Tarek Razek

Hypertonic saline resuscitation attenuates neutrophil lung sequestration and transmigration by diminishing leukocyte-endothelial interactions in a two-hit model of hemorrhagic shock and infection.

BACKGROUND Hypertonic saline (HTS) attenuates polymorphonuclear neutrophil (PMN)-mediated tissue injury after hemorrhagic shock. We hypothesized that HTS resuscitation reduces early in vivo endothelial cell (EC)-PMN interactions and late lung PMN sequestration in a two-hit model of hemorrhagic shock followed by mimicked infection. METHODS Thirty-two mice were hemorrhaged (40 mm Hg) for 60 minutes and then given intratracheal lipopolysaccharide (10 microg) 1 hour after resuscitation with shed blood and either HTS (4 mL/kg 7.5% NaCl) or Ringers lactate (RL) (twice shed blood volume). Eleven controls were not manipulated. Cremaster intravital microscopy quantified 5-hour EC-PMN adherence, myeloperoxidase assay assessed lung PMN content (2 1/2 and 24 hours), and lung histology determined 24-hour PMN transmigration. RESULTS Compared with RL, HTS animals displayed 55% less 5-hour EC-PMN adherence (p = 0.01), 61% lower 24-hour lung myeloperoxidase ( p= 0.007), and 57% lower mean 24-hour lung histologic score ( p= 0.027). CONCLUSION Compared with RL, HTS resuscitation attenuates early EC-PMN adhesion and late lung PMN accumulation in hemorrhagic shock followed by inflammation. HTS resuscitation may attenuate PMN-mediated organ damage.

The Current Status of Traumatic Diaphragmatic Injury: Lessons Learned From 105 Patients Over 13 Years

BACKGROUND Our understanding of traumatic diaphragmatic injury (TDI) is based primarily on outdated retrospective series. We sought to reexamine present day patterns of diagnosis, associated injuries, predictors of mortality, and long-term outcomes of this condition. METHODS A prospectively entered trauma database from the Montréal General Hospital was reviewed for patients admitted with a TDI from 1993 to 2006. Hospital charts were reviewed, and patient characteristics, mechanism of injury, associated injuries, operative management, and postoperative outcomes were recorded. Logistic regression was used to identify predictors for mortality. RESULTS Identified were 105 patients with TDI consisting of blunt in 37% and penetrating in 63%. Only 23% of TDI were diagnosed on initial chest roentgenogram. External wounds in penetrating TDI cases were found in the abdomen alone in 19%, in the chest alone in 46%, and in both in 35%, which was associated with intraabdominal organ injury in 83%, 55%, and 87%, respectively. Less than half of patients had a diaphragmatic hernia. Lung, chest wall, and thoracic organ injuries were more common in blunt trauma, but there was no significant difference between abdominal injuries in both mechanisms. Overall mortality from TDI was 18%, and there was no difference between blunt and penetrating injury. In blunt trauma, brain injury and an Injury Severity Score (ISS) exceeding 15 were independently associated with increased death. In penetrating trauma, only an ISS exceeding 15 predicted death. CONCLUSIONS Traumatic diaphragmatic injury remains a challenge to diagnose and treat, primarily due to the presence of associated injuries. The high incidence of intraabdominal organ injury, irrespective of the site of penetrating wound, dictates a transabdominal approach for exploration and repair. Severity of associated injuries (ISS) predicts death.

Severely injured geriatric population: morbidity, mortality, and risk factors.

BACKGROUND With an increasing life expectancy and more active elderly population, management of geriatric trauma patients continues to evolve. The aim was to describe the mechanism and injuries of severely injured geriatric patients and to identify risk factors associated with mortality. METHODS The Trauma Registry at a Canadian Level I trauma center was queried for all trauma patients older than 65 years and injury severity score >15 from 2004 to 2006, resulting in a retrospective chart review of 276 patients. The data were subsequently analyzed using univariate and multivariate analysis. RESULTS Average age was 81.5 years (mean injury severity score of 25). Most common comorbid illness was hypertension (57.3%) and most frequent mechanism of injury was falls (72.3%). The overall mortality was comparable with the US National Trauma Data Bank (26.8% vs. 32.0%, confidence interval, 0.00-0.10). Geriatric patients requiring intubation, blood transfusions, or suffering from head, C-spine, or chest trauma had an increased likelihood of death. In-hospital respiratory, gastrointestinal, or infectious complications also had higher likelihood of death. CONCLUSIONS Falls continue to be the most frequent mechanism of injury in severely injured geriatric patients. Risk factors associated with a higher likelihood of death are identified. More research is needed to better understand this important and increasing group of trauma patients.

Assessing the impact of the trauma team training program in Tanzania.

BACKGROUND In sub-Saharan Africa, injury is responsible for more deaths and disability-adjusted life years than AIDS and malaria combined. The trauma team training (TTT) program is a low-cost course designed to teach a multidisciplinary team approach to trauma evaluation and resuscitation. The purpose of this study was to assess the impact of TTT on trauma knowledge and performance of Tanzanian physicians and nurses; and to demonstrate the validity of a questionnaire assessing trauma knowledge. METHODS This is a prospective study of physicians and nurses from Dar es Salaam undergoing TTT (n = 20). Subjects received a precourse test and, after the course, an alternate postcourse test. The equivalence and construct validity of these 15-item multiple-choice questionnaires was previously demonstrated. After the course, subjects were divided into four teams and underwent a multiple injuries simulation, which was scored with a trauma resuscitation simulation assessment checklist. A satisfaction questionnaire was then administered. Test data are expressed as median score (interquartile ratio) and were analyzed with the Wilcoxons signed rank test. RESULTS After the TTT course, subjects improved their scores from 9 (5-12) to 13 (9-13), p = 0.0004. Team performance scores for the simulation were all >80%. Seventy-five percent of subjects were very satisfied with TTT and 90% would strongly recommend it to others and would agree to teach future courses. CONCLUSIONS After completion of TTT, there was a significant improvement in trauma resuscitation knowledge, based on results from a validated questionnaire. Trauma team performance was excellent when assessed with a novel trauma simulation assessment tool. Participants were very supportive of the course.

Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care in critically ill patients

BACKGROUND A multidisciplinary tracheostomy team was created in 2005 to follow critically ill patients who had undergone a tracheostomy until their discharge from hospital. Composed of a surgeon, surgical resident, respiratory therapist, speech-language pathologist and clinical nurse specialist, this team has been meeting twice a week for rounds involving patients who transitioned from the intensive care unit (ICU) to the medical and surgical wards. Our objective was to assess the impact of this multidisciplinary team on downsizing and decannulation times, on the incidence of speaking valve placement and on the incidence of tracheostomy-related complications on the ward. METHODS This study was conducted at a tertiary care, level-1 trauma centre and teaching hospital and involved all patients who had received a tracheostomy during admission to the ICU from Jan. 1 to Dec. 31, 2004 (preservice group), and from Jan. 1 to Dec. 31, 2006 (postservice group). We compared the outcomes of patients who required tracheostomies in a 12-month period after the team was created with those of patients from a similar time frame before the establishment of the team. RESULTS There were 32 patients in the preservice group and 54 patients in the postservice group. Under the new tracheostomy service, there was a decrease in incidence of tube blockage (5.5% v. 25.0%, p = 0.016) and calls for respiratory distress (16.7% v. 37.5%, p = 0.039) on the wards. A significantly larger proportion of patients also received speaking valves (67.4% v. 19.4%, p < 0.001) after creation of the team. Furthermore, there appeared to be a decreased time to first tube downsizing (26.0 to 9.4 d) and decreased time to decannulation (50.4 to 28.4 d), although this did not reach statistical significance owing to our small sample size. CONCLUSION Standardized care provided by a specialized multidisciplinary tracheostomy team was associated with fewer tracheostomy-related complications and an increase in the use of a speaking valve.

Assessing the need for reintubation: a prospective evaluation of unplanned endotracheal extubation.

OBJECTIVE Unplanned endotracheal extubation (UEE) is a common complication in medical intensive care units but very little data about UEE in surgical populations are available. Our hypothesis is that the surgical intensive care unit (SICU) population requires reintubation less frequently compared with the medical intensive care unit population. We prospectively gathered data on patients in a SICU in an attempt to identify the incidence of UEE and to study the need for reintubation after UEE. METHODS During an 18-month period, we prospectively identified SICU patients from a quality improvement database who required ventilatory support. All patients who self-extubated were included in the study. RESULTS Fifty-eight of 1,178 intubated patients experienced unplanned extubation 61 times during the 18-month period. A total of 22 patients (36%) required reintubation, whereas 39 patients (64%) did not. Thirty-three patients self-extubated while being actively weaned from ventilatory support. Of these, only 5 patients (15%) required reintubation and 28 patients (85%) did not (p < 0.01). CONCLUSION A total of 85% of patients who self-extubate during the weaning process did not require reintubation in our study. Those who have an FiO2 >50%, a lower PaO2/FiO2 ratio, had UEE occur by accident, or were not being weaned when UEE occurred required reintubation more frequently. These data suggest that some of our SICU patients are intubated longer than necessary, which may translate into more ventilator related complications, longer ICU stays and increased cost.

Prioritizing injury care: a review of trauma capacity in low and middle-income countries

BACKGROUND Trauma is a large contributor to the global burden of disease, particularly in low and middle-income countries (LMICs). This study aimed to summarize the literature assessing surgical capacity in LMICs to provide a current assessment of trauma capacity, which will help guide future efforts. MATERIALS AND METHODS The MEDLINE database was queried via PubMed to identify studies assessing baseline surgical capacity in individual LMICs. Data were collected from each study by extracting the relevant information from the full-published text or tables. Trauma capacity was evaluated using 12 surrogate criteria of trauma care, including laparotomy, cricothyroidotomy and chest tube insertion capabilities, and accessibility to a blood bank. RESULTS Seventeen studies were reviewed, documenting data from 531 hospitals in seventeen countries. None of the countries had access to all twelve trauma criteria in all their hospitals. Endotracheal intubation and cricothyrotomy or tracheostomy were available at 48% (107/222) and 41% (163/418) of facilities, respectively. Bag mask valves were available at 61% (234/383) of the institutions. Although 87% (193/221) of facilities responded that they were able to provide initial resuscitation, only 48% (169/349) of them had access to a blood bank and 70% (191/271) had access to intravenous fluids. A third or less of district hospitals had access to basic resuscitation (33%; 8/24), endotracheal tubes (32%; 31/97), blood banks (31%; 32/102), and cricothyrotomies and/or tracheostomies (32%; 30/95). CONCLUSIONS Deficiencies in trauma capacity in LMICs remain widespread. This study provides specific avenues for improved evaluations of trauma capacity and for strengthening trauma systems in LMICs.

Using the age-adjusted Charlson comorbidity index to predict outcomes in emergency general surgery.

BACKGROUND We evaluated the role of the Charlson age-comorbidity index (CACI), a weighted comorbidity index that reflects cumulative increased likelihood of 1-year mortality, in predicting perioperative outcomes in an emergency general surgery population at a large Canadian teaching hospital. METHODS A retrospective chart review of emergency general surgery admissions in 2010 was conducted. Patients who had surgery were identified. Mode of surgery and CACI were recorded, as well as measures of outcome, including 30-day mortality and intensive care unit (ICU) admission. A multivariate stepwise logistic regression model was created to assess the effect of age-adjusted Charlson comorbidity index on postoperative outcomes while controlling for the effect of possible confounders. The prediction ability of CACI for mortality was assessed using receiver operating characteristic analyses considering the area under the curve and its 95% confidence intervals (CIs). RESULTS Of the 529 admissions to general surgery from the emergency department, 257 patients underwent a surgical intervention. The CACI scores ranged from 0 to 16. We described a total of 11 deaths (4.3%) and 30 ICU admissions (11.7%). CACI was associated with an increased risk of 30-day mortality (adjusted odds ratio,1.39; 95% CI, 1.11–1.73; p = 0.0034). Receiver operating characteristic analysis was consistent with high accuracy of CACI for mortality prediction alone, resulting in area under the curve or c statistic of 0.90 (95% CI, 0.84–0.95). CACI was similar in predicting mortality to a multivariate model. CACI was also found to be associated with ICU admission (adjusted odds ratio, 1.17; 95% CI, 1.01–1.37; p < 0.0382). CACI is not as good a predictor for ICU admission when compared with the multivariate model. CONCLUSION We have shown that the CACI is a valid tool for 30-day mortality prediction in the context of emergency general surgery. LEVEL OF EVIDENCE Prognostic study, level III.

Augmenting surgical capacity in resource-limited settings

www.thelancet.com Vol 380 August 25, 2012 713 Defi ciencies in access to surgical care in low-income and middle-income countries are well recognised. Despite the awareness and benchmarks generated by the Millennium Development Goals, most sub-Saharan African nations have a negative annual growth rate in the number of physicians compared with their population growth rate. In several sub-Saharan African nations, there are only 0·9 physicians per 1000 population, compared with 21 physicians per 1000 population in the UK and 28 per 1000 population in the USA. These trends raise concerns about the morbidity, mortality, and disability-adjusted life-years lost due to injury and diseases requiring surgical treatment (including obstetrics) in sub-Saharan Africa. Policy makers and health-care leaders in Rwanda, a nation with only 0·1 general surgeons per 100 000 population (compared with 6·4 per 100 000 in the USA), have recognised the substantial negative socioeconomic eff ect caused by such defi ciencies and have committed themselves to tackling these challenges. 5–7 A partnership has been created between the Faculty of Medicine at the National University of Rwanda and McGill University Health Centre, Canada, to build on the academic elements of the only surgical residency in Rwanda. A needs assessment was done revealing a substantial requirement to augment surgical capacity through growth of the existing programme. Historically, the residency training has been service based, with relatively few academic activities; a refl ection of an overwhelming clinical workload and substantial staff shortages. These factors have resulted in a low intake of residents into the programme. Through the partnership, a system-based curriculum was developed, which is divided into 2-week modules covering locally relevant topics of general surgery. Each module contains lectures, resident case presentations, a journal club, morbidity and mortality rounds, and module evaluation by the residents. A Canadian surgeon, whose subspecialty is matched to the module topic, participates on a rotating basis in daily academic and clinical activities. This surgeon is not meant to replace local faculty in their responsibilities, but rather functions as an educator, moderator, and facilitator for the programme. Most activities are implemented by local faculty and residents. All activities are supervised by local faculty. These principles promote local programme accountability and, in keeping with the concept of “train the trainer”, form the necessary foundation for programme sustainability and success. This paradigm improves on previous models addressing the high morbidity and mortality from injury and surgical disease. Such models range from short-term, service-provision programmes, which, although they provide an exceptional service to indiv idual patients, are heavily dependent on the donor organisation, to slightly longer programmes that focus on surgical education, such as essential surgical skills, and trauma. We now recognise that the highest impact programmes for increasing surgical capacity will be based on long-term partnerships focused on training of local physicians, thereby increasing information retention and sustain ability. For the implementation of productive programmes, there are several important principles: local motivation and accountability, establishment of strong partnerships, understanding the local environment, curricu lum development based on local needs and not on western models, early programme assessment, and substantial involvement of local partners for pro gramme development. Additionally, the focus should be on Augmenting surgical capacity in resource-limited settings 7 Jylha M. What is self-rated health and why does it predict mortality? Towards a unifi ed conceptual model. Soc Sci Med 2009; 69: 307–16. 8 Mackenbach JP, Simon JG, Looman CW, Joung IM. Self-assessed health and mortality: could psychosocial factors explain the association? Int J Epidemiol 2002; 31: 1162–68. 9 Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997; 38: 21–37. 10 Zavalaa DE, Bokongo S, John IA, et al. Implementing a hospital based injury surveillance system in Africa: lessons learned. Med Confl Surviv 2008; 24: 260–72. 11 Abramsky T, Watts CH, Garcia-Moreno C, et al. What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health 2011; 11: 109. 12 Rani M, Bonu S. Attitudes toward wife beating: a cross-country study in Asia. J Interpers Violence 2009; 24: 1371–97. 13 Hargreaves JR, Bonell CP, Boler T, et al. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS 2008; 22: 403–14. 14 Gupta R, Dandu M, Packel L, et al. Depression and HIV in Botswana: a population-based study on gender-specifi c socioeconomic and behavioral correlates. PLoS One 2010; 5: e14252. 15 Lee J. Pathways from education to depression. J Cross Cult Gerontol 2011; 26: 121–35. 16 WHO. Constitution of the World Health Organization as adopted by the International Health Conference, New York, 1946. http://www.who.int/ governance/eb/who_constitution_en.pdf (accessed May 26, 2011).

A Descriptive Study of Bicycle Helmet Use in Montreal, 2011

ObjectiveThe purpose of this study was to describe bicycle helmet use among Montreal cyclists as a step towards injury prevention programming.MethodsUsing a cross-sectional study design, cyclists were observed during 60-minute periods at 22 locations on the island of Montreal. There were 1–3 observation periods per location. Observations took place between August 16 and October 31, 2011. Standard statistical methods were used, unadjusted and adjusted odds ratios and 95% confidence interval were calculated.ResultsA total of 4,789 cyclists were observed. The helmet-wearing proportion of all cyclists observed was 46% (95% CI 44-47). Women had a higher helmet-wearing proportion than men (50%, 95% CI 47–52 vs. 44%, 95% CI 42–45, respectively). Youth had the highest helmet-wearing proportion (73%, 95% CI 64-81), while young adults had the lowest (34%, 95% CI 30-37). Visible minorities were observed wearing a helmet 29% (95% CI 25-34) of the time compared to Caucasians, 47% (95% CI 46-49). BIXI (bike sharing program) riders were observed wearing a helmet 12% (95% CI 10-15) of the time compared to riders with their own bike, 51% (95% CI 49-52).ConclusionsAlthough above the national average, bicycle helmet use in Montreal is still considerably low given that the majority of cyclists do not wear a helmet. Injury Prevention Programs could target the entire cyclist population, but special attention may be warranted in specific groups such as young men, visible minorities, BIXI riders, and those riding in tourist areas. Additionally, a collaborative enterprise with the bicycle sharing system BIXI Montreal™ could prove to be fruitful in addressing the availability of bike helmets for BIXI riders.RésuméObjectifDécrire le port du casque de cycliste chez les cyclistes montréalais en vue d’instaurer des programmes de prévention des blessures.MéthodeÀ la faveur d’une étude transversale, nous avons observé les cyclistes sur des périodes de 60 minutes à 22 endroits sur l’île de Montréal. Il y a eu de 1 à 3 périodes d’observation à chaque endroit. Les observations ont eu lieu entre le 16 août et le 31 octobre 2011. Nous avons utilisé des méthodes statistiques types et calculé les rapports de cotes ajustés et non ajustés et les intervalles de confiance de 95 %.RésultatsNous avons observé 4 789 cyclistes en tout. La proportion observée de cyclistes portant le casque était de 46 % globalement (IC de 95 %: 44-47). Cette proportion était plus élevée chez les femmes (50 %, IC de 95 %: 47–52) que chez les hommes (44 %, IC de 95 %: 42–45). Les jeunes étaient proportionnellement les plus nombreux à porter un casque (73 %, IC de 95 %: 64-81), tandis que les jeunes adultes étaient proportionnellement les moins nombreux à le faire (34 %, IC de 95 %: 30-37). Le port du casque observé chez les cyclistes membres de minorités visibles était de 29 % (IC de 95 %: 25-34), contre 47 % chez les cyclistes blancs (IC de 95 %: 46-49). Les utilisateurs du BIXI (vélo en libre-service) ont été observés en train de porter un casque 12 % du temps (IC de 95 %: 10-15), contre 51 % du temps chez les cyclistes ayant leur propre vélo (IC de 95 %: 49-52).ConclusionsBien qu’il soit supérieur à la moyenne nationale, le port du casque de cycliste à Montréal est encore très faible, car la majorité des cyclistes n’en porte pas. Les programmes de prévention des blessures pourraient cibler tous les cyclistes, mais il serait justifié d’accorder une attention particulière à certains groupes: les jeunes hommes, les minorités visibles, les utilisateurs du BIXI et les cyclistes dans les zones touristiques. Par ailleurs, une collaboration avec le système de vélos en libre-service BIXI Montréalmc en vue d’assurer la disponibilité de casques de cyclistes pour les usagers du BIXI pourrait être fructueuse.