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

Development and validation of the tic score for early detection of traumatic coagulopathy upon hospital admission: a cohort study

BACKGROUND

Critically injured patients need rapid and appropriate hemostatic treatment, which requires prompt identification of trauma-induced coagulopathy (TIC) upon hospital admission. We developed and validated the performance of a clinical score based on prehospital resuscitation parameters and vital signs at hospital admission for early diagnosis of TIC.

METHODS

The score was derived from a level-1 trauma center registry (training set). It was then validated on data from two other level-1 trauma centers: first on a trauma registry (retrospective validation set), and then on a prospective cohort (prospective validation set). TIC was defined as a PTratio > 1.2 at hospital admission. Prehospital (vital signs and resuscitation care) and admission data (vital signs and laboratory parameters) were collected. We considered parameters independently associated with TIC in the score (binomial logistic regression). We estimated the score's performance for the prediction of TIC.

RESULTS

A total of 3489 patients were included, and among these a TIC was observed in 22% (95% CI 21-24%) of cases. Five criteria were identified and included in the TIC Score: Glasgow coma scale < 9, Shock Index > 0.9, hemoglobin < 11 g.dL-1, prehospital fluid volume > 1000 ml, and prehospital use of norepinephrine (yes/no). The score, ranging from 0 and 9 points, had good performance for the identification of TIC (AUC: 0.82, 95% CI: 0.81-0.84) without differences between the three sets used. A score value < 2 had a negative predictive value of 93% and was selected to rule-out TIC. Conversely, a score value ≥ 6 had a positive predictive value of 92% and was selected to indicate TIC.

CONCLUSION

The TIC Score is quick and easy to calculate and can accurately identify patients with TIC upon hospital admission.

Is it possible to improve prediction of outcome and blood requirements in the severely injured patients by defining categories of coagulopathy?

PURPOSE

It has been suggested to define the Trauma-induced coagulopathy (TIC) with a PT_ratio threshold of 1.20. We hypothesized that a more pragmatic classification would grade severity according to the PT_ratio (or corresponding ROTEM clotting time: EXTEM-CT), and that this would correlate better with the need for blood products (BP) and prognosis.

METHODS

Retrospective analysis of prospectively collected data of 1076 severely injured patients admitted from 01/2011 to 12/2019 in a university hospital. To determine the number of TIC categories and the best PT_ratio or EXTEM-CT thresholds for mortality at 24-h, a modified Mazumdar approach was used. Multivariate regression analyses were done to describe the relationship between PT_ratio and ROTEM parameter subclasses with mortality.

RESULTS

Three thresholds were, respectively, identified for PT_ratio (1.20, 1.90 and 3.00) and EXTEM-CT (90 s, 130 s, 200 s). The following categories were defined for PT_ratio: ≤ 1.20 (No TIC), 1.21-1.90 (Moderate TIC), 1.91-3.00 (severe TIC), > 3.00 (major TIC); and for EXTEM-CT: < 91 s (no TIC), 91-130 s (moderate TIC), 131-200 s (severe TIC) and > 200 s (major TIC). We observed that when the PT_ratio (or EXTEM-CT) increased, mortality and BP requirements increased. After multiple adjustments, we observed that each subclass of PT_ratio and EXTEM-CT was independently associated with mortality at 24-h.

CONCLUSION

In this study, we have described a pragmatic classification of coagulopathy utilizing PT_ratio and EXTEM-CT where increasing severity was associated with prognosis and the amount of BP administered. This could allow clinicians to better predict the outcome and anticipate the need for blood products.

Which injured patients with moderate fibrinogen deficit need fibrinogen supplementation?

Background

In severely injured patients, fibrinogen supplementation is recommended when fibrinogenemia is < 1.5 g L⁻¹, but some teams have suggested to use higher thresholds (fibrinogenemia < 2.0 g L⁻¹ or FIBTEM clot amplitude at 5 min (A5) values < 11 mm). The goal of this study was to specify in patients with a moderate fibrinogen deficit (MFD) whether some admission characteristics would be associated with fibrinogen administration at 24 h.

Methods

Prospective analysis of retrospectively collected data from a trauma registry (01/2011–12/2019). MFD-C was defined by a fibrinogenemia 1.51–1.99 g L⁻¹ or the corresponding FIBTEM-A5 values (MFD-A5) that were determined from linear regression and ROC curve analysis. Administration of fibrinogen were described according to the following admission parameters: shock index (SI) > 1, hemoglobin level < 110 g L⁻¹ (HemoCue®), and base deficit > 5 mEq L⁻¹. Data are expressed as count (%), median [IQR].

Results

1076 patients were included in the study and 266 (27%) had MFD-C, among them, 122/266 (46%) received fibrinogen. Patients with MFD-C who received fibrinogen were more severely injured (ISS: 27 [19–36] vs. 24 [17–29]) and had more impaired vital signs (base deficit: 5.4 [3.6–7.8] vs. 3.8 [2.0–6.0]). Linear regression analysis found a positive correlation between fibrinogen level and FIBTEM-A5 (r: 0.805). For a fibrinogen level < 1.5 g L⁻¹ and < 2.0 g L⁻¹, FIBTEM-A5 thresholds were 6 mm (sensitivity 85%, specificity 83%, AUC: 0.934) and 9 mm (sensitivity 84%, specificity 69%, AUC: 0.874), respectively. MFD-A5 values (185 (27%) patients) were defined as a FIBTEM-A5 between 7 and 9 mm. More than 50% of MFD-C patients presenting a SI > 1, a hemoglobin level < 110 g L⁻¹, or a base deficit > 5.0 mEq L⁻¹ received fibrinogen. The relative risk [95% CI] for fibrinogen administration (SI > 1) were 1.39 [1.06–1.82] for MFD-C, and 2.17 [1.48–3.19] for MFD-A5. Results were not modified after adjustment on the ISS.

Conclusions

We have shown in this study an association between shock parameters and fibrinogen administration. Further studies are needed to determine how these parameters may be used to guide fibrinogen administration in trauma patients with MFD.

Increased Risk of Perioperative Complications in Dialysis Patients Following Rotator Cuff Repairs and Knee Arthroscopy

Purpose

To determine the effects of dialysis on postoperative and perioperative complications following rotator cuff repair (RCR) and knee arthroscopy (KA).

Methods

The National Surgical Quality Improvement Program (NSQIP) was queried from 2006 to 2018. Groups were matched for age, sex, body mass index, smoking status, preoperative functional status, and the American Society of Anesthesiologists (ASA) status. Chi-squared tests and Fisher’s exact tests were used to analyze the comorbidities. Differences in occurrences of postoperative adverse events (AE), mortality within 30 days, reoperations with 30 days, extended hospital stay (≥2 days), and readmissions within 30 days were analyzed using the Mantel-Haenszel test. Sign tests were used to evaluate differences in operative time, as well as length of hospital stay.

Results

Dialysis patients in both the RCR and KA groups had greater odds of experiencing any AE (OR: 6.33 and 7.46, P value: .031 and <.001, respectively) and readmission within 30 days (OR: 10.5 and 4.1, P value: .015 and .014, respectively). They also had significantly greater operating times (P = .049 for both). Dialysis patients undergoing KA had greater odds of staying in the hospital ≥2 days (OR: 10, P = <.001) and being reoperated on within 30 days (OR: 3.78, P = .033). The total hospital stay was significantly greater for dialysis patients in the KA group (P < .001) but not in the RCR group (P = .088). None of the individual AE’s significantly differed between the dialysis and non-dialysis patients in the RCR cohort; however, dialysis patients in the KA cohort had greater incidences of three AE’s.

Conclusions

This study identified significantly worse short-term complication rates in dialysis patients undergoing RCR and KA. Careful preoperative evaluation and postoperative surveillance are warranted in this high-risk patient group. Patients should be counseled appropriately on the increased complication risks associated with RCR and KA surgeries.

Level of Evidence

Level III, retrospective cohort study.

Dialysis Dependence Is Associated With Significantly Increased Odds of Perioperative Adverse Events After Geriatric Hip Fracture Surgery Even After Controlling for Demographic Factors and Comorbidities

Previous studies evaluating the risk of perioperative adverse events after hip fracture surgery for dialysis-dependent patients are either institutional cohort studies or limited by patient numbers. The current study uses the National Surgical Quality Improvement Program database's large national patient population and 30-day follow-up window to address these weaknesses.

Collecting core data in physician-staffed pre-hospital helicopter emergency medical services using a consensus-based template: international multicentre feasibility study in Finland and Norway

BACKGROUND

Comparison of services and identification of factors important for favourable patient outcomes in emergency medical services (EMS) is challenging due to different organization and quality of data. The purpose of the present study was to evaluate the feasibility of physician-staffed EMS (p-EMS) to collect patient and system level data by using a consensus-based template.

METHODS

The study was an international multicentre observational study. Data were collected according to a template for uniform reporting of data from p-EMS using two different data collection methods; a standard and a focused data collection method. For the standard data collection, data were extracted retrospectively for one year from all FinnHEMS bases and for the focused data collection, data were collected prospectively for six weeks from four selected Norwegian p-EMS bases. Completeness rates for the two data collection methods were then compared and factors affecting completeness rates and template feasibility were evaluated. Standard Chi-Square, Fisher's Exact Test and Mann-Whitney U Test were used for group comparison of categorical and continuous data, respectively, and Kolomogorov-Smirnov test for comparison of distributional properties.

RESULTS

All missions with patient encounters were included, leaving 4437 Finnish and 128 Norwegian missions eligible for analysis. Variable completeness rates indicated that physiological variables were least documented. Information on pain and respiratory rate were the most frequently missing variables with a standard data collection method and systolic blood pressure was the most missing variable with a focused data collection method. Completeness rates were similar or higher when patients were considered severely ill or injured but were lower for missions with short patient encounter. When a focused data collection method was used, completeness rates were higher compared to a standard data collection method.

CONCLUSIONS

We found that a focused data collection method increased data capture compared to a standard data collection method. The concept of using a template for documentation of p-EMS data is feasible in physician-staffed services in Finland and Norway. The greatest deficiencies in completeness rates were evident for physiological parameters. Short missions were associated with lower completeness rates whereas severe illness or injury did not result in reduced data capture.

Effects of modification of trauma bleeding management: A before and after study

OBJECTIVE

We hypothesised that the association of tranexamic acid (TXA) administration and thromboelastometry-guided haemostatic therapy (TGHT) with implementation of Damage Control Resuscitation (DCR) reduced blood products (BP) use and massive transfusion (MT).

METHODS

Retrospective comparison of 2 cohorts of trauma patients admitted in a university hospital, before (Period 1) and after implementation of DCR, TXA (first 3-hours) and TGHT (Period 2). Patients were included if they received at least 1 BP (RBC, FFP or platelet) or coagulation factor concentrates (fibrinogen or prothrombin complex) during the first 24-hours following the admission.

RESULTS

380 patients were included. Patients in Period 2 (n = 182) received less frequently a MT (8% vs. 33%, P < 0.01), significantly less BP (RBC: 2 units [1-5] vs. 6 [3-11]; FFP: 0 units [0-2] vs. 4 [2-8]) but more fibrinogen concentrates (3.0 g [1.5-4.5] vs. 0.0 g [0.0-3.0], P < 0.01). Multivariate logistic regression analysis identified Period 1 as being associated with an increased risk of receiving MT (OR: 26.1, 95% CI: 9.7-70.2) and decreased survival at 28 days (OR: 2.0, 95% CI: 1.0-3.9). After propensity matching, the same results were observed but there was no difference for survival and a significant decrease for the cost of BP (2370 ± 2126 vs. 3284 ± 3812 €, P: 0.036).

CONCLUSION

Following the implementation of a bundle of care including DCR, TGHT and administration of TXA, we observed a decrease to the use of blood products, need for MT and an improvement of survival.

The survival benefit of palliative gastrectomy and/or metastasectomy in gastric cancer patients with synchronous metastasis: a population-based study using propensity score matching and coarsened exact matching

Introduction: Palliative surgeries were controversial for asymptomatic metastatic gastric cancer (mGC) patients. This study was aimed to evaluate survival benefit of palliative surgeries to gastric and/or metastatic tumors in mGC patients based on U.S population.

Materials and Methods: A total of 8345 gastric cancer patients diagnosed with synchronous distal metastasis between 2004 to 2013 from the Surveillance, Epidemiology, and End Results Program (SEER) database were divided into four groups according to surgery strategies: surgeries to both primary and metastatic tumors (SPM), gastrectomy only (GO), metastasectomy only (MO) and no surgery performed (NS). Their clinicopathological characteristics and overall survival (OS) were analyzed before and after propensity score matching (PSM) and coarsened exact matching (CEM).

Results: The median OS of SPM and GO patients was both significantly higher than NS patients (11 months vs. 8 months vs. 5 months; P<0.001, respectively) while that of MO was not (6 months vs. 5 months; P= 0.286). In comparisons between surgery strategies, survival benefit was similar between SPM and GO groups (P=0.389) and both showed significantly better survival than MO patients (P<0.001). All surgery strategies were proved to be favorable prognostic factors over non-surgical treatment (Hazard ratio (HR) for SPM: 0.60, P<0.001; HR for GO: 0.62, P<0.001; HR for MO: 0.91, P=0.046). Similar results were obtained after matching by PSM and CEM except that prognostic impact of MO deteriorated.

Conclusions: Gastrectomy plus metastasectomy or gastrectomy alone could be adopted as a choice of improving survival in the U.S population. Metastasectomy alone is not generally recommended.

Analyses of clinical outcomes after severe pelvic fractures: an international study

Background

This study aimed to compare treatment outcomes between patients with severe pelvic fractures treated at a representative trauma center that was established in Korea since 2015 and matched cases treated in the USA.

Methods

Two cohorts were selected from a single institution trauma database in South Korea (Ajou Trauma Data Bank (ATDB)) and the National Trauma Data Bank (NTDB) in the USA. Adult blunt trauma patients with a pelvic Abbreviated Injury Scale >3 were included. Patients were matched based on covariates that affect mortality rate using a 1:1 propensity score matching (PSM) approach. We compared differences in outcomes between the two groups, performed survival analysis for the cohort after PSM and identified factors associated with mortality. Lastly, we analyzed factors related to outcomes in the ATDB dataset comparing a period prior to the implementation of the trauma center according to US standards, an interim period and a postimplementation period.

Results

After PSM, a total of 320 patients (160 in each cohort) were identified for comparison. Inhospital mortality was significantly higher in the ATDB cohort using χ² test, but it was not statistically significant when using Kaplan-Meier survival curves and Cox regression analysis. Moreover, the mortality rate was similar comparing the NTDB cohort to ATDB data reflecting the post-trauma center establishment period. Older age, lower systolic blood pressure (SBP) and Glasgow Coma Scale (GCS) at admission were factors associated with mortality.

Discussion

Mortality rate after severe pelvic fractures was significantly associated with older age, lower SBP and GCS scores at admission. Efforts to establish a trauma center in South Korea led to improvement in outcomes, which are comparable to those in US centers.

Level of evidence

Level IV.

Comparison of trauma outcomes between Japan and the USA using national trauma registries

Background

The National Trauma Data Bank (NTDB) has served as a global benchmark for trauma care quality and outcomes. Herein, we compared patient characteristics, trauma management, and outcomes between Japanese emergency and critical care centers and US level 1 trauma centers using the Japanese Trauma Data Bank (JTDB) and NTDB.

Methods

A retrospective cohort matching (1:1) study was performed. Patients treated in 2013 with an Injury Severity Score ≥9 were included. The primary outcome measure was in-hospital mortality. The secondary outcome measures included the hospital length of stay and the rate of use of radiological diagnostic modalities.

Results

A total of 14 960 pairs with well-balanced characteristics were generated from 22 535 and 112 060 eligible patients in the JTDB and NTDB, respectively. Before matching, the in-hospital mortality was higher in the JTDB than in the NTDB (7.6% vs. 6.1%; OR, 1.28; 95% CI 1.21 to 1.35). However, after matching, the in-hospital mortality was lower in the JTDB cohort (4.2% vs. 5.8%; OR, 0.72; 95% CI 0.65 to 0.80). CT scans were used in >80% of JTDB patients, which was more than 1.5 times as often as the use in the NTDB cohort. In subgroup analyses, only patients who received a blood transfusion had a poorer survival outcome in the JTDB compared with the NTDB (OR, 1.32; 95% CI 1.07 to 1.64).

Discussion

We observed marked differences in trauma care between Japan and the USA. Although the quality of the recent Japanese trauma care appears to be approaching that of the USA, it may be further improved, such as by the establishment of transfusion protocols.

Level of evidence

Level IV.

Dialysis is an independent risk factor for perioperative adverse events, readmission, reoperation, and mortality for patients undergoing elective spine surgery

BACKGROUND CONTEXT

The prevalence of dialysis-dependent patients in the United States is growing. Prior studies evaluating the risk of perioperative adverse events for dialysis-dependent patients are either institutional cohort studies limited by patient numbers or administrative database studies limited to inpatient data.

PURPOSE

The present study uses a large, national sample with 30-day follow-up to investigate dialysis as risk factor for perioperative complications independent of patient demographics or comorbidities.

STUDY DESIGN/SETTING

This is a retrospective cohort study.

PATIENT SAMPLE

Patients undergoing elective spine surgery with or without dialysis from the 2005-2015 National Surgical Quality Improvement Program (NSQIP) database were included in the study.

OUTCOME MEASURES

Postoperative complications within 30 days and binomial reoperation, readmission, and mortality within 30 days were determined.

METHODS

The 2005-2015 NSQIP databases were queried for adult dialysis-dependent and dialysis-independent patients undergoing elective spinal surgery. Differences in 30-day outcomes were compared using risk-adjusted multivariate regression and coarsened exact matching analysis for adverse events, unplanned readmission, reoperation, and mortality. The percentage of complications occurring before versus after hospital discharge was also assessed. The authors have no financial disclosures related to the present study.

RESULTS

A total of 467 dialysis and 173,311 non-dialysis patients met the inclusion criteria. Controlling for age, gender, body mass index, functional status, and American Society of Anesthesiologists (ASA) class, dialysis patients were found to be at significantly greater odds of any adverse event (odds ratio [OR]=2.52 before, 2.17 after matching, p=<.001), major adverse event (OR=2.90 before, 2.52 after matching, p=<.001), and minor adverse event (OR=1.50 before matching, p=<.025, but not significantly different after matching). Further, dialysis patients were significantly more likely to return to the operating room (OR=2.77 before, 2.50 after matching, p=<.001), have unplanned readmissions (OR=2.73 before, 2.37 after matching, p=<.001), and die within 30 days (OR=3.77 before, 2.71 after matching, p=<.001). Adverse events occurred after discharge for 51.78% of non-dialysis patients and for 43.80% of dialysis patients.

CONCLUSIONS

Dialysis patients undergoing elective spine surgery are at significantly higher risk of aggregated adverse outcomes, return to the operating room, readmission, and death than non-dialysis patients, even after controlling for patient demographics and overall health (as indicated by ASA class). These differences need to be considered when determining treatment options. Additionally, with bundled payments expected in spine surgery, physicians and hospitals need to account for increased costs and liabilities when working with dialysis patients.

Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND

The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes.

METHODS

We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria.

RESULTS

We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization.

CONCLUSIONS

This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.

Dialysis Patients Undergoing Total Knee Arthroplasty Have Significantly Increased Odds of Perioperative Adverse Events Independent of Demographic and Comorbidity Factors

BACKGROUND

The prevalence of dialysis-dependent patients is growing, and an increasing number of these patients are being considered for total knee arthroplasty (TKA). Studies assessing the preoperative risk associated with TKA in this population are limited to institutional cohorts with small sample sizes or national inpatient databases that lack follow-up data.

METHODS

The 2006-2015 National Surgical Quality Improvement Program databases were queried for adult patients undergoing elective TKA. Differences in 30-day any/severe/minor adverse event, need for reoperation, readmission, and mortality were compared for dialysis-dependent and nondialysis TKA patients using risk-adjusted logistic regression. To account for the smaller number of dialysis patients and variations in study populations, coarsened exact matching was used. The proportion of adverse events that occurred before vs after discharge was also assessed.

RESULTS

In total, 250 dialysis-dependent patients and 163,560 nondialysis patients met inclusion criteria. After controlling for patient demographics (age, sex, body mass index, functional status) and overall health (American Society of Anesthesiologists class), matched analysis revealed dialysis-dependent patients to be significantly more likely to experience any adverse event (odds ratio = 2.01; 95% confidence interval [CI], 1.34-3.02; P = .001), severe adverse event (odds ratio = 2.49; 95% CI, 1.61-3.84; P < .001), reoperation (odds ratio = 2.38; 95% CI, 1.19-4.75; P = .014), readmission (odds ratio = 2.32; 95% CI, 1.47-3.66; P = .001), and mortality (odds ratio = 6.71; 95% CI, 2.99-22.50; P = .002). The majority of adverse outcomes occurred postdischarge.

CONCLUSION

Independent of patient demographics and overall health (American Society of Anesthesiologists), patients undergoing dialysis before TKA are significantly more likely to experience 30-day adverse outcomes than matched nondialysis cohorts. Preoperative evaluation of bone health status and management of medical treatment are warranted in this fragile population. Cautious surgical planning, patient counseling, and heightened surveillance are necessitated throughout their perioperative period and postoperative recovery plans may need to be different from nondialysis counterparts. Furthermore, hospitals and physicians must take these increased risks into account when working on bundle payment reimbursement strategies and resource allocation.

LEVEL OF EVIDENCE

3.

Comparison of outcomes in severely injured patients between a South Korean trauma center and matched patients treated in the United States

BACKGROUND

The South Korean government recently developed a master plan for establishing a national trauma system based on the implementation of regional trauma centers. We aimed to compare outcomes between severely injured patients treated at a recently established South Korean trauma center and matched patients treated in American level-1 trauma centers.

METHODS

Two cohorts were selected from an institutional trauma database at Ajou University Medical Center (AUMC) and the American National Trauma Data Bank. Adult patients with an Injury Severity Score of ≥9 were included. Patients were matched based on covariates that affect mortality, using 1:1 propensity score matching. We compared outcomes between the two datasets and performed survival analyses.

RESULTS

We created 1,451 and 2,103 matched pairs for the pre-trauma center and post-trauma center periods, respectively. The in-hospital mortality rate was higher in the institutional trauma database pre-trauma center period compared with the American National Trauma Data Bank (11.6% versus 8.1%, P<.001). However, the mortality rate decreased in the institutional trauma database post-trauma center period and was similar to that in the American National Trauma Data Bank (6.9% versus 6.8%, P=.903). Being treated at Ajou University Medical Center Trauma Center was significantly associated with higher mortality during the pre-trauma center period (OR: 1.842, 95% CI: 1.336-2.540; P<.001), although no significant association was observed during the post-trauma center period (OR: 1.102, 95% CI: 0.827-1.468; P=.509).

CONCLUSION

The mortality rate improved after a trauma center was established in a South Korean hospital and is similar to that from matched cases treated at American level-1 trauma centers. Thus, creating trauma centers and a regional trauma system may improve outcomes in major trauma cases.

A Calculated Risk: Performing Laparoscopic Cholecystectomy for Acute Cholecystitis on Patients with End Stage Renal Disease

End-stage renal disease (ESRD) is a multifactorial disease linked to socioeconomic status and associated with worse surgical outcomes. We explore intraoperative and postoperative outcomes in patients with cholecystitis undergoing laparoscopic cholecystectomy (LC). The Nationwide Inpatient Sample from 2005 to 2012 was used to identify patients undergoing LC for cholecystitis using ICD-9 codes. Outcomes of interest were mortality, common bile duct injury, conversion to open, intraoperative complications, postoperative complications, length of stay (LOS), and total charge. Univariate analysis was performed using t test for continuous variables and chi-squared test for categorical variables. Multivariable models were created that adjusted for age, demographics, year of admission, comorbidities, and presence of ESRD. Of 225,058 patients that underwent LC, 2,115 had ESRD. On univariate analysis, the ESRD cohort had a higher incidence of mortality and complications: intraoperative, mechanical wound, respiratory, cardiovascular, and postoperative infections. ESRD patients had higher median LOS and total charge. Multi-variate analysis showed ESRD as an independent risk factor for mortality, mechanical wound complications, and intraoperative complications. Negative binomial regression analysis showed that ESRD patients had LOS 50.4 per cent longer than non-ESRD patients. Linear regression analysis showed that, after adjustment, ESRD patients had total charge 6.82 per cent higher than non-ESRD patients. In this large retrospective analysis, we find that after adjusting for clinical, socioeconomic, and demographic variables, ESRD is an independent risk factor for increased mortality, intraoperative complications, mechanical wound complications, increased LOS, and cost for patients undergoing LC. Prospective studies exploring risk optimization strategies for patients with ESRD are warranted.

Comparison of Epidemiology of the Injuries and Outcomes in Two First-Level Trauma Centers in Colombia Using the Pan-American Trauma Registry System

INTRODUCTION

The aim of this study was to compare the epidemiology of traumatic injuries and mortality outcomes between two tertiary-care trauma centers in Colombia using data from Pan-American Trauma Registry (PATR).

METHODS

January 1-December 31, 2012, data from the Hospital Universitario del Valle (HUV, public) and Fundacion Valle del Lili (FVL, private) in Cali, Colombia, were considered. Differences in demographic and clinical information were compared using descriptive statistics. Propensity score matching was used to match patients on age, gender, and ISS. Within matched cohorts, multivariable logistic regression models were used to assess for differences in in-hospital mortality, further adjusting for insurance type, employment, heart rate, presence of hypotension (SBP < 90), and GCS score.

RESULTS

HUV (8539; 78% male) and FVL (10,456; 60% male) had a combined total of 18,995 trauma cases in 2012 with comparable mean ages of 29.7 years. There were significant differences in insurance status, injury severity, and mechanism of injury between patients at HUV and FLV. On risk-adjusted logistic regression analyses with propensity score matched cohorts, the odds of death in HUV was higher compared to patients presenting at FVL hospital (OR [95% CI]:4.93 [3.37-7.21], p < 0.001).

CONCLUSION

The study established the utility of the PATR and revealed important trends in patient demographics, injury epidemiology, and mortality outcomes, which can be used to target trauma initiatives throughout the region. It underscores the profound importance that differences in case mix play in the risk of trauma-related mortality, further emphasizing the need to monitor and evaluate unique aspects of trauma in LMIC.

LEVEL OF EVIDENCE

III.

Comparative assessment of in-hospital trauma mortality at a South African trauma center and matched patients treated in the United States

BACKGROUND

The unacceptably high rate of death and disability due to injury in Sub-Saharan Africa is alarming. The objective of this work was to compare mortality rates between severely injured trauma patients at a high-volume trauma center in South Africa with matched patients in the United States.

METHODS

Clinical databases from the Groote Schuur Hospital for patients treated in Cape Town, South Africa and the American College of Surgeon's National Trauma Databank for patients treated at large academic trauma centers in the United States were used. Coarsened exact matching identified the most comparable patient populations based on sex, age, intent, injury type, injury mechanism, Injury Severity Score, Glasgow Coma Score, and systolic blood pressure. Conditional logistic regression generated odds ratios for mortality among the entire sample and clinically relevant subgroups.

RESULTS

Coarsened exact matching matched 97.9% of the Groote Schuur Hospital patient sample, resulting in 3,206 matched-pairs between the Groote Schuur Hospital and National Trauma Databank cohorts. Conditional logistic regression revealed an odds ratio of mortality of 1.67 (95% confidence interval, 1.10-2.52) for patients at Groote Schuur Hospital compared with matched patients from the National Trauma Databank. Subset analyses revealed significantly increased odds of mortality among patients with blunt injuries (odds ratio 3.40, 95% confidence interval, 1.68-6.88) and patients with a Glasgow Coma Score of 8 or lower (odds ratio 4.33, 95% confidence interval, 2.10-8.95). No statistically significant difference was identified among patients with penetrating injuries or with a Glasgow Coma Score >8 (P value .90 and .39, respectively).

CONCLUSION

International comparisons of interhospital variation in risk-adjusted outcomes following trauma can identify opportunities for quality improvement and have the potential to measure the impact of any corrective strategy implemented.

Prehospital parameters can help to predict coagulopathy and massive transfusion in trauma patients

BACKGROUND

This study aimed to evaluate the accuracy of prehospital parameters, including vital signs and resuscitation (fluids, vasopressor), to predict trauma-induced coagulopathy (TIC, fibrinogen <1·5 g/l or PT_ratio > 1·5 or platelet count <100 × 10⁹ /l), and a massive transfusion (MT, ≥10 RBC units within the first 24 h).

METHODS

From a trauma registry (2011-2015), in which patients are prospectively included, we retrospectively retrieved the heart rate (HR), systolic blood pressure (SBP), volume of prehospital fluids and administration of noradrenaline. We calculated the shock index (SI: HR/SBP), the MGAP prehospital triage score and the Injury Severity Score (ISS). We also identified patients who had positive criteria from the Resuscitation Outcome Consortium (ROC, SBP < 70 mmHg or SBP 70-90 and HR > 107 pulse/min). For these parameters, we drew a ROC curve and defined a cut-off value to predict TIC or MT. The strength of association between prehospital parameters and TIC as well as MT was assessed using logistic regression, and cut-off values were determined using ROC curves.

RESULTS

Among the 485 patients included in the study, TIC was observed in 112 patients (23%) and MT in 22 patients (5%). For the prediction of TIC, ISS had good accuracy (AUC: 0·844, 95% confidence interval, CI: 0·799-0·879), as did the volume of fluids (>1000 ml) given during prehospital care (AUC: 0·801, 95% CI: 0·752-0·842). For the prediction of MT, ISS had excellent accuracy (AUC: 0·932, 95% CI: 0·866-0·966), whereas good accuracy was found for SI (> 0·9; AUC: 0·859, 95% CI: 0·705-0·936), vasopressor administration (AUC: 0·828, 95% CI: 0·736-0·890) and fluids (>1000 ml; AUC: 0·811, 95% CI: 0·737-0·867). Vasopressor administration, ISS and SI were independent predictors of TIC and MT, whereas fluid volume and ROC criteria were independent predictor of TIC but not MT. No independent relationship was found between MGAP and TIC or MT.

CONCLUSIONS

Prehospital parameters including the SI and resuscitation may help to better identify the severity of bleeding in trauma patients and the need for blood product administration at admission.

Emergency Department Wait Time and Treatment of Traumatic Digit Amputation: Do Race and Insurance Matter?

BACKGROUND

Little is known about the association between the quality of trauma care and management of nonfatal injuries. The authors used emergency department wait times as a proxy for hospital structure, process, and availability of on-call surgeons with microsurgical skills. They evaluated the association between average hospital emergency department wait times and likelihood of undergoing digit replantation for patients with traumatic amputation digit injuries. The authors hypothesized that hospitals with shorter emergency department wait times were associated with higher odds of replantation.

METHODS

Using the 2007 to 2012 National Trauma Data Bank, the authors' final sample included 12,126 patients. Regression modeling was used to first determine factors that were associated with longer emergency department wait times among patients with digit amputation injuries. Second, the authors examined the association between emergency department wait times for this population at a hospital level and replantation after all types of digit amputation and after complicated thumb amputation injuries only.

RESULTS

For patients with simple and complicated thumb amputation injuries, and patients with complicated thumb amputation injuries only, longer emergency department wait times were associated with lower odds of replantation. In addition, being minority and having no insurance were associated with longer emergency department wait times; teaching hospitals were associated with shorter emergency department wait times; and finally, for patients with complicated thumb amputation injuries only, there was no association between patients' minority or insurance status and replantation.

CONCLUSION

Variation in emergency department wait time and its effects on treatment of traumatic digit amputation may reflect maldistribution of hand or plastic surgeons with the required microsurgical skills among trauma centers across the United States.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Early Predictors of Mortality in Geriatric Patients With Trauma

OBJECTIVE

To identify variables that predict mortality in geriatric patients with trauma.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

A total of 147 geriatric patients with trauma (age ≥65) with a predicted probability of survival of 10%-75% based on the Trauma Score-Injury Severity Score (TRISS).

MAIN OUTCOME MEASUREMENTS

Patients were divided into 2 cohorts: survivors and nonsurvivors. The following variables available at presentation were analyzed: age, mechanism of injury, temperature, systolic blood pressure, pulse rate, shock index, respiratory rate, Glasgow Coma Scale (GCS) score, base deficit, and hematocrit (HCT). The Injury Severity Score (ISS) and TRISS were calculated for both cohorts.

RESULTS

Of the 147 patients analyzed, 84 (57%) died during the index hospitalization and 63 (43%) survived. The mean age of nonsurvivors was significantly higher than that of survivors (78.6 vs. 76.1 years; P < 0.04). A greater number of nonsurvivors (72.6%) sustained injuries as a result of a low-energy mechanism compared with survivors (54%; P = 0.02). GCS, temperature, and respiratory rate were significantly lower for nonsurvivors, whereas base deficit was higher (P < 0.05). The TRISS was predictive of survival (TRISS 0.27 vs. 0.53, P < 0.001), but the distinguishing capacity of the TRISS to predict mortality was limited (area under the receiver operator curve; 0.67; 95% confidence interval 0.58-0.76; P < 0.0001).

CONCLUSIONS

Older age, lower GCS, and a low-energy mechanism of injury are associated with a higher mortality rate in this at-risk geriatric trauma population. Early identification of predictors of mortality may help care providers more accurately assess injury burden in geriatric patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Influence of sub-specialty surgical care on outcomes for pediatric emergency general surgery patients in a low-middle income country

BACKGROUND

Whether adult general surgeons should handle pediatric emergencies is controversial. In many resource-limited settings, pediatric surgeons are not available. The study examined differences in surgical outcomes among children/adolescents managed by pediatric and adult general surgery teams for emergency general surgical (EGS) conditions at a university-hospital in South Asia.

METHODS

Pediatric patients (<18y) admitted with an EGS diagnosis (March 2009-April 2014) were included. Patients were dichotomized by adult vs. pediatric surgical management team. Outcome measures included: length of stay (LOS), mortality, and occurrence of ≥1 complication(s). Descriptive statistics and multivariable regression analyses with propensity scores to account for potential confounding were used to compare outcomes between the two groups. Quasi-experimental counterfactual models further examined hypothetical outcomes, assuming that all patients had been treated by pediatric surgeons.

RESULTS

A total of 2323 patients were included. Average age was 7.1y (±5.5 SD); most patients were male (77.7%). 1958 (84.3%) were managed by pediatric surgery. The overall probability of developing a complication was 1.8%; 0.9% died (all adult general surgery). Patients managed by adult general surgery had higher risk-adjusted odds of developing complications (OR [95%CI]: 5.42 [2.10-14.00]) and longer average LOS (7.98 vs. 5.61 days, p < 0.01). 39.8% fewer complications and an 8.2% decrease in LOS would have been expected if all patients had been managed by pediatric surgery.

CONCLUSION

Pediatric patients had better post-operative outcomes under pediatric surgical supervision, suggesting that, where possible in resource-constrained settings, resources should be allocated to promote development and staffing of pediatric surgical specialties parallel to adult general surgical teams.

Restructuring an evolving Irish trauma system: What can we learn from Europe and Australia?

AIM

Major trauma is a leading cause of mortality and disability. Internationally, major trauma centres and comprehensive trauma networks are associated with improved outcomes. This study aimed to examine selected international trauma systems in Europe and Australia to identify common themes that may aid reconfiguration of the Irish trauma service.

METHODS

An electronic search strategy was utilised using Medline, and a search of the grey literature using Google and Google Scholar. Search terms included "trauma systems", "trauma care", "major trauma centre" and "trauma network". Relevant articles were reviewed and data summarised in a narrative format.

RESULTS

Republic of Ireland currently lacks designated major trauma centres and surrounding trauma networks. Lessons from international models and data from the on-going national trauma audit may guide reconfiguration. Well-functioning trauma systems internationally bear striking similarities, and involve a hub and spoke model. This model has a central major trauma centre, surrounded by a co-ordinated trauma network with trauma units. Concentration of major trauma into high volume centres is key, but these centres must be adequately resourced to deliver a high quality service. Investment in and co-ordination of prehospital care is essential to overcome geographical impediments to centralising trauma care. Funding of rehabilitation infrastructure and resources is also an integral part of a well-functioning trauma system. Trauma outcome data is key to informing trauma system design, with dissemination of this data and public engagement critical for change.

CONCLUSION

International models of trauma care provide valuable lessons for countries currently in process of reconfiguring trauma services.

Are the paradigms in trauma disease changing?

Despite an annual trauma mortality of 5 million people worldwide, resulting in countless physical disabilities and enormous expenses, there are no standardized guidelines on trauma organization and management. Over the last few decades there have been very notorious improvements in severe trauma care, though organizational and economical aspects such as research funding still need to be better engineered. Indeed, trauma lags behind other serious diseases in terms of research and organization. The rapid developments in trauma care have produced original models available for research projects, initial resuscitation protocols and radiological procedures such as CT for the initial management of trauma patients, among other advances. This progress underscores the need for a multidisciplinary approach to the initial management and follow-up of this complicated patient population, where intensivists play a major role in both the patient admission and subsequent care at the trauma unit.

Outcomes of trauma care at centers treating a higher proportion of older patients: the case for geriatric trauma centers

BACKGROUND

The burden of injury among older patients continues to grow and accounts for a disproportionate number of trauma deaths. We wished to determine if older trauma patients have better outcomes at centers that manage a higher proportion of older trauma patients.

METHODS

The National Trauma Data Bank years 2007 to 2011 was used. All high-volume Level 1 and Level 2 trauma centers were included. Trauma centers were categorized by the proportion of older patients seen. Adult trauma patients were categorized as older (≥65 years) and younger adults (16-64 years). Coarsened exact matching was used to determine differences in mortality and length of stay between older and younger adults. Risk-adjusted mortality ratios by proportion of older trauma patients seen were analyzed using multivariate logistic regression models and observed-expected ratios.

RESULTS

A total of 1.9 million patients from 295 centers were included. Older patients accounted for one fourth of trauma visits. Matched analysis revealed that older trauma patients were 4.2 times (95% confidence interval, 3.99-4.50) more likely to die than younger patients. Older patients were 34% less likely to die if they presented at centers treating a high versus low proportion of older trauma (odds ratio, 0.66; 95% confidence interval, 0.54-0.81). These differences were independent of trauma center performance.

CONCLUSION

Geriatric trauma patients treated at centers that manage a higher proportion of older patients have improved outcomes. This evidence supports the potential advantage of treating older trauma patients at centers specializing in geriatric trauma.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Saving lives, limbs and livelihoods: considerations in restructuring a national trauma service

STUDY HYPOTHESIS

Level 1 trauma centers reduce mortality and improve functional outcomes in major trauma. Despite this, many countries, including Ireland, do not have officially designated major trauma centers (MTC). This study aimed to examine international trauma systems, and determine how to "best fit" trauma care in a small country (Ireland) to international models.

METHODS

The literature was reviewed to examine international models of trauma systems. An estimate of Irish trauma burden and distribution was made using data from the Road Safety Authority (RSA) on serious or fatal RTAs. Models of a restructured trauma service were constructed and compared with international best practice.

RESULTS

Internationally, a major trauma center surrounded by a regional trauma network has emerged as the gold standard in trauma care. In Ireland, there are no nationally coordinated trauma networks and care is provided by 26 acute hospitals with a mean distance to hospital from RTAs of 20.6 km ± 15.6. Based on our population, Ireland needs two Level 1 MTCs (in the two areas of major population density in the east and south), with robust surrounding trauma networks including Level 2 or 3 trauma centers. With this model, the estimated mean number of cases per Level 1 MTC per year would be 628, with a mean distance to MTC of 80.5 ± 59.2 km, (maximum distance 263.5 km).

CONCLUSION

Clearly designated and adequately resourced MTCs with trauma networks are needed to improve trauma outcomes, with concomitant investment in pre-hospital infrastructure.

Effectiveness of a combination prevention strategy for HIV risk reduction with men who have sex with men in Central America: a mid-term evaluation

BACKGROUND

Despite over a decade of research and programming, little evidence is available on effective strategies to reduce HIV risks among Central American men who have sex with men (MSM). The Pan-American Social Marketing Organization (PASMO) and partners are implementing a HIV Combination Prevention Program to provide key populations with an essential package of prevention interventions and services: 1) behavioral, including interpersonal communications, and online outreach; 2) biomedical services including HIV testing and counseling and screening for STIs; and 3) complementary support, including legal support and treatment for substance abuse. Two years into implementation, we evaluated this program's effectiveness for MSM by testing whether exposure to any or a combination of program components could reduce HIV risks.

METHODS

PASMO surveyed MSM in 10 cities across Guatemala, El Salvador, Nicaragua, Costa Rica, and Panama in 2012 using respondent-driven sampling. We used coarsened exact matching to create statistically equivalent groups of men exposed and non-exposed to the program, matching on education, measures of social interaction, and exposure to other HIV prevention programs. We estimated average treatment effects of each component and all combined to assess HIV testing and condom use outcomes, using multivariable logistic regression. We also linked survey data to routine service data to assess program coverage.

RESULTS

Exposure to any program component was 32% in the study area (n = 3531). Only 2.8% of men received all components. Men exposed to both behavioral and biomedical components were more likely to use condoms and lubricant at last sex (AOR 3.05, 95% CI 1.08, 8.64), and those exposed to behavioral interventions were more likely to have tested for HIV in the past year (AOR 1.76, 95% CI 1.01, 3.10).

CONCLUSIONS

PASMO's strategies to reach MSM with HIV prevention programming are still achieving low levels of population coverage, and few men are receiving the complete essential package. However, those reached are able to practice HIV prevention. Combination prevention is a promising approach in Central America, requiring expansion in coverage and intensity.

Association between race and age in survival after trauma

IMPORTANCE

Racial disparities in survival after trauma are well described for patients younger than 65 years. Similar information among older patients is lacking because existing trauma databases do not include important patient comorbidity information.

OBJECTIVE

To determine whether racial disparities in trauma survival persist in patients 65 years or older.

DESIGN, SETTING, AND PARTICIPANTS

Trauma patients were identified from the Nationwide Inpatient Sample (January 1, 2003, through December 30, 2010) using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Injury severity was ascertained by applying the Trauma Mortality Prediction Model, and patient comorbidities were quantified using the Charlson Comorbidity Index.

MAIN OUTCOMES AND MEASURES

In-hospital mortality after trauma for blacks vs whites for younger (16-64 years of age) and older (≥65 years of age) patients was compared using 3 different statistical methods: univariable logistic regression, multivariable logistic regression with and without clustering for hospital effects, and coarsened exact matching. Model covariates included age, sex, insurance status, type and intent of injury, injury severity, head injury severity, and Charlson Comorbidity Index.

RESULTS

A total of 1,073,195 patients were included (502,167 patients 16-64 years of age and 571,028 patients ≥65 years of age). Most older patients were white (547,325 [95.8%]), female (406 158 [71.1%]), and insured (567,361 [99.4%]) and had Charlson Comorbidity Index scores of 1 or higher (323,741 [56.7%]). The unadjusted odds ratios (ORs) for death in blacks vs whites were 1.35 (95% CI, 1.28-1.42) for patients 16 to 64 years of age and 1.00 (95% CI, 0.93-1.08) for patients 65 years or older. After risk adjustment, racial disparities in survival persisted in the younger black group (OR, 1.21; 95% CI, 1.13-1.30) but were reversed in the older group (OR, 0.83; 95% CI, 0.76-0.90). This finding was consistent across all 3 statistical methods.

CONCLUSIONS AND RELEVANCE

Different racial disparities in survival after trauma exist between white and black patients depending on their age group. Although younger white patients have better outcomes after trauma than younger black patients, older black patients have better outcomes than older white patients. Exploration of this paradoxical finding may lead to a better understanding of the mechanisms that cause disparities in trauma outcomes.

In-hospital mortality among patients injured in motor vehicle crashes in a Saudi Arabian hospital relative to large U.S. trauma centers

Background

Traffic-related fatalities are a leading cause of premature death worldwide. According to the 2012 report the Global Burden of Disease 2010, traffic injuries ranked 8th as a cause of death in 2010, compared to 10th in 1990. Saudi Arabia is estimated to have an overall traffic fatality rate more than double that of the U.S., but it is unknown whether mortality differences also exist for injured patients seeking medical care. We aim to compare in-hospital mortality between Saudi Arabia and the United States, adjusting for severity and demographic variables.

Methods

The analysis included 485,611 patients from the U.S. National Trauma Data Bank (NTDB) and 5,290 patients from a trauma registry at King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia. For comparability, we restricted our sample to NTDB data from level-I public trauma centers (≥400 beds) in the U.S. Multiple logistic regression analyses were performed to evaluate the effect of setting (KAMC vs. NTDB) on in-hospital mortality after adjusting for age, sex, Triage-Revised Scale (T-RTS), Injury Severity Score (ISS), mechanism of injury, hypotension, surgery and head injuries. Interactions between setting and ISS, and predictors were also evaluated.

Results

Injured patients in the Saudi registry were more likely to be males, and younger than those from the NTDB. Patients at the Saudi hospital were at higher risk of in-hospital death than their U.S. counterparts. In the highest severity group (ISSs, 25–75), the odds ratio of in-hospital death in KAMC versus NTDB was 5.0 (95% CI 4.3-5.8). There were no differences in mortality between KAMC and NTDB among patients from lower ISS groups (ISSs, 1–8, 9–15, and 16–24).

Conclusions

Patients who are severely injured following traffic crash injuries in Saudi Arabia are significantly more likely to die in the hospital than comparable patients admitted to large U.S. trauma centers. Further research is needed to identify reasons for this disparity and strategies for improving the care of patients severely injured in traffic crashes in Saudi Arabia.

Electronic supplementary material

The online version of this article (doi:10.1186/s40621-014-0021-4) contains supplementary material, which is available to authorized users.

Do community-based strategies reduce HIV risk among people who inject drugs in China? A quasi-experimental study in Yunnan and Guangxi provinces

Background

HIV transmission among people who inject drugs (PWID) is high in Yunnan and Guangxi provinces in southwest China. To address this epidemic, Population Services International (PSI) and four cooperating agencies implemented a comprehensive harm reduction model delivered through community-based drop-incenters (DiC) and peer-led outreach to reduce HIV risk among PWID.

Methods

We used 2012 behavioral survey data to evaluate the effectiveness of this model for achieving changes in HIV risk, including never sharing needles or syringes, always keeping a clean needle on hand, HIV testing and counseling (HTC), and consistent condom use. We used respondent-driven sampling to recruit respondents. We then used coarsened exact matching (CEM) to match respondents during analysis to improve estimation of the effects of exposure to both DiC and outreach, only DiC, and only outreach, modeled using multivariable logistic regression.

Results

We found a significant relationship between participating in both peer-led DiC-based activities and outreach and having a new needle on hand (odds ratio (OR) 1.53, p < .05) and consistent condom use (OR 3.31, p < .001). We also found a significant relationship between exposure to DiC activities and outreach and HIV testing in Kunming (OR 2.92, p < .01) and exposure to peer-led outreach and HIV testing through referrals in Gejiu, Nanning, and Luzhai (OR 3.63, p < .05).

Conclusions

A comprehensive harm reduction model delivered through peer-led and community-based strategies reduced HIV risk among PWID in China. Both DiC activities and outreach were effective in providing PWID behavior change communications (BCC) and HTC. HTC is best offered in settings like DiCs, where there is privacy for testing and receiving results. Outreach coverage was low, especially in Guangxi province where the implementation model required building the technical capacity of government partners and grassroot organizations. Outreach appears to be most effective for referring PWID into HTC, especially when DiC-based HTC is not available and increasing awareness of DiCs where PWID can receive more intensive BCC interventions.

Reducing HIV risk among transgender women in Thailand: a quasi-experimental evaluation of the sisters program

Transgender women are particularly at risk of HIV infection, but little evidence exists on effective HIV prevention strategies with this population. We evaluated whether Sisters, a peer-led program for transgender women, could reduce HIV risks in Pattaya, Thailand. The study used time-location sampling to recruit 308 transgender women in Pattaya into a behavioral survey in 2011. Coarsened exact matching was used to create statistically equivalent groups of program participants and non-participants, based on factors influencing likelihood of program participation. Using multivariable logistic regression, we estimated effects of any program participation and participation by delivery channel on: condom use at last sex; consistent condom and condom/water-based lubricant use in the past 3 months with commercial, casual, and regular partners; and receipt of HIV testing in the past 6 months. Program coverage reached 75% of the population. In a matched sub-sample (n = 238), participation in outreach was associated with consistent condom/water-based lubricant use with commercial partners (AOR 3.22, 95% CI 1.64-6.31). Attendance at the Sisters drop-in center was associated with receiving an HIV test (AOR 2.58, 95% CI 1.47-4.52). Dedicated transgender-friendly programs are effective at reducing HIV risks and require expansion to better serve this key population and improve HIV prevention strategies.

The initial management of severe trauma patients at hospital admission

The initial management of trauma patient is a critical period aiming at: stabilizing the vital functions; following a rigorous injury assessment; defining a therapeutic strategy. This management has to be organized to minimize loss of time that would be deleterious for the patients outcome. Thus, before patient arrival, the trauma team alert should lead to the initiation of care procedures adapted to the announced severity of the patient. Moreover, each individual should know its role in advance and the team should be managed by only one individual (the trauma leader) to avoid conflicts of decision. A rapid trauma injury assessment aims not only at guiding resuscitation (chest drainage, pelvic contention, to define the mean arterial pressure goal) but also to decide a critical intervention in case of hemodynamic instability (laparotomy, thoracotomy, arterial embolisation). This initial assessment includes a chest and a pelvic X-ray, abdominal ultrasound (extended to the lung) and transcranial Doppler (TCD). The whole body scanner with administration of intravenous contrast material is the cornerstone of the injury assessment but can be done for patients stabilized after the initial resuscitation.