery Intensive Care Unit in a Level I trauma center in Toronto, Ontario, Canada. Agreement between near simultaneous arterial and venous BD was calculated using the Bland-Altman method. McNemar’s test was used for differences in BDs in the presence or absence of OS and in elderly patients. RESULTS BDs for 466 arterial and venous samples from 72 patients were compared pairwise. There was no significant difference between samples (p = 0.88). Ninety-eight percent of samples were within 3.0 mmol/L of each other. No significant differences were detected between venous and arterial BD in the presence of OS or in the elderly (p = 0.72 and p = 0.25, respectively). CONCLUSION Arterial and venous BDs agree, including in the presence of OS and in the elderly. Consideration may be given to venous sampling both in the intensive care unit or in other areas of care, such as the trauma bay. LEVEL OF EVIDENCE Diagnostic study, level III.

A systematic review of propensity score methods in the acute care surgery literature: avoiding the pitfalls and proposing a set of reporting guidelines

BackgroundPropensity score methods are techniques commonly employed in observational research to account for confounding when estimating the effects of treatments and exposures. These methods have been increasingly employed in the acute care surgery literature in an attempt to infer causality; however, the adequacy of reporting and the appropriateness of statistical analyses when using propensity score matching remain unclear.ObjectivesThe goal of this systematic review is to assess the adequacy of reporting of propensity score methods, with an emphasis on propensity score matching (to assess balance and the use of appropriate statistical tests), in acute care surgery (ACS) studies and to provide suggestions for improvement for junior investigators.MethodsWe searched three databases, and other relevant literature (from January 2005 to June 2015) to identify observational studies within the ACS literature using propensity score methods (PROSPERO No: CRD42016036432). Two reviewers extracted data and assessed the quality of the studies retrieved by reviewing the adequacy of both overall reporting and of the propensity score matching methods used.ResultsA total of 49/71 (69%) of studies adequately reported propensity score methods overall. Matching was the most common propensity score method used in 46/71 (65%) studies, with 36/46 (78%) studies reporting matching methods adequately. Only 19/46 (41%) of matching studies reported the balance of baseline characteristics between treated and untreated subjects while 6/46 (13%) used correct statistical methods to assess balance. There were 35/46 (76%) of matching studies that explicitly used statistical methods appropriate for the analysis of matched data when estimating the treatment effect and its statistical significance.ConclusionWe have proposed reporting guidelines for the use of propensity score methods in the acute care surgery literature. This is to help investigators improve the adequacy of reporting and statistical analyses when using observational data to estimate effects of treatments and exposures.

The politics of avoidable blindness in Latin America--surgery, solidarity, and solutions: the case of Misión Milagro.

Avoidable blindness, especially when caused by cataracts, is a disease primarily of the economically disadvantaged sectors of the population. With a focus on Latin America and the Caribbean, this paper focuses on the program Misión Milagro within its historical, political, and economic contexts. This initiative, led by the governments of Cuba and Venezuela, covers close to 35 countries across Latin America, the Caribbean, Asia, and Africa. It is well-known throughout Latin America as close to 2 million patients have undergone free screening, corrective surgery, and rehabilitation since its inception in 2004. Misión Milagro shows that implementation of a massive initiative to curb avoidable blindness caused by cataracts in a relatively short time is feasible. The program is also built upon a unique model of international cooperation, which stresses social objectives and solidarity rather than hegemonic international initiatives built on commercial relationships. It also provides elements that could be applied to other public health issues of global or national relevance, not only to other low-middle-income countries, but also to high-income countries such as Canada.