Statin therapy and postoperative short-term mortality after rectal cancer surgery

AIM

This study aimed to assess the correlation between regular statin therapy and postoperative mortality following surgical resection for rectal cancer.

METHOD

This retrospective cohort study included all adult patients undergoing abdominal rectal cancer surgery in Sweden between January 2007 and September 2016. Data were gathered from the Swedish Colorectal Cancer Registry, a large population-based prospectively collected registry. Statin users were defined as patients with one or more collected prescriptions of a statin within 12 months before the date of surgery. The statin-positive and statin-negative cohorts were matched by propensity scores based on baseline demographics.

RESULTS

A total of 11 966 patients underwent surgical resection for rectal cancer, of whom 3019 (25%) were identified as statin users. After applying propensity score matching (1:1), 3017 pairs were available for comparison. In the matched groups, statin users demonstrated reduced 90-day all-cause mortality (0.7% vs. 5.5%, p < 0.001) and also showed significantly reduced cause-specific mortality due to cardiovascular and respiratory events, as well as sepsis and multiorgan failure. The significant postoperative survival benefit of statin users was seen despite a higher rate of cardiovascular comorbidity.

CONCLUSION

Preoperative statin therapy displays a strong association with reduced postoperative mortality following surgical resection for rectal cancer. The results from the current study warrant further investigation to determine whether a causal relationship exists.

Hospital academic status is associated with failure-to-rescue after colorectal cancer surgery

BACKGROUND

Failure-to-rescue is a quality indicator measuring the response to postoperative complications. The current study aims to compare failure-to-rescue in patients suffering severe complications after surgery for colorectal cancer between hospitals based on their university status.

METHODS

Patients undergoing colorectal cancer surgery from January 2015 to January 2020 in Sweden were included through the Swedish Colorectal Cancer Registry in the current study. Severe postoperative complications were defined as Clavien-Dindo ≥3. Failure-to-rescue incidence rate ratios were calculated comparing university versus nonuniversity hospitals.

RESULTS

A total of 23,351 patients were included in this study, of whom 2,964 suffered severe postoperative complication(s). University hospitals had lower failure-to-rescue rates with an incidence rate ratios of 0.62 (0.46-0.84, P = .002) compared with nonuniversity hospitals. There were significantly lower failure-to-rescue rates in almost all types of severe postoperative complications at university than nonuniversity hospitals.

CONCLUSION

University hospitals have a lower risk for failure-to-rescue compared with nonuniversity hospitals. The exact mechanisms behind this finding are unknown and warrant further investigation to identify possible improvements that can be applied to all hospitals.

The mortality burden in patients with hip fractures and dementia

Purpose

Dementia is strongly associated with postoperative death in patients subjected to hip fracture surgery. Nevertheless, there is a distinct lack of research investigating the cause of postoperative mortality in patients with dementia. This study aims to investigate the distribution and the risk of cause-specific postoperative mortality in patients with dementia compared to the general hip fracture population.

Methods

All adults who underwent emergency hip fracture surgery in Sweden between 1/1/2008 and 31/12/2017 were considered for inclusion. Pathological, conservatively managed fractures, and reoperations were excluded. The database was retrieved by cross-referencing the Swedish National Quality Registry for Hip Fracture patients with the Swedish National Board of Health and Welfare quality registers. A Poisson regression model was used to determine the association between dementia and all-cause as well as cause-specific 30-day postoperative mortality.

Results

134,915 cases met the inclusion criteria, of which 20% had dementia at the time of surgery. The adjusted risk of all-cause 30-day postoperative mortality was 67% higher in patients with dementia after hip fracture surgery compared to patients without dementia [adj. IRR (95% CI): 1.67 (1.60–1.75), p < 0.001]. The risk of cause-specific mortality was also higher in patients with dementia, with up to a sevenfold increase in the risk cerebrovascular mortality [adj. IRR (95% CI): 7.43 (4.99–11.07), p < 0.001].

Conclusions

Hip fracture patients with dementia have a higher risk of death in the first 30 days postoperatively, with a substantially higher risk of mortality due to cardiovascular, respiratory, and cerebrovascular events, compared to patients without dementia.

Bile duct clearance and cholecystectomy for choledocholithiasis: Definitive single-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography versus staged procedures

BACKGROUND

Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner.

METHODS

Records were reviewed for all patients admitted between January 2015 and December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intraoperative rendezvous endoscopic retrograde cholangiopancreatography (ERCP) at index admission (one stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two stages) at the Irish hospital. Clinical characteristics, postprocedural complications, and inpatient duration were compared between cohorts.

RESULTS

Three hundred fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222 (62.2%) underwent a one-stage procedure in Sweden, while 135 (37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and preoperative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein, 136 ± 137 vs. 95 ± 102 mg/L; p = 0.024), had higher incidence of comorbidities (age-adjusted Charlson Comorbidity Index, ≥3; 37.8% vs. 20.0%; p = 0.003), and overall were less fit for surgery (American Society of Anesthesiologists, ≥3; 11.7% vs. 3.7%; p < 0.001). Despite this, a significantly shorter mean time to definitive treatment, that is, cholecystectomy (3.1 ± 2.5 vs. 40.3 ± 127 days, p = 0.017), without excess morbidity, was seen in the one-stage compared with the two-stage cohort. Patients in the one-stage cohort experienced shorter mean postprocedure length of stay (3.0 ± 4.7 vs. 5.0 ± 4.6 days, p < 0.001) and total length of hospital stay (6.5 ± 4.6 vs. 9.0 ± 7.3 days, p = 0.002). The only significant difference in postoperative complications between the cohorts was urinary retention, with a higher incidence in the one-stage cohort (19% vs. 1%, p = 0.004).

CONCLUSION

Where appropriate expertise and logistics exist within developing models of acute care surgery worldwide, consideration should be given to index-admission laparoscopic cholecystectomy with intraoperative ERCP for the treatment of choledocholithiasis. Our data suggest that this strategy significantly shortens the time to definitive treatment and decreases total hospital stay without any excess in adverse outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care Management Level IV.

A nationwide observational cohort study of the relationship between beta-blockade and survival after hip fracture surgery

PURPOSE

Despite advances in the care of hip fractures, this area of surgery is associated with high postoperative mortality. Downregulating circulating catecholamines, released as a response to traumatic injury and surgical trauma, is believed to reduce the risk of death in noncardiac surgical patients. This effect has not been studied in hip fractures. This study aims to assess whether survival benefits are gained by reducing the effects of the hyper-adrenergic state with beta-blocker therapy in patients undergoing emergency hip fracture surgery.

METHODS

This is a retrospective nationwide observational cohort study. All adults [Formula: see text] 18 years were identified from the prospectively collected national quality register for hip fractures in Sweden during a 10-year period. Pathological fractures were excluded. The cohort was subdivided into beta-blocker users and non-users. Poisson regression with robust standard errors and adjustments for confounders was used to evaluate 30-day mortality.

RESULTS

134,915 patients were included of whom 38.9% had ongoing beta-blocker therapy at the time of surgery. Beta-blocker users were significantly older and less fit for surgery. Crude 30-day all-cause mortality was significantly increased in non-users (10.0% versus 3.7%, p < 0.001). Beta-blocker therapy resulted in a 72% relative risk reduction in 30-day all-cause mortality (incidence rate ratio 0.28, 95% CI 0.26-0.29, p < 0.001) and was independently associated with a reduction in deaths of cardiovascular, respiratory, and cerebrovascular origin and deaths due to sepsis or multiorgan failure.

CONCLUSIONS

Beta-blockers are associated with significant survival benefits when undergoing emergency hip fracture surgery. Outlined results strongly encourage an interventional design to validate the observed relationship.

Pre-operative beta-blocker therapy does not affect short-term mortality after esophageal resection for cancer

BACKGROUND

It has been postulated that the hyperadrenergic state caused by surgical trauma is associated with worse outcomes and that β-blockade may improve overall outcome by downregulation of adrenergic activity. Esophageal resection is a surgical procedure with substantial risk for postoperative mortality. There is insufficient data to extrapolate the existing association between preoperative β-blockade and postoperative mortality to esophageal cancer surgery. This study assessed whether preoperative β-blocker therapy affects short-term postoperative mortality for patients undergoing esophageal cancer surgery.

METHODS

All patients with an esophageal cancer diagnosis that underwent surgical resection with curative intent from 2007 to 2017 were retrospectively identified from the Swedish National Register for Esophagus and Gastric Cancers (NREV). Patients were subdivided into β-blocker exposed and unexposed groups. Propensity score matching was carried out in a 1:1 ratio. The outcome of interest was 90-day postoperative mortality.

RESULTS

A total of 1466 patients met inclusion criteria, of whom 35% (n = 513) were on regular preoperative β-blocker therapy. Patients on β-blockers were significantly older, more comorbid and less fit for surgery based on their ASA score. After propensity score matching, 513 matched pairs were available for analysis. No difference in 90-day mortality was detected between β-blocker exposed and unexposed patients (6.0% vs. 6.6%, p = 0.798).

CONCLUSION

Preoperative β-blocker therapy is not associated with better short-term survival in patients subjected to curative esophageal tumor resection.

Local Tranexamic Acid for Local Hemostasis in an Animal Liver Injury Model

Background:

Hyperfibrinolysis is a state of increased clot resolution often seen in trauma patients with ongoing hemorrhage. Tranexamic acid (TXA) inhibits fibrinolysis preventing clot resolution affecting hemorrhage continuation and is used by intravenous administration.

Aims:

The purpose of this study was to evaluate the local tranexamic acid application for hemostatic control in an experimental animal liver injury model.

Settings and Design:

This study was an experimental prospective treatment study to check the local TXA effects on liver injury. This study was approved by the Ethics Committee.

Materials and Methods:

Twenty adult male Sprague-Dawley white rats were equally randomized to two groups after a standardized liver injury was conducted under anesthesia. One group were “liver-packed” with gauze (TXA [−]) and the other group with gauze soaked in TXA (TXA [+]). Bleeding from the injured middle liver lobe was measured at 2 and 15 min, and at 48h second-look surgery, with euthanasia conducted at 14 days. The liver was sent for histopathological and stereological analysis.

Statistical Analysis and Results:

There was no difference in bleeding at 2 or 15 min after packing; however, larger amount of free blood at 48 h in the TXA (−) group was noticed. Five animals in the TXA (−) were alive at 14 days compared to eight animals in the TXA (+) group. Significantly larger volume density of fibrosis, granulation tissue, and amorphous tissue were seen in the TXA (+) group compared to the TXA (−) group at the stereological analysis.

Conclusion:

Local TXA application on the injured liver surface might offer better hemostatic control than packing alone. Further studies are mandated before the clinical application of our findings.

The association between the Revised Cardiac Risk Index and short-term mortality after hip fracture surgery

PURPOSE

The post-operative mortality after hip fracture surgery is high and has remained largely unchanged during the last decades. The Revised Cardiac Risk Index (RCRI) is a tool used to evaluate the 30-day risk of, among other outcomes, post-operative mortality. The aim of this study is to determine the association between the RCRI score and post-operative mortality in patients undergoing hip fracture surgery.

METHODS

Data was obtained from the national hip fracture register which was cross-referenced with patients' electronic hospital records. All adults who underwent primary emergency hip fracture surgery in Orebro County, Sweden, between January 1, 2013 and December 31, 2017, were included. Patients were divided into two cohorts: low RCRI (score = 0-1) and high RCRI (score ≥ 2). A Poisson regression model was employed to investigate the association between a high RCRI score and 30- and 90-day post-operative mortality.

RESULTS

A total of 2443 patients, of whom 446 (18%) had a high RCRI score, were included in the current study. When adjusting for age, sex, comorbidities and type of surgery, the incidence of 30-day mortality increased by 46% in the high RCRI cohort (adj. IRR 1.46, 95% CI, 1.10-1.94, p = 0.010). Similar results were observed for 90-day mortality (adj. IRR 1.50, 95% CI, 1.21-1.84, p < 0.001).

CONCLUSION

The RCRI is applicable to patients that undergo surgery for traumatic hip fractures. A high RCRI score is associated with an increased incidence of both 30- and 90-day post-operative mortality. Future studies to evaluate these findings are needed.

Limited Effect of Beta-blockade on Postoperative Outcome After Laparoscopic Gastric Bypass Surgery

BACKGROUND

The benefit of beta-blockade on postoperative outcome remains controversial, though recent studies have suggested a role during major non-cardiac surgery. The benefit of beta-blockade during minimally invasive gastric bypass surgery remains unclear. The aim of the present study was to evaluate the possible association between preoperative beta-blocker therapy and postoperative outcome after laparoscopic gastric bypass surgery.

METHODS

Patients operated with primary laparoscopic gastric bypass surgery in Sweden between 2007 and 2017 were identified through the Scandinavian Obesity Surgery Registry. The dataset was linked to the Swedish National Patient Registry, the Swedish Prescribed Drug Registry, and Statistics Sweden. The main outcome was serious postoperative complication within 30 days of surgery; with postoperative complication, 90-day and 1-year mortality, and weight loss at 2 years after surgery as secondary endpoints. The Poisson regression model was used to evaluate primary and secondary categorical outcomes. A general mixed model was performed to evaluate 2-year weight loss.

RESULTS

In all, 50281 patients were included in the study. No difference was seen between patients on beta-blockade and the control group regarding postoperative complications (adjusted incidence rate ratio 1.04 (95%CI 0.93-1.15), p = 0.506), serious postoperative complication (adjusted IRR 1.06 95%CI 0.89-1.27), p = 0.515), 90-day mortality (adjusted IRR 0.71 (95%CI 0.24-2.10), p = 0.537), and 1-year mortality (adjusted IRR 1.26 (95%CI 0.67-2.36), p = 0.467). Weight loss 2 years after surgery was slightly greater in patients on beta-blockade (adjusted coefficient 0.53 (95%CI 0.19-0.87), p = 0.002).

CONCLUSIONS

Beta-blockade has limited impact on postoperative outcome after laparoscopic gastric bypass surgery.

β-adrenergic blockade is associated with a reduced risk of 90-day mortality after surgery for hip fractures

Background

There is a significant postoperative mortality risk in patients subjected to surgery for hip fractures. Adrenergic hyperactivity induced by trauma and subsequent surgery is thought to be an important contributor. By downregulating the effect of circulating catecholamines the increased risk of postoperative mortality may be reduced. The aim of the current study is to assess the association between regular β-blocker therapy and postoperative mortality.

Methods

This cohort study used the prospectively collected Swedish National Quality Registry for hip fractures to identify all patients over 40 years of age subjected to surgery for hip fractures between 2013 and 2017 in Örebro County, Sweden. Patients with ongoing β-blocker therapy at the time of surgery were allocated to the β-blocker-positive cohort. The primary outcome of interest was 90-day postoperative mortality. Risk factors for 90-day mortality were evaluated using Poisson regression analysis.

Results

A total of 2443 patients were included in this cohort of whom 900 (36.8%) had ongoing β-blocker therapy before surgery. The β-blocker positive group was significantly older, less fit for surgery based on their American Society of Anesthesiologists classification and had a higher prevalence of comorbidities. A significant risk reduction in 90-day mortality was detected in patients receiving β-blockers (adjusted incidence rate ratio=0.82, 95% CI 0.68 to 0.98, p=0.03).

Conclusions

β-blocker therapy is associated with a significant reduction in 90-day postoperative mortality after hip fracture surgery. Further investigation into this finding is warranted.

Level of evidence

Therapeutic study, level III; prognostic study, level II.

Effects of beta-blocker therapy on mortality after elective colon cancer surgery: a Swedish nationwide cohort study

OBJECTIVE

Colon cancer surgery remains associated with substantial postoperative morbidity and mortality despite advances in surgical techniques and care. The trauma of surgery triggers adrenergic hyperactivation which drives adverse stress responses. We hypothesised that outcome benefits are gained by reducing the effects of hyperadrenergic activity with beta-blocker therapy in patients undergoing colon cancer surgery. This study aims to test this hypothesis.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

This is a nationwide study which includes all adult patients undergoing elective colon cancer surgery in Sweden over 10 years. Patient data were collected from the Swedish Colorectal Cancer Registry. The national drugs registry was used to obtain information about beta-blocker use. Patients were subdivided into exposed and unexposed groups. The association between beta-blockade, short-term and long-term mortality was evaluated using Poisson regression, Kaplan-Meier curves and Cox regression.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome of interest was 1-year all-cause mortality. Secondary outcomes included 90-day all-cause and 5-year cancer-specific mortality.

RESULTS

The study included 22 337 patients of whom 36.1% were prescribed preoperative beta-blockers. Survival was higher in patients on beta-blockers up to 1 year after surgery despite this group being significantly older and of higher comorbidity. Regression analysis demonstrated significant reductions in 90-day deaths (IRR 0.29, 95% CI 0.24 to 0.35, p<0.001) and a 43% risk reduction in 1-year all-cause mortality (adjusted HR 0.57, 95% CI 0.52 to 0.63, p<0.001) in beta-blocked patients. In addition, cancer-specific mortality up to 5 years after surgery was reduced in beta-blocked patients (adjusted HR 0.80, 95% CI 0.73 to 0.88, p<0.001).

CONCLUSION

Preoperative beta-blockade is associated with significant reductions in postoperative short-term and long-term mortality following elective colon cancer surgery. Its potential prophylactic effect warrants further interventional studies to determine whether beta-blockade can be used as a way of improving outcomes for this patient group.

Closed-Suction Drain Placement at Laparotomy in Isolated Solid Organ Injury is Not Associated with Decreased Risk of Deep Surgical Site Infection

The purpose of this study was to investigate the role of intra-abdominal closed-suction drainage after emergent trauma laparotomy for isolated solid organ injuries (iSOI) and to determine its association with deep surgical site infections (DSSI). All patients subjected to trauma laparotomy between January 2006 and December 2008 for an iSOI at two Level I urban trauma centers were identified. Patients with isolated hepatic, splenic, or renal injuries were included. Study variables extracted included demographics, clinical characteristics, intra-abdominal injuries, drain placement, DSSI, septic events, intensive care unit and hospital length of stay, and in-hospital mortality. Diagnosis of DSSI was based on abdominal computed tomography scan demonstrating an intra-abdominal collection combined with fever and elevated white blood cell count. For the analysis, patients were stratified based on injury severity. To identify an independent association between closed-suction drain placement and DSSI, stepwise logistic regression analysis was performed. Overall, 142 patients met the inclusion criteria with 80 per cent (n = 114) having severe iSOI. In 47 per cent (n = 53) of the patients with a severe injury, an intra-abdominal drain was placed. A drain was placed more often in patients with a blunt trauma with more severe injury defined by Injury Severity Score and abdominal Abbreviated Injury Scale Score and those who underwent splenectomy ( P < 0.05). There was a three-fold increased risk of DSSI in patients subjected to drain placement (odds ratio, 2.8; 95% confidence interval, 1.0 to 8.2; P = 0.046). Subgroup analysis demonstrated those who sustained severe hepatic injury receiving a drain had a significantly increase risk of DSSI ( P = 0.02). There was no statistical difference in the rate of DSSI based on the presence or absence of an intra-abdominal drain after severe splenic injury (17 vs 18%, P = 0.88). The use of intra-abdominal closed-suction drains after iSOI is not associated with decreased risk of DSSI.

Self-reported and actual adherence to the Tokyo guidelines in the European snapshot audit of complicated calculous biliary disease

BACKGROUND

Complicated acute biliary calculous disease poses clinical challenges. The European Society of Trauma and Emergency Surgery (ESTES) snapshot audit of complicated biliary calculous disease aims to make novel comparisons between self-reported institutional adherence to the Tokyo guidelines (TG18) and 'real-world' contemporary practice across Europe.

METHODS

A preplanned analysis of a prospective observational multicentre audit that captured patients undergoing emergency admission for complicated biliary calculous disease (complicated cholecystitis, biliary pancreatitis, or choledocholithiasis with or without cholangitis) between 1 and 31 October 2018 was performed. An anonymized survey was administered to participating sites.

RESULTS

Following an open call for participation, 25 centres from nine countries enrolled 338 patients. All centres completed the anonymized survey. Fifteen centres (60 per cent) self-reported that a minority of patients were treated surgically on index admission, favouring interval cholecystectomy. This was replicated in the snapshot audit, in which 152 of 338 patients (45·0 per cent) underwent index admission cholecystectomy, 17 (5·0 per cent) had interval cholecystectomy, and the remaining 169 (50·0 per cent) had not undergone surgery by the end of the 60-day follow-up. Centres that employed a dedicated acute care surgery model of care were more likely to perform index admission cholecystectomy compared with a traditional general surgery 'on call' service (57 versus 38 per cent respectively; odds ratio 2·14 (95 per cent c.i. 1·37 to 3·35), P < 0·001). Six centres (24 per cent) self-reported routinely performing blood cultures in acute cholecystitis; patient-level audit data revealed that blood cultures were done in 47 of 154 patients (30·5 per cent). No centre self-reported omitting antibiotics in the management of acute cholecystitis, and 144 of 154 (93·5 per cent) of patients in the snapshot audit received antibiotics during their index admission.

CONCLUSION

Awareness of TG18 recommendations was high, but self-reported adherence and objective snapshot audit data showed low compliance with TG18 in patients with complicated acute biliary calculous disease.

The statistical importance of P-POSSUM scores for predicting mortality after emergency laparotomy in geriatric patients

Background

Geriatric patients frequently undergo emergency general surgery and accrue a greater risk of postoperative complications and fatal outcomes than the general population. It is highly relevant to develop the most appropriate care measures and to guide patient-centered decision-making around end-of-life care.

Portsmouth - Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) has been used to predict mortality in patients undergoing different types of surgery. In the present study, we aimed to evaluate the relative importance of the P-POSSUM score for predicting 90-day mortality in the elderly subjected to emergency laparotomy from statistical aspects.

Methods

One hundred and fifty-seven geriatric patients aged ≥65 years undergoing emergency laparotomy between January 1st, 2015 and December 31st, 2016 were included in the study. Mortality and 27 other patient characteristics were retrieved from the computerized records of Örebro University Hospital in Örebro, Sweden. Two supervised classification machine methods (logistic regression and random forest) were used to predict the 90-day mortality risk. Three scalers (Standard scaler, Robust scaler and Min-Max scaler) were used for variable engineering. The performance of the models was evaluated using accuracy, sensitivity, specificity and area under the receiver operating characteristic curve (AUC). Importance of the predictors were evaluated using permutation variable importance and Gini importance.

Results

The mean age of the included patients was 75.4 years (standard deviation =7.3 years) and the 90-day mortality rate was 29.3%. The most common indication for surgery was bowel obstruction occurring in 92 (58.6%) patients. Types of post-operative complications ranged between 7.0–36.9% with infection being the most common type. Both the logistic regression and random forest models showed satisfactory performance for predicting 90-day mortality risk in geriatric patients after emergency laparotomy, with AUCs of 0.88 and 0.93, respectively. Both models had an accuracy > 0.8 and a specificity ≥0.9. P-POSSUM had the greatest relative importance for predicting 90-day mortality in the logistic regression model and was the fifth important predictor in the random forest model. No notable change was found in sensitivity analysis using different variable engineering methods with P-POSSUM being among the five most accurate variables for mortality prediction.

Conclusion

P-POSSUM is important for predicting 90-day mortality after emergency laparotomy in geriatric patients. The logistic regression model and random forest model may have an accuracy of > 0.8 and an AUC around 0.9 for predicting 90-day mortality. Further validation of the variables’ importance and the models’ robustness is needed by use of larger dataset.

The Relationship Between Severe Complications, Beta-Blocker Therapy and Long-Term Survival Following Emergency Surgery for Colon Cancer

BACKGROUND

Emergency surgery for colon cancer carries significant morbidity, and studies show more than doubled mortality when comparing elective to emergency surgery. The relationship between postoperative complications and survival has been outlined. Beta-blocker therapy has been linked to improved postoperative outcomes. This study aims to assess the impact of postoperative complications on long-term survival following emergency surgery for colon cancer and to determine whether beta-blockade can reduce complications.

STUDY DESIGN

This cohort study utilized the prospective Swedish Colorectal Cancer Registry to identify adults undergoing emergency colon cancer surgery between 2011 and 2016. Prescription data for preoperative beta-blocker therapy were collected from the national drug registry. Cox regression was used to evaluate the effect of beta-blocker exposure and complications on 1-year mortality, and Poisson regression was used to evaluate beta-blocker exposure in patients with major complications.

RESULTS

A total of 3139 patients were included with a mean age of 73.1 [12.4] of which 671 (21.4%) were prescribed beta-blockers prior to surgery. Major complications occurred in 375 (11.9%) patients. Those suffering major complications showed a threefold increase in 1-year mortality (adjusted HR = 3.29; 95% CI 2.75-3.94; p < 0.001). Beta-blocker use was linked to a 60% risk reduction in 1-year mortality (adjusted HR = 0.40; 95% CI 0.26-0.62; p < 0.001) but did not show a statistically significant association with reductions in major complications (adjusted IRR = 0.77; 95% CI 0.59-1.00; p = 0.055).

CONCLUSION

The development of major complications after emergency colon cancer surgery is associated with increased mortality during one year after surgery. Beta-blocker therapy may protect against postoperative complications.

Beta-blocker Therapy is Associated with Decreased 1-year Mortality After Emergency Laparotomy in Geriatric Patients

Background and Aims:

Emergency laparotomy is associated with a great risk of mortality in the elderly. The hyperadrenergic state induced by surgical trauma may play an important role in the pathophysiology of this increased risk. Studies have shown that beta-blocker exposure may be associated with decreased morbidity and mortality in the perioperative period. We aimed to study the effect of beta-blocker on mortality in geriatric patients undergoing emergency laparotomy.

Material and Methods:

This is a retrospective study of patients who underwent emergency laparotomy between 1 January 2015 and 31 December 2016 at a single institution. The outcomes of interest were the association between post-operative complications and in-hospital and 1-year mortality in patients on beta-blocker therapy (BB(+)) and those who were not (BB(−)). The Poisson regression analysis was used to evaluate the association.

Results:

A total of 192 patients were included of whom 62 (32.2%) had pre-operative beta-blocker therapy with continued exposure during their hospital stay. The in-hospital mortality was 17.7% in the BB(+) and 23.8% in the BB(−) cohorts ( p = 0.441). One-year mortality was significantly lower in the BB(+) group compared to the BB(−) group (30.6% versus 47.7%; p = 0.038). After adjusting for confounders, the incidence of deaths during 1 year post-operatively decreased by 35% in the BB(+) group (incidence rate ratio = 0.65, p = 0.004). No significant differences in the incidence of post-operative complications between the two groups could be measured.

Conclusion:

Beta-blocker therapy may be associated with reduced 1-year mortality following emergency laparotomy in geriatric patients.

Prognostic Value of P-POSSUM and Osteopenia for Predicting Mortality After Emergency Laparotomy in Geriatric Patients

Objective

To evaluate the Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (P-POSSUM) in comparison with other risk factors for mortality including osteopenia as an indicator for frailty in geriatric patients subjected to emergency laparotomy.

Methods

All geriatric patients (≥65 years) undergoing emergency laparotomy at a single university hospital between 1/2015 and 12/2016 were included in this cohort study. Demographics and outcomes were retrospectively collected from medical records. Association between prognostic markers and 30-day mortality was assessed using Poisson and backward stepwise regression models. Prognostic value was assessed using receiver operating characteristic (ROC) curves.

Results

209 patients were included with a mean age of 76 ± 7.3 years. American Society of Anesthesiologists (ASA) classification, age, indication and type of surgery, hypotension, transfusion requirement and current malignancy proved to be statistically significant predictors of 30-day mortality. P-POSSUM mortality was statistically significant in the backward stepwise regression (incidence rate ratio=1.58, 95% CI: 1.16-2.15, p=0.004) while osteopenia was not. P-POSSUM had poor prognostic value for 30-day mortality with an area under the ROC curve (AUC) of 0.59. The prognostic value of P-POSSUM improved significantly when adjusting for patient covariates (AUC=0.83).

Conclusion

P-POSSUM and osteopenia alone hardly predict 30-day mortality in geriatric patients following emergency laparotomy. P-POSSUM adjusted for other patient covariates improves the prediction.

Effect of beta-blocker therapy on early mortality after emergency colonic cancer surgery

Background

Emergency colorectal cancer surgery is associated with significant mortality. Induced adrenergic hyperactivity is thought to be an important contributor. Downregulating the effects of circulating catecholamines may reduce the risk of adverse outcomes. This study assessed whether regular preoperative beta-blockade reduced mortality after emergency colonic cancer surgery.

Methods

This cohort study used the prospectively collected Swedish Colorectal Cancer Registry to recruit all adult patients requiring emergency colonic cancer surgery between 2011 and 2016. Patients were subdivided into those receiving regular beta-blocker therapy before surgery and those who were not (control). Demographics and clinical outcomes were compared. Risk factors for 30-day mortality were evaluated using Poisson regression analysis.

Results

A total of 3187 patients were included, of whom 685 (21·5 per cent) used regular beta-blocker therapy before surgery. The overall 30-day mortality rate was significantly reduced in the beta-blocker group compared with controls: 3·1 (95 per cent c.i. 1·9 to 4·7) versus 8·6 (7·6 to 9·8) per cent respectively (P &lt; 0·001). Beta-blocker therapy was the only modifiable protective factor identified in multivariable analysis of 30-day all-cause mortality (incidence rate ratio 0·31, 95 per cent c.i. 0·20 to 0·47; P &lt; 0·001) and was associated with a significant reduction in death of cardiovascular, respiratory, sepsis and multiple organ failure origin.

Conclusion

Preoperative beta-blocker therapy may be associated with a reduction in 30-day mortality following emergency colonic cancer surgery.

The Effect of Early Positive Cultures on Mortality in Ventilated Trauma Patients

BACKGROUND

The purpose was to examine the incidence of positive cultures in a highly susceptible subset of trauma patients admitted to the surgical intensive care unit (SICU) for mechanical ventilation and to examine the impact of their timing on outcomes.

PATIENTS AND METHODS

A retrospective review was conducted of blunt trauma patients admitted to the SICU for mechanical ventilation at a level I trauma center over a five-year period. All urine, blood, and sputum cultures were abstracted. Patients with at least one positive culture were compared with those with negative or no cultures. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to calculate the adjusted hazard ratio (AHR).

RESULTS

The median age of 635 patients meeting inclusion criteria was 46 and 74.2% were male. A total of 298 patients (46.9%) had at least one positive culture, with 28.9% occurring within two days of admission. Patients with positive cultures were more likely to be severely injured with an injury severity score (ISS) ≥16 (68.5% vs. 45.1%, p < 0.001). Overall mortality was 22%. Patients who had their first positive culture within two and three days from admission had a significantly higher AHR for mortality (AHR: 14.46, p < 0.001 and AHR: 10.59, p = 0.028, respectively) compared to patients with a positive culture at day six or later.

CONCLUSIONS

Early positive cultures are common among trauma patients requiring mechanical ventilation and are associated with higher mortality. Early identification with "damage control cultures" obtained on admission to aid with early targeted treatment might be justified.

Simultaneous common bile duct clearance and laparoscopic cholecystectomy: experience of a one-stage approach

Introduction

The timing and optimal method for common bile duct (CBD) clearance and laparoscopic cholecystectomy remains controversial. Several different approaches are available in clinical practice. The current study presents the experience of two European hospitals of simultaneous laparoscopic cholecystectomy (LC) and intra-operative endoscopic retrograde cholangiopacreatography (IO-ERCP) done by surgeons.

Methods

Retrospective analysis of all consecutive patients subjected to LC + IO-ERCP during their index admission between 4/2014 and 9/2016. Data accrued included patient demographics, laboratory markers, operation time (min) reported as mean (± SD) and hospital length of stay (LOS) reported as median (lower quartile, upper quartile).

Results

During the 29-month study, a total of 201 consecutive LC + IO-ERCPs were performed. The mean age of patients was 55 ± 19 years and 67% were female. The mean intervention time was 105 ± 44 min. The total LOS was 4 (3,  7) days and the post-operative LOS was 2 (1,  3) days. A total of 6 (3%) patients experienced post-interventional pancreatitis and two (1%) patients suffered a Strasberg type A bile leak. All patients were successfully discharged.

Conclusion

Simultaneous LC + IO-ERCP is associated with few complications. Further studies investigating cost-benefit and patient satisfaction are warranted.

Does Beta-Blockade Reduce the Risk of Depression in Patients with Isolated Severe Extracranial Injuries?

Background

Approximately half of trauma patients develop post-traumatic depression. It is suggested that beta-blockade impairs trauma memory recollection, reducing depressive symptoms. This study investigates the effect of early beta-blockade on depression following severe traumatic injuries in patients without significant brain injury.

Methods

Patients were identified by retrospectively reviewing the trauma registry at an urban university hospital between 2007 and 2011. Severe extracranial injuries were defined as extracranial injuries with Abbreviated Injury Scale score ≥3, intracranial Abbreviated Injury Scale score <3 and an Injury Severity Score ≥16. In-hospital deaths and patients prescribed antidepressant therapy ≤1 year prior to admission were excluded. Patients were stratified into groups based on pre-admission beta-blocker status. The primary outcome was post-traumatic depression, defined as receiving antidepressants ≤1 year following trauma.

Results

Five hundred and ninety-six patients met the inclusion criteria with 11.4% prescribed pre-admission beta-blockade. Patients receiving beta-blockers were significantly older (57 ± 18 vs. 42 ± 17 years, p < 0.001) with lower Glasgow Coma Scale score (12 ± 3 vs. 14 ± 2, p < 0.001). The beta-blocked cohort spent significantly longer in hospital (21 ± 20 vs. 15 ± 17 days, p < 0.01) and intensive care (4 ± 7 vs. 3 ± 5 days, p = 0.01). A forward logistic regression model was applied and predicted lack of beta-blockade to be associated with increased risk of depression (OR 2.7, 95% CI 1.1–7.2, p = 0.04). After adjusting for group differences, patients lacking beta-blockers demonstrated an increased risk of depression (AOR 3.3, 95% CI 1.2–8.6, p = 0.02).

Conclusions

Pre-admission beta-blockade is associated with a significantly reduced risk of depression following severe traumatic injury. Further investigation is needed to determine the beneficial effects of beta-blockade in these instances.

Outcomes after resection versus non-resection management of penetrating grade III and IV pancreatic injury: A trauma quality improvement (TQIP) databank analysis

BACKGROUND

High-grade traumatic pancreatic injuries are associated with significant morbidity and mortality. Non-resection management is associated with fewer complications in pediatric patients. The present study evaluates outcomes following resection versus non-resection management of severe pancreatic injury caused by penetrating trauma.

METHODS

A retrospective study of the Trauma Quality Improvement Program (TQIP) database was performed from 1/2010 to 12/2014. Patients with AAST Organ Injury Scale pancreatic grade III and IV injuries caused by penetrating trauma were included in the study. Demographics, vital signs on admission, Abbreviated Injury Scale per body region, Injury Severity Score, transfusion and therapeutic modality were obtained. Mortality, length of stay (LOS), pseudocyst, pancreatitis, sepsis, thromboembolism, renal failure, ARDS and unplanned ICU admission or re-operation were stratified according to injury grade and treatment modality. Patients were stratified into those who did/did not undergo pancreatic resection.

RESULTS

A total of 4,098 patients had a pancreatic injury of which 15.9% (n=653) had a grade III and 6.7% (n=274) a grade IV pancreatic injury. There were no differences in patient demographics or overall injury severity between the resected and non-resected cohorts within each pancreatic injury grade. Forty-two percent of grade III and 38.0% of grade IV injuries underwent pancreatic resection. The total LOS was longer in the resection arm irrespective of pancreatic injury severity. There was no significant difference in morbidity between cohorts. Similarly, mortality was not significantly different between the two management approaches for grade III: 15.1% (95% CI 11.0-19.9) vs. 18.4% (95% CI 14.6-22.6), p=0.32 and grade IV: 24.0% (95% CI: 16.2-33.4) vs. 27.1% (95% CI: 20.5-34.4), p=0.68.

CONCLUSION

Resection for treatment of grade III and IV pancreatic injury is not associated with a significant decrease in mortality but is associated with an increase in hospital LOS.

β-Blocker after severe traumatic brain injury is associated with better long-term functional outcome: a matched case control study

PURPOSE

Severe traumatic brain injury (TBI) is the predominant cause of death and disability following trauma. Several studies have observed improved survival in TBI patients exposed to β-blockers, however, the effect on functional outcome is poorly documented.

METHODS

Adult patients with severe TBI (head AIS ≥ 3) were identified from a prospectively collected TBI database over a 5-year period. Patients with neurosurgical ICU length of stay <48 h and those dying within 48 h of admission were excluded. Patients exposed to β-blockers ≤ 48 h after admission and who continued with treatment until discharge constituted β-blocked cases and were matched to non β-blocked controls using propensity score matching. The outcome of interest was Glasgow Outcome Scores (GOS), as a measure of functional outcome up to 12 months after injury. GOS ≤ 3 was considered a poor outcome. Bivariate analysis was deployed to determine differences between groups. Odds ratio and 95% CI were used to assess the effect of β-blockers on GOS.

RESULTS

362 patients met the inclusion criteria with 21% receiving β-blockers during admission. After propensity matching, 76 matched pairs were available for analysis. There were no statistical differences in any variables included in the analysis. Mean hospital length of stay was shorter in the β-blocked cases (18.0 vs. 26.8 days, p < 0.01). The risk of poor long-term functional outcome was more than doubled in non-β-blocked controls (OR 2.44, 95% CI 1.01-6.03, p = 0.03).

CONCLUSION

Exposure to β-blockers in patients with severe TBI appears to improve functional outcome. Further prospective randomized trials are warranted.

Risk factors for depression following traumatic injury: An epidemiological study from a scandinavian trauma center

INTRODUCTION

A significant proportion of patients suffer depression following traumatic injuries. Once manifested, major depression is challenging to overcome and its presence risks impairing the potential for physical rehabilitation and functional recovery. Risk stratification for early detection and intervention in these instances is important. This study aims to investigate patient and injury characteristics associated with an increased risk for depression.

METHODS

All patients with traumatic injuries were recruited from the trauma registry of an urban university hospital between 2007 and 2012. Patient and injury characteristics as well as outcomes were collected for analysis. Patients under the age of eighteen, prescribed antidepressants within one year of admission, in-hospital deaths and deaths within 30days of trauma were excluded. Pre- and post-admission antidepressant data was requested from the national drugs registry. Post-traumatic depression was defined as the prescription of antidepressants within one year of trauma. To isolate independent risk factors for depression a multivariable forward stepwise logistic regression model was deployed.

RESULTS

A total of 5981 patients met the inclusion criteria of whom 9.2% (n=551) developed post-traumatic depression. The mean age of the cohort was 42 [standard deviation (SD) 18] years and 27.1% (n=1620) were females. The mean injury severity score was 9 (SD 9) with 18.4% (n=1100) of the patients assigned a score of at least 16. Six variables were identified as independent predictors for post-traumatic depression. Factors relating to the patient were female gender and age. Injury-specific variables were penetrating trauma and GCS score of≤8 on admission. Furthermore, intensive care admission and increasing hospital length of stay were predictors of depression.

CONCLUSION

Several risk factors associated with the development of post-traumatic depression were identified. A better targeted in-hospital screening and patient-centered follow up can be offered taking these risk factors into consideration.

Consistent high prevalence of Exophiala dermatitidis, a neurotropic opportunist, on railway sleepers

Environmental isolation of black yeasts potentially causing human disorders is essential for understanding ecology and routes of infection. Several Exophiala species show prevalence for man-made environments rich in monoaromatic compounds, such as creosote-treated or petroleum-stained railway sleepers. Ambient climatic conditions play a role in species composition in suitable habitats. Therefore, the aim of the present study was to establish the composition of Exophiala species in railway stations as a potential source of human infections in a subtropical region with evaluation of their antifungal susceptibility profiles. We examined 150 railway samples using cotton swabs moistened with sterile physiological saline. Black yeasts and relatives were selected on theirs colony morphology and identified based on ITS rDNA sequencing. Overall, 36 (24%) of samples were positive for black yeast-like fungi, i.e., Exophiala dermatitidis (n=20, 55.6%) was predominant, followed by E. phaeomuriformis (n=9, 25%), E. heteromorpha (n=5, 13.9%), and E. xenobiotica (n=2, 5.6%). Massive contaminations of E. dermatitidis were seen on railway sleepers on creosoted oak wood at the region close to the sea level, while in cold climates were primarily contaminated with clinically insignificant or rare human opportunists (E. crusticola). It seems that, high temperature and humidity are significant effect on species diversity. Moreover, the MIC results for all E. dermatitidis and E. phaeomuriformis strains revealed the widest range and the highest MICs to caspofungin (range 1-16mg/L, Geometric mean 4.912mg/L), and the lowest MIC for posaconazole (0.016-0.031mg/L, G mean 0.061mg/L). However, their clinical effectiveness in the treatment of Exophiala infections remains to be determined.

Does early beta-blockade in isolated severe traumatic brain injury reduce the risk of post traumatic depression?

INTRODUCTION

Depressive symptoms occur in approximately half of trauma patients, negatively impacting on functional outcome and quality of life following severe head injury. Pontine noradrenaline has been shown to increase upon trauma and associated β-adrenergic receptor activation appears to consolidate memory formation of traumatic events. Blocking adrenergic activity reduces physiological stress responses during recall of traumatic memories and impairs memory, implying a potential therapeutic role of β-blockers. This study examines the effect of pre-admission β-blockade on post-traumatic depression.

METHODS

All adult trauma patients (≥18 years) with severe, isolated traumatic brain injury (intracranial Abbreviated Injury Scale score (AIS) ≥3 and extracranial AIS <3) were recruited from the trauma registry of an urban university hospital between 2007 and 2011. Exclusion criteria were in-hospital deaths and prescription of antidepressants up to one year prior to admission. Pre- and post-admission β-blocker and antidepressant therapy data was requested from the national drugs registry. Post-traumatic depression was defined as the prescription of antidepressants within one year of trauma. Patients with and without pre-admission β-blockers were matched 1:1 by age, gender, Glasgow Coma Scale, Injury Severity Score and head AIS. Analysis was carried out using McNemar's and Student's t-test for categorical and continuous data, respectively.

RESULTS

A total of 545 patients met the study criteria. Of these, 15% (n=80) were prescribed β-blockers. After propensity matching, 80 matched pairs were analyzed. 33% (n=26) of non β-blocked patients developed post-traumatic depression, compared to only 18% (n=14) in the β-blocked group (p=0.04). There were no significant differences in ICU (mean days: 5.8 (SD 10.5) vs. 5.6 (SD 7.2), p=0.85) or hospital length of stay (mean days: 21 (SD 21) vs. 21 (SD 20), p=0.94) between cohorts.

CONCLUSION

β-blockade appears to act prophylactically and significantly reduces the risk of post-traumatic depression in patients suffering from isolated severe traumatic brain injuries. Further prospective randomized studies are warranted to validate this finding.

Is human Dectin-1 Y238X gene polymorphism related to susceptibility to recurrent vulvovaginal candidiasis?

Background and Purpose:

Vulvovaginal candidiasis is a frequent disease affecting approximately more than %75 of all childbearing women at least once in their lifetime by overgrowth of opportunistic Candida species. Recurrent vulvovaginal candidiasis (RVVC) is common in otherwise healthy individuals. Several risk factors were reported to contribute to RVVC susceptibility. A polymorphism in Dectin-1 (Y238X, rs16910526 ) was identified in patients with RVVC and hypothesized that genetic factors play an important role in susceptibility to RVVC. Herein, we aimed to survey the polymorphisms in the Dectin-1 gene, linked to susceptibility to RVVC.

Materials and Methods:

In the current study, blood samples were obtained from 25 patients who had frequent vulvovaginal candidiasis relapses and were diagnosed as RVVC. In addition, blood cultures were obtained from control group comprising of healthy individuals (n=25) with no history of RVVC, vaginal discharge, or itching on the day of examination. Dectin-1 Y238X gene polymorphism was investigated using Bi-PASA and DNA sequencing.

Results:

The analysis revealed that all of the patients were wild-type homozygous for Dectin-1 Y238X polymorphisms. None of the individuals showed heterozygous or mutant homozygous Dectin-1 polymorphism.

Conclusion:

No significant correlations were observed between the susceptibility to RVVC and Dectin-1 Y238X polymorphism in the Iranian population, which was not previously studied.

Digital rectal examination for initial assessment of the multi-injured patient: Can we depend on it?

BACKGROUND

Digital rectal examination (DRE) is part of the assessment of trauma patients as recommended by ATLS(®). The theory behind is to aid early diagnosis of potential lower intestinal, urethral and spinal cord injuries. Previous studies suggest that test characteristics of DRE are far from reliable. This study examines the correlation between DRE findings and diagnosis and whether DRE findings affect subsequent management.

MATERIALS AND METHODS

Patients with ICD-10 codes for spinal cord, urethral and lower intestinal injuries were identified from the trauma registry at an urban university hospital between 2007 and 2011. A retrospective review of electronic medical records was carried out to analyse DRE findings and subsequent management.

RESULTS

253 patients met the inclusion criteria with a mean age of 44 ± 20 years and mean ISS of 26 ± 16. 160 patients had detailed DRE documentation with abnormal findings in 48%. Sensitivity rate was 0.47. Correlational analysis between examination findings and diagnosis gave a kappa of 0.12. Subsequent management was not altered in any case due to DRE findings.

CONCLUSION

DRE in trauma settings has low sensitivity and does not change subsequent management. Excluding or postponing this examination should therefore be considered.

GIS based analysis of Intercity Fatal Road Traffic Accidents in Iran

Road traffic accidents including intercity car traffic accidents (ICTAs) are among the most important causes of morbidity and mortality due to the growing number of vehicles, risky behaviors, and changes in lifestyle of the general population. A sound knowledge of the geographical distribution of car traffic accidents can be considered as an approach towards the accident causation and it can be used as an administrative tool in allocating the sources for traffic accidents prevention. This study was conducted to investigate the geographical distribution and the time trend of fatal intercity car traffic accidents in Iran. To conduct this descriptive study, all Iranian intercity road traffic mortality data were obtained from the Police reports in the Statistical Yearbook of the Governor's Budget and Planning. The obtained data were for 17 complete Iranian calendar years from March 1997 to March 2012. The incidence rate (IR) of fatal ICTAs for each year was calculated as the total number of fatal ICTAs in every 100000 population in specified time intervals. Figures and maps indicating the trends and geographical distribution of fatal ICTAs were prepared while using Microsoft Excel and ArcGis9.2 software. The number of fatal car accidents showed a general increasing trend from 3000 in 1996 to 13500 in 2012. The incidence of fatal intercity car accidents has changed from six in 100000 population in 1996 to 18 in 100000 population in 2012. GIS based data showed that the incidence rate of ICTAs in different provinces of Iran was very divergent. The highest incidence of fatal ICTAs was in Semnan province (IR= 35.2), followed by North Khorasan (IR=22.7), and South Khorasan (IR=22). The least incidence of fatal ICTAs was in Tehran province (IR=2.4) followed by Khozestan (IR=6.5), and Eastern Azarbayejan (IR=6.6). The compensation cost of fatal ICTAs also showed an increasing trend during the studied period. Since an increasing amount of money was being paid yearly for the car accidents, which were in their nature preventable, the key players in road safety including governments, car manufacturers, and road developers were recommended to use GIS based accident data for a more efficient planning and budgeting towards the intercity car accidents reduction.

Information needs assessment of medical equipment offices based on Critical Success Factors (CSF) and Business System Planning (BSP) methods

Introduction: Given the ever-increasing importance and value of information, providing the management with a reliable information system, which can facilitate decision-making regarding planning, organization and control, is vitally important. This study aimed to analyze and evaluate the information needs of medical equipment offices. Methods: This descriptive applied cross-sectional study was carried out in 2010. The population of the study included the managers of statistic and medical records at the offices of vice-chancellor for treatment in 39 medical universities in Iran. Data were collected by using structured questioners. With regard to different kinds of designing information systems, sampling was done by two methods, BSP (based on processes of job description) and CSF method (based on critical success factors). The data were analyzed by SPSS-16. Results: Our study showed that 41% of information needs were found to be critical success factors of managers of office. The first priority of managers was "the number of bed and bed occupancy in hospitals". Of 29 identified information needs, 62% were initial information needs of managers (from the viewpoints of managers). Of all, 4% of the information needs were obtained through the form, 14% through both the form and database, 11% through the web site, and 71% had no sources (forms, databases, web site). Conclusion: Since 71% of the information needs of medical equipment offices managers had no information sources, the development of information system in these offices seems to be necessary. Despite the important role of users in designing the information systems (identifying 62% of information needs), other scientific methods is also needed to be utilized in designing the information systems.

Spatial distribution and prevalence of physical disabilities in the provinces of Iran

Introduction: To identify the influential social factors and spatial distribution of physical disabilities in Iran between 2006 and 2011. Materials and Methods: First, the prevalence of physical disability in each province between 2006 and 2011 was mapped via GIS. Moreover, the percentage of physical disability was estimated with regard to age, sex, and residential area. Finally, the prevalence of physical disability was estimated with regard to the afore-mentioned variables. Findings: The findings revealed that in the majority of the provinces of Iran, there was a decreasing trend in the prevalence of physical disability from 2006 to 2011. The prevalence of physical disability in the total population of the country was also decreased during these years. The results were also indicative of a higher prevalence among men than among women and also in rural residential areas than in urban areas. Conclusion: The results of this research can be used to identify the high- and low-risk areas. In addition, this information can be used for the etiology and the specification of the factors that cause the residents of some regions to get afflicted more than the others.

Spatial distribution and the prevalence of speech disorders in the provinces of Iran

Objective: To identify the spatial distribution and prevalence of speech disorder in Iran. Materials and methods: First, the prevalence of speech disorder in 2006 and 2011 was mapped via GIS for each province. Moreover, the prevalence of this disorder was calculated and classified according to age, sex, and residential area. Results: The prevalence in the majority of provinces indicated an overall decrease. Furthermore, its prevalence among the whole population of Iran in 2006 and 2011 was 2.2 and 2 per 1000 people, respectively. The highest prevalence was observed among people aged 75 years and older. Results showed that speech disorders are more prevalent among men compared to women and also among rural residents compared to those in urban areas. Conclusion: It is necessary to identify the high-risk areas in order to well organize the limited facilities to meet the actual needs of patients with speech disorder.

Penetrating cardiac trauma in adolescents: a rare injury with excessive mortality

BACKGROUND

Penetrating cardiac injuries in pediatric patients are rarely encountered. Likewise, the in-hospital outcome measures following these injuries are poorly described.

METHODS

All pediatric patients (<18years) sustaining penetrating cardiac injuries between 1/2000 and 12/2010 were retrospectively identified using the trauma registry of an urban level I trauma center. Demographic and admission variables, operative findings, and hospital course were extracted. Outpatient follow-up data were obtained through chart reviews and cardiac-specific imaging studies.

RESULTS

During the 11-year study period, 32 of the 4569 pediatric trauma admissions (0.7%) sustained penetrating cardiac injuries. All patients were male and the majority suffered stab wounds (81.2%). The mean systolic blood pressure on admission was 28.8±52.9mmHg and the mean ISS was 46.9±27.7. Cardiac chambers involved were the right ventricle (46.9%), the left ventricle (43.8%), and the right atrium (18.8%). Overall, 9 patients (28.1%) survived to hospital discharge. Outpatient follow-up echocardiography was available for 4 patients (44.4%). An abnormal echocardiography result was found in 1 patient, demonstrating hypokinesia and tricuspid regurgitation.

CONCLUSIONS

Penetrating cardiac trauma is a rare injury in the pediatric population. Cardiac chambers predominantly involved are the right and left ventricles. This injury is associated with a low in-hospital survival (<30%).

Closed-suction drain placement at laparotomy in isolated solid organ injury is not associated with decreased risk of deep surgical site infection

The purpose of this study was to investigate the role of intra-abdominal closed-suction drainage after emergent trauma laparotomy for isolated solid organ injuries (iSOI) and to determine its association with deep surgical site infections (DSSI). All patients subjected to trauma laparotomy between January 2006 and December 2008 for an iSOI at two Level I urban trauma centers were identified. Patients with isolated hepatic, splenic, or renal injuries were included. Study variables extracted included demographics, clinical characteristics, intra-abdominal injuries, drain placement, DSSI, septic events, intensive care unit and hospital length of stay, and in-hospital mortality. Diagnosis of DSSI was based on abdominal computed tomography scan demonstrating an intra-abdominal collection combined with fever and elevated white blood cell count. For the analysis, patients were stratified based on injury severity. To identify an independent association between closed-suction drain placement and DSSI, stepwise logistic regression analysis was performed. Overall, 142 patients met the inclusion criteria with 80 per cent (n=114) having severe iSOI. In 47 per cent (n=53) of the patients with a severe injury, an intra-abdominal drain was placed. A drain was placed more often in patients with a blunt trauma with more severe injury defined by Injury Severity Score and abdominal Abbreviated Injury Scale Score and those who underwent splenectomy (P<0.05). There was a three-fold increased risk of DSSI in patients subjected to drain placement (odds ratio, 2.8; 95% confidence interval, 1.0 to 8.2; P=0.046). Subgroup analysis demonstrated those who sustained severe hepatic injury receiving a drain had a significantly increase risk of DSSI (P=0.02). There was no statistical difference in the rate of DSSI based on the presence or absence of an intra-abdominal drain after severe splenic injury (17 vs 18%, P=0.88). The use of intra-abdominal closed-suction drains after iSOI is not associated with decreased risk of DSSI.

Venous thromboembolic events in isolated severe traumatic brain injury

OBJECTIVE

The purpose of this study was to investigate the effect of prophylactic anticoagulation on the incidence of venous thromboembolic events (VTE) in patients suffering from isolated severe traumatic brain injury (TBI).

MATERIALS AND METHODS

Retrospective matched case-control study in adult patients sustaining isolated severe TBI (head AIS ≥3, with extracranial AIS ≤2) receiving VTE prophylaxis while in the surgical intensive care unit from 1/2007 through 12/2009. Patients subjected to VTE prophylaxis were matched 1:1 by age, gender, glasgow coma scale (GCS) score at admission, presence of hypotension on admission, injury severity score, and head abbreviated injury scale (AIS) score, with patients who did not receive chemical VTE prophylaxis. The primary outcome measure was VTE. Secondary outcomes were SICU and hospital length of stay (HLOS), adverse effects of anticoagulation, and mortality.

RESULTS

After propensity matching, 37 matched pairs were analysed. Cases and controls had similar demographics, injury characteristics, rate of craniotomies/craniectomies, SICU LOS, and HLOS. The median time of commencement of VTE prophylaxis was 10 days. The incidence of VTE was increased 3.5-fold in the controls compared to the cases (95% CI 1.0-12.1, P=0.002). The mortality was higher in patients who did not receive anticoagulation (19% vs. 5%, P=0.001). No adverse outcomes were detected in the anticoagulated patients.

CONCLUSION

Prophylactic anticoagulation decreases the overall risk for clinically significant VTE in patients with severe isolated TBI. Prospective validation of the timing and safety of chemical VTE prophylaxis in these instances is warranted.

Erythropoiesis-stimulating agent administration and survival after severe traumatic brain injury: a prospective study

OBJECTIVE

To validate previous findings of the effects of erythropoiesis-stimulating agent (ESA) administration following severe traumatic brain injury.

DESIGN

Prospective observational study of all patients with severe traumatic brain injury admitted to the surgical intensive care unit (SICU) at our institution from January 1, 2009, to December 31, 2010 (head Abbreviated Injury Scale score ≥3). Propensity scores were calculated to match patients who received ESA within 30 days after admission to patients who did not receive ESA.

PATIENTS

A total of 566 patients with severe traumatic brain injury were admitted to the SICU. After matching in a 1:1 ratio, 75 matched pairs were analyzed.

MAIN OUTCOME MEASURES

Δ Glasgow Coma Scale score (difference between admission and SICU discharge), in-hospital morbidity, and mortality.

RESULTS

Patients who received ESA and control subjects who did not receive ESA had similar age, mechanisms of injury, vital signs on admission, Abbreviated Injury Scale scores, Injury Severity Scores, and specific intracranial injuries. Patients who received ESA experienced significantly longer lengths of stay in the SICU (mean [SD], 16.1 [1.3] days vs 8.6 [0.8] days; P < .001) and comparable SICU-free days. There was no statistically significant difference in the incidence of major in-hospital complications including deep venous thrombosis and pulmonary embolism when comparing the 2 study cohorts. The Δ Glasgow Coma Scale mean [standard error of the mean] score was 3.0 [0.4] and 2.4 [0.5] in patients who received ESA and those who did not, respectively (P = .33). However, in-hospital mortality was significantly lower for patients who received ESA compared with those who did not (9.3% vs 25.3%; odds ratio, 0.25; 95% CI, 0.08-0.75; P = .012).

CONCLUSIONS

Erythropoiesis-stimulating agent administration demonstrates a significant survival advantage without an increase in morbidity in patients with severe traumatic brain injury.

The diagnostic accuracy of 64-slice computed tomography in detecting clinically significant arterial bleeding after pelvic fractures

The purpose of this study was to determine the diagnostic accuracy of the 64-slice multidetector computed tomography (MDCT) in detecting active pelvic arterial bleeding associated with blunt pelvic fractures. We hypothesized that this modality yields high accuracy. We conducted a retrospective review of all MDCT detected pelvic fractures over an 18-month period admitted to LAC+ USC Medical Center, a Level 1 trauma center. The main outcome was the presence of contrast extravasation (CE) on admission MDCT, consistent with clinically significant arterial bleeding requiring a subsequent embolization or intraoperative ligation of pelvic arteries. Overall, 127 patients met study criteria and 12 per cent (n = 15) had CE on admission MDCT of which four were managed conservatively. Eighty-two per cent (n = 9) of the remaining 11 patients who went on to have invasive procedure had active arterial bleeding that required embolization or surgical ligation. Two of the 112 (1.8%) patients without CE on their admission MDCT were subjected to embolization after further investigation with angiography as a result of the severity of their pelvic fracture and continuous transfusion requirements. The calculated sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of the 64-slice MDCT to identify clinically relevant arterial bleeding were 82, 95, 60, 98, and 94 per cent, respectively. The modern 64-slice MDCT provides relatively high diagnostic accuracy in detecting a clinically relevant arterial hemorrhage after blunt pelvic fracture. Nevertheless, in patients with clinical signs of ongoing hemorrhage, timely angiography or operative intervention is warranted, even in the absence of MDCT contrast extravasation.

Effect of age on cervical spine injury in pediatric population: a National Trauma Data Bank review

BACKGROUND

The objective of this study was to characterize the incidence, risk factors, and patterns of cervical spine injury (CSI) in different pediatric developmental ages.

METHODS

A retrospective review of the National Trauma Data Bank was conducted for the period of January 2002 through December 2006 to identify pediatric patients admitted following blunt trauma. Patients were stratified into 4 developmental age groups: infants/toddlers (age 0-3 years), preschool/young children (age 4-9 years), preadolescents (age 10-13 years), and adolescents (age 14-17 years). Patients with a CSI were identified by the International Classification of Diseases, Ninth Revision codes. Demographics, clinical injury data, level of CSI, and outcomes were abstracted and analyzed.

RESULTS

A total of 240,647 patients met the inclusion criteria. Of these, 1.3% (n = 3,035) sustained a CSI. The incidence of CSI in the stratified age groups was 0.4% in infants/toddlers, 0.4% in preschool/young children, 0.8% in preadolescents, and 2.6% in adolescents. The level of CSI (upper [C1-C4] vs lower [C5-C7]) according to the age groups was as follows: infants and toddlers, 70% vs 25%; preschool/young children, 74% vs 17%; preadolescents, 52% vs 37%; and adolescents, 40% vs 45%, respectively. The adjusted risk for CSI increased 2-fold in preadolescents and 5-fold in adolescents.

CONCLUSION

The incidence of pediatric CSI increases in a stepwise fashion after 9 years of age. We noted an increase in lower CSI and a decrease in upper CSI after the age of 9 years. The incidence of upper CSI compared with lower CSI was higher in preadolescents (52% vs 37%) and almost equal in adolescents (40% vs 45%).

Antibodies to amino acid 200-239 (p200) of Ro52 as serological markers for the risk of developing congenital heart block

Maternal autoantibodies to the p200-epitope of Ro52 have been suggested to correlate with development of congenital heart block. The aim of the present study was to evaluate the clinical relevance and predictive value of p200-antibodies in high-risk pregnancies. Sera from 515 Finnish, Swedish and American women were included in the study. Sera originated from 202 mothers with an infant affected by second- or third-degree atrioventricular block (AVB), 177 mothers with rheumatic disease having infants with normal heart rate and female blood donors (n = 136). A novel serological assay for Ro52 p200-antibodies with intra- and inter-assay variability of 3% and 3.8% respectively was developed. Mothers of children affected by AVB II-III had significantly higher p200-antibody levels than mothers with rheumatic disease having children with normal heart rate (P < 0.001). In the Swedish cohort, a distinction between foetuses with normal conduction, AVB I, AVB II and III was possible. A significant difference in anti-p200 levels between AVB I and AVB II-III groups compared with foetuses with normal conduction (P < 0.05 and P < 0.01) was observed. Using p200-antibodies as a second step analysis in Ro52-positive pregnancies increased the positive predictive value for foetal cardiac involvement (AVB I, II or III) from 0.39 (0.27-0.51) to 0.53 (0.37-0.68). In conclusion, Ro52 p200-antibodies may occur in women with unaffected children, but levels are significantly higher in mothers of children with congenital heart block and are suggested as a relevant marker in evaluating the risk for foetal AV block.

Hypoglycemic neuropathy

Hypoglycemia is a relatively common condition primarily affecting diabetic patients treated with insulin or other hypoglycemic drugs and insulinoma patients. Clinical experience and experimental studies show that hypoglycemia may cause alterations both in the central (CNS) and the peripheral (PNS) nervous system. Hypoglycemic effects on the CNS include various symptoms such as irritability and lack of concentration, disruption of cognitive functions, convulsions and unconsciousness. As for pathology, a loss of neurons has been noted, being more obvious in the cerebral cortex and the hippocampus than in the brain stem, cerebellum and spinal cord. Myelin damage and glial changes have also been observed in the CNS. The development of pathological changes in the brain has mainly been studied on autopsy material from patients who died in insulin coma and in animals exposed to a severe hypoglycemia and showing an isoelectric electroencephalogram. It has been suggested that hypoglycemic loss of neurons in the brain is related to excititoxic actions of aspartate on N-methyl-D-aspartate receptors. With respect to the PNS, scattered clinical observations in humans and experimental studies in animals show that hypoglycemia causes a distal axonopathy including both degenerative and regenerative events. In this respect, motor axons seem to be more vulnerable than sensory axons. Animal experiments show that a peripheral neuropathy may develop even in cases with a mild hypoglycemia compatible with a generally normal behavior. The cellular mechanisms behind the development of hypoglycemic PNS alterations are unknown. To elucidate the pathophysiology of hypoglycemic neuropathy more basic research is needed.

Hypoglycaemic neuropathy in diabetic BB/Wor rats treated with insulin implants affects ventral root axons but not dorsal root axons

It is believed that hyperglycaemia underlies diabetic neuropathy. However, low blood glucose values may also cause pathological changes in peripheral nerves and in neuronal perikarya. This study examined spinal roots, dorsal root ganglia and the ventral horn at the segmental level L5 in long-term insulin-treated eu-/hypoglycaemic diabetic rats with an obvious plantar nerve pathology. The purpose was to determine whether hypoglycaemic neuropathy affects sensory and/or motor neurons at root and/or perikaryal levels. Electron microscopic examination of dorsal roots from eu-/hypoglycaemic rats showed a normal qualitative morphology and normal numbers of unmyelinated and myelinated axons. In ventral roots the picture varied. Whereas two rats exhibited an essentially normal morphology, three rats presented moderate or marked signs of pathology such as clusters of small and medium-sized myelinated axons, medium-sized myelinated axons with abnormally thin sheaths, large unmyelinated axons and signs of past or ongoing axonal degeneration. Light microscopic examination of the L5 dorsal root ganglion and ventral horn showed a qualitatively normal picture in eu-/hypoglycaemic rats and the mean number of large ventral horn neurons per section was normal. These results suggest that the type of eu-/hypoglycaemia examined here affects ventral root axons but not dorsal root axons, that the degree of ventral root pathology is variable and that sensory and motor neuron perikarya do not appear to be affected.

Hypoglycaemic neuropathy: occurrence of axon terminals in plantar skin and plantar muscle of diabetic BB/Wor rats treated with insulin implants

It is generally believed that diabetic neuropathy is due to chronic hyperglycaemia. However, experience from insulinoma patients and experimental studies show that hypoglycaemia may also cause neuropathy. Accordingly, the plantar nerves of diabetic eu-/hypoglycaemic BB/Wor rats treated with insulin implants exhibit a distinct neuropathy. To what extent hypoglycaemic neuropathy affects axon terminals in skin and muscle is unknown. In the present study we examine the occurrence of epidermal axon profiles and the neuropeptide calcitonin gene-related peptide (CGRP) in plantar skin, and of end plate axon terminals in a plantar muscle of diabetic BB/Wor rats subjected to long periods of hypoglycaemia. The number of protein gene product-immunoreactive axon profiles was found to be normal in heel skin biopsy specimens from eu-/hypoglycaemic rats, but many profiles were short and thin. The content of CGRP in the skin biopsy samples was significantly below normal. After staining with antibodies against the vesicular acetylcholine transporter protein, the occurrence of end plate axon terminals was significantly reduced in sections from the flexor hallucis brevis muscle of eu-/hypoglycaemic rats. Moreover, the end plate axon terminals tended to be abnormally small in these rats. We conclude that the hypoglycaemic neuropathy seen in plantar nerve trunks of diabetic BB/Wor rats treated with insulin implants is accompanied by mild alterations in the epidermal innervation of plantar skin and a more obviously abnormal nerve terminal pattern in plantar muscle.