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Carenzo L, Calgaro G, Rehn M, Perkins Z, Qasim ZA, Gamberini L, Ter Avest E. Contemporary management of traumatic cardiac arrest and peri-arrest states: a narrative review. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:66. [PMID: 39327636 PMCID: PMC11426104 DOI: 10.1186/s44158-024-00197-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Accepted: 08/29/2024] [Indexed: 09/28/2024]
Abstract
Trauma is a leading cause of death and disability worldwide across all age groups, with traumatic cardiac arrest (TCA) presenting a significant economic and societal burden due to the loss of productive life years. Despite TCA's high mortality rate, recent evidence indicates that survival with good and moderate neurological recovery is possible. Successful resuscitation in TCA depends on the immediate and simultaneous treatment of reversible causes according to pre-established algorithms. The HOTT protocol, addressing hypovolaemia, oxygenation (hypoxia), tension pneumothorax, and cardiac tamponade, forms the foundation of TCA management. Advanced interventions, such as resuscitative thoracotomy and resuscitative endovascular balloon occlusion of the aorta (REBOA), further enhance treatment. Contemporary approaches also consider metabolic factors (e.g. hyperkalaemia, calcium imbalances) and hemostatic resuscitation. This narrative review explores the advanced management of TCA and peri-arrest states, discussing the epidemiology and pathophysiology of peri-arrest and TCA. It integrates classic TCA management strategies with the latest evidence and practical applications.
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Affiliation(s)
- Luca Carenzo
- Department of Anesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Milano, 20089, Italy.
| | - Giulio Calgaro
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
| | - Marius Rehn
- Pre-Hospital Division, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- The Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Zane Perkins
- Centre for Trauma Sciences, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- London's Air Ambulance and Barts Health NHS Trust, Royal London Hospital, London, UK
| | - Zaffer A Qasim
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Ewoud Ter Avest
- London's Air Ambulance and Barts Health NHS Trust, Royal London Hospital, London, UK
- Department of Emergency Medicine, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
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Ahn ES, Kim KH, Park JH, Song KJ, Shin SD. Disparity in guideline adherence for prehospital care according to patient age in emergency medical service transport for moderate to severe trauma. Injury 2024; 55:111630. [PMID: 38839516 DOI: 10.1016/j.injury.2024.111630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/27/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVES The aim of this study was to investigate the association between patient age and guideline adherence for prehospital care in emergency medical services (EMS) for moderate to severe trauma. METHODS This was a retrospective observational study that used a nationwide EMS-based trauma database from 2016 to 2019. Adult trauma patients whose injury severity score was greater than or equal to nine were screened, and those with cardiac arrest or without outcome data were excluded. The enrolled patients were categorized into four groups according to patient age: young (<45 years), middle-aged (45-64 years), old (65-84 years), and very old (>84 years). The primary outcome was guideline adherence, which was defined as following all prehospital care components: airway management for level of consciousness below verbal response, oxygen supply for pulse oximetry under 94 %, intravenous fluid administration for systolic blood pressure under 90 mmHg, scene resuscitation time within 10 min, and transport to the trauma center or level 1 emergency department. Multivariable logistic regression was conducted to calculate the adjusted odds ratios (aORs) and 95 % confidence intervals (95 % CIs). RESULTS Among the 430,365 EMS-treated trauma patients, 38,580 patients were analyzed-9,573 (24.8 %) in the young group, 15,296 (39.7 %) in the middle-aged group, 9,562 (24.8 %) in the old group, and 4,149 (10.8 %) in the very old group. The main analysis revealed a lower probability of guideline adherence in the old group (aOR 95 % CI = 0.84 (0.76-0.94)) and very old group (aOR 95 % CI = 0.68 (0.58-0.81)) than in the young group. CONCLUSION We found disparities in guideline adherence for prehospital care according to patient age at the time of EMS assessment of moderate to severe trauma. Considering this disparity, the prehospital trauma triage and management for older patients needs to be improved and educated to EMS providers.
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Affiliation(s)
- Eun Seon Ahn
- Department of Emergency Medicine, Seoul National University Hospital, Korea
| | - Ki Hong Kim
- Department of Emergency Medicine, Seoul National University Hospital, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea.
| | - Jeong Ho Park
- Department of Emergency Medicine, Seoul National University Hospital, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
| | - Kyoung Jun Song
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea; Department of Emergency Medicine, Seoul National University Boramae Medical Center, Korea
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Korea; Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, Korea
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Rowe CJ, Nwaolu U, Martin L, Huang BJ, Mang J, Salinas D, Schlaff CD, Ghenbot S, Lansford JL, Potter BK, Schobel SA, Gann ER, Davis TA. Systemic inflammation following traumatic injury and its impact on neuroinflammatory gene expression in the rodent brain. J Neuroinflammation 2024; 21:211. [PMID: 39198925 PMCID: PMC11360339 DOI: 10.1186/s12974-024-03205-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 08/16/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Trauma can result in systemic inflammation that leads to organ dysfunction, but the impact on the brain, particularly following extracranial insults, has been largely overlooked. METHODS Building upon our prior findings, we aimed to understand the impact of systemic inflammation on neuroinflammatory gene transcripts in eight brain regions in rats exposed to (1) blast overpressure exposure [BOP], (2) cutaneous thermal injury [BU], (3) complex extremity injury, 3 hours (h) of tourniquet-induced ischemia, and hind limb amputation [CEI+tI+HLA], (4) BOP+BU or (5) BOP+CEI and delayed HLA [BOP+CEI+dHLA] at 6, 24, and 168 h post-injury (hpi). RESULTS Globally, the number and magnitude of differentially expressed genes (DEGs) correlated with injury severity, systemic inflammation markers, and end-organ damage, driven by several chemokines/cytokines (Csf3, Cxcr2, Il16, and Tgfb2), neurosteroids/prostaglandins (Cyp19a1, Ptger2, and Ptger3), and markers of neurodegeneration (Gfap, Grin2b, and Homer1). Regional neuroinflammatory activity was least impacted following BOP. Non-blast trauma (in the BU and CEI+tI+HLA groups) contributed to an earlier, robust and diverse neuroinflammatory response across brain regions (up to 2-50-fold greater than that in the BOP group), while combined trauma (in the BOP+CEI+dHLA group) significantly advanced neuroinflammation in all regions except for the cerebellum. In contrast, BOP+BU resulted in differential activity of several critical neuroinflammatory-neurodegenerative markers compared to BU. t-SNE plots of DEGs demonstrated that the onset, extent, and duration of the inflammatory response are brain region dependent. Regardless of injury type, the thalamus and hypothalamus, which are critical for maintaining homeostasis, had the most DEGs. Our results indicate that neuroinflammation in all groups progressively increased or remained at peak levels over the study duration, while markers of end-organ dysfunction decreased or otherwise resolved. CONCLUSIONS Collectively, these findings emphasize the brain's sensitivity to mediators of systemic inflammation and provide an example of immune-brain crosstalk. Follow-on molecular and behavioral investigations are warranted to understand the short- to long-term pathophysiological consequences on the brain, particularly the mechanism of blood-brain barrier breakdown, immune cell penetration-activation, and microglial activation.
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Affiliation(s)
- Cassie J Rowe
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA.
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA.
| | - Uloma Nwaolu
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
| | - Laura Martin
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- F. Edward Hébert School of Medicine, Uniformed Service University, Bethesda, MD, USA
| | - Benjamin J Huang
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- F. Edward Hébert School of Medicine, Uniformed Service University, Bethesda, MD, USA
| | - Josef Mang
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- F. Edward Hébert School of Medicine, Uniformed Service University, Bethesda, MD, USA
| | - Daniela Salinas
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
| | - Cody D Schlaff
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
| | - Sennay Ghenbot
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
| | - Jefferson L Lansford
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
| | - Benjamin K Potter
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- F. Edward Hébert School of Medicine, Uniformed Service University, Bethesda, MD, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University, Bethesda, MD, USA
| | - Seth A Schobel
- Surgical Critical Care Initiative (SC2i), Uniformed Services University, Bethesda, MD, USA
| | - Eric R Gann
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, MD, USA
- Surgical Critical Care Initiative (SC2i), Uniformed Services University, Bethesda, MD, USA
| | - Thomas A Davis
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University, 4301 Jones Bridge Road, Building A Room 3009E, Bethesda, MD, 20814, USA
- F. Edward Hébert School of Medicine, Uniformed Service University, Bethesda, MD, USA
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Kim JG, Choi HY, Kang GH, Jang YS, Kim W, Lee Y, Ahn C. Prognostic Association between Injury Severity Score and the Outcomes of Elderly Patients with Trauma in South Korea. J Pers Med 2024; 14:674. [PMID: 39063928 PMCID: PMC11277643 DOI: 10.3390/jpm14070674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/16/2024] [Accepted: 06/21/2024] [Indexed: 07/28/2024] Open
Abstract
This study investigated the impact of the Injury Severity Score (ISS) on treatment approaches and survival outcomes in trauma patients, focusing on comparing elderly (≥65 years) with non-elderly patients. It analyzed adult trauma cases with abnormal Revised Trauma Scores from January to December 2019, categorizing patients into three severity groups based on ISS: mild (1-8), moderate (9-15), and severe (≥16). The study examined how ISS influenced therapeutic interventions and survival among elderly patients, comparing these outcomes to non-elderly patients using multivariable logistic regression analysis. In 16,336 adult trauma cases out of 52,262 patients, including 4886 elderly and 11,450 non-elderly patients, findings revealed that in the severe group, elderly patients had a lower, though not statistically significant, incidence of surgical or embolization interventions compared to the moderate group, differing from non-elderly patients. No significant differences were observed in the mild group between elderly and non-elderly patients. However, elderly patients had higher intervention rates in the moderate group and lower in the severe group, with significantly lower survival-to-discharge rates in the severe group. The ISS is insufficient for assessing trauma severity in elderly patients. Additional tools are needed for better evaluation and treatment decisions.
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Affiliation(s)
- Jae-Guk Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea; (J.-G.K.); (G.-H.K.); (Y.-S.J.); (W.K.); (Y.L.)
| | - Hyun-Young Choi
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea; (J.-G.K.); (G.-H.K.); (Y.-S.J.); (W.K.); (Y.L.)
| | - Gu-Hyun Kang
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea; (J.-G.K.); (G.-H.K.); (Y.-S.J.); (W.K.); (Y.L.)
| | - Yong-Soo Jang
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea; (J.-G.K.); (G.-H.K.); (Y.-S.J.); (W.K.); (Y.L.)
| | - Wonhee Kim
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea; (J.-G.K.); (G.-H.K.); (Y.-S.J.); (W.K.); (Y.L.)
| | - Yoonje Lee
- Department of Emergency Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea; (J.-G.K.); (G.-H.K.); (Y.-S.J.); (W.K.); (Y.L.)
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul 06974, Republic of Korea;
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Baird MD, Madha ES, Arnaouti M, Cahill GL, Hewa Kodikarage SN, Harris RE, Murphy TP, Bartel MC, Rich EL, Pathirana YG, Kim E, Bain PA, Alswaiti GT, Ratnayake AS, Worlton TJ, Joseph MN. Global assessment of military and civilian trauma systems integration: a scoping review. Int J Surg 2024; 110:3617-3632. [PMID: 38935828 PMCID: PMC11175771 DOI: 10.1097/js9.0000000000001265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/21/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The global burden of trauma disproportionately affects low-income countries and middle-income countries (LMIC), with variability in trauma systems between countries. Military and civilian healthcare systems have a shared interest in building trauma capacity for use during peace and war. However, in LMICs it is largely unknown if and how these entities work together. Understanding the successful integration of these systems can inform partnerships that can strengthen trauma care. This scoping review aims to identify examples of military-civilian trauma systems integration and describe the methods, domains, and indicators associated with integration including barriers and facilitators. METHODS A scoping review of all appropriate databases was performed to identify papers with evidence of military and civilian trauma systems integration. After manuscripts were selected for inclusion, relevant data was extracted and coded into methods of integration, domains of integration, and collected information regarding indicators of integration, which were further categorized into facilitators or barriers. RESULTS Seventy-four studies were included with authors from 18 countries describing experiences in 23 countries. There was a predominance of authorship and experiences from High-Income Countries (91.9 and 75.7%, respectively). Five key domains of integration were identified; Academic Integration was the most common (45.9%). Among indicators, the most common facilitator was administrative support and the lack of this was the most common barrier. The most common method of integration was Collaboration (50%). CONCLUSION Current evidence demonstrates the existence of military and civilian trauma systems integration in several countries. High-income country data dominates the literature, and thus a more robust understanding of trauma systems integration, inclusive of all geographic locations and income statuses, is necessary prior to development of a framework to guide integration. Nonetheless, the facilitators identified in this study describe the factors and environment in which integration is feasible and highlight optimal indicators of entry.
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Affiliation(s)
- Michael D. Baird
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Emad S. Madha
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of General Surgery, Walter Reed National Military Medical Center
| | - Matthew Arnaouti
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Royal National Orthopaedic Hospital, Stanmore, Middlesex
| | - Gabrielle L. Cahill
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Head and Neck Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Sadeesh N. Hewa Kodikarage
- Department of Surgery, Army Hospital Colombo
- Postgraduate Institute of Medicine, University of Colombo, Colombo Sri Lanka
| | | | - Timothy P. Murphy
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Megan C. Bartel
- Department of General Surgery, Walter Reed National Military Medical Center
| | - Elizabeth L. Rich
- Department of Orthopedic Surgery, Walter Reed National Military Medical Center
| | - Yasar G. Pathirana
- Department of Surgery, Army Hospital Colombo
- Postgraduate Institute of Medicine, University of Colombo, Colombo Sri Lanka
| | - Eungjae Kim
- School of Medicine, Uniformed Services University
| | - Paul A. Bain
- Countway Library, Harvard Medical School, Boston
| | | | | | - Tamara J. Worlton
- Department of General Surgery, Walter Reed National Military Medical Center
- Department of Surgery, Uniformed Services University, Bethesda
| | - Michelle N. Joseph
- Program in Global Surgery and Social Change
- Department of Global Health and Social Medicine
- Department of Surgery, Uniformed Services University, Bethesda
- Clinical Trials Unit, University of Warwick, Warwickshire, UK
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Song C, Liu W, Luo Y, Liu J, Jiang G, Wang R, He Z, Wang X, Mao W. Alterations in the immune landscape characterized by inflammatory activation and immune escape within 12 h after trauma. Immunobiology 2024; 229:152801. [PMID: 38593729 DOI: 10.1016/j.imbio.2024.152801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 03/15/2024] [Accepted: 03/29/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND Trauma is statistically a significant cause of mortality among patients across countries. Nevertheless, the precise correlation between genetic diagnostic markers and the intricate mechanism of trauma remains indistinct. METHODS Our study exclusively centered on trauma patients and selected three trauma-related datasets from the Gene Expression Omnibus (GEO) database, all of which had blood samples collected within post-traumatic 12 h. Differential gene screening, the WGCNA and Cytoscape software were employed to analyze the two datasets, with a particular emphasis on the top 100 genes selected based on MCC algorithm scores. A logistic diagnostic model was constructed by analyzing the intersection genes in the third dataset, leading to the identification of diagnostic biomarkers with high efficiency. The global immune landscape of these patients was extensively investigated using a multidimensional approach. Meanwhile, the underlying pathological and physiological mechanisms associated with early trauma status are summarized by integrating existing literature. RESULTS Out of these two GEO datasets, 21 overlapping genes were identified and incorporated into in the logistic diagnostic model constructed in the GSE36809 dataset. A panel of 9 genes was uncovered as a diagnostic biomarker, and their expression and correlation were subsequently verified. Additionally, by virtue of various algorithms, the findings revealed an upregulation of neutrophil expression and a downregulation of CD8+ T cell expression, indicating characteristic early trauma-induced inflammation activation and immune suppression. The correlation observed between the feature genes and immune cells serves to validate the exceptional diagnostic capability of these 9 genes in identifying trauma status and their promising potential for patients who could benefit from targeted immune interventions. Drawing from these findings, the discussion section offers insights into the underlying pathological and physiological mechanisms at play. CONCLUSION Our research has discovered a novel diagnostic biomarker and unveiled its association with post-traumatic immune alterations. This breakthrough enables accurate and timely diagnosis of early trauma, facilitating the implementation of appropriate healthcare interventions.
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Affiliation(s)
- Chenghu Song
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi 214023, China
| | - Weici Liu
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi 214023, China
| | - Yu Luo
- Department of Emergency Medicine, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi 214023, China
| | - Jiwei Liu
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi 214023, China
| | - Guanyu Jiang
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi 214023, China
| | - Ruixin Wang
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi 214023, China
| | - Zhao He
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi 214023, China.
| | - Xiaokun Wang
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi 214023, China.
| | - Wenjun Mao
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi 214023, China.
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Zahra W, Nayar SK, Bhadresha A, Jasani V, Aftab S. Safety of tranexamic acid in surgically treated isolated spine trauma. World J Orthop 2024; 15:346-354. [PMID: 38680673 PMCID: PMC11045465 DOI: 10.5312/wjo.v15.i4.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/07/2024] [Accepted: 03/19/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Tranexamic acid (TXA), a synthetic antifibrinolytic drug, effectively reduces blood loss by inhibiting plasmin-induced fibrin breakdown. This is the first study in the United Kingdom to investigate the effectiveness of TXA in the surgical management of isolated spine trauma. AIM To assess the safety of TXA in isolated spine trauma. The primary and secondary outcomes are to assess the rate of thromboembolic events and to evaluate blood loss and the incidence of blood transfusion, respectively. METHODS This prospective observational study included patients aged ≥ 17 years with isolated spine trauma requiring surgical intervention over a 6-month period at two major trauma centers in the United Kingdom. RESULTS We identified 67 patients: 26 (39%) and 41 (61%) received and did not receive TXA, respectively. Both groups were matched in terms of age, gender, American Society of Anesthesiologists grade, and mechanism of injury. A higher proportion of patients who received TXA had a subaxial cervical spine injury classification or thoracolumbar injury classification score > 4 (74% vs 56%). All patients in the TXA group underwent an open approach with a mean of 5 spinal levels involved and an average operative time of 203 min, compared with 24 patients (58%) in the non-TXA group who underwent an open approach with an average of 3 spinal levels involved and a mean operative time of 159 min. Among patients who received TXA, blood loss was < 150 and 150-300 mL in 8 (31%) and 15 (58%) patients, respectively. There were no cases of thromboembolic events in any patient who received TXA. CONCLUSION Our study demonstrated that TXA is safe for isolated spine trauma. It is challenging to determine whether TXA effectively reduces blood loss because most surgeons prefer TXA for open or multilevel cases. Further, larger studies are necessary to explore the rate, dosage, and mode of administration of TXA.
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Affiliation(s)
- Wajiha Zahra
- Trauma and Orthopedics Department, University Hospital of North Midlands NHS Trust, Stoke-on-Trent ST4 6QG, United Kingdom
| | - Sandeep Krishan Nayar
- Trauma and Orthopedics Department, Royal London Hospital, Barts Health Institute, London E1 1BB, United Kingdom
| | - Ashwin Bhadresha
- Trauma and Orthopedics Department, Royal London Hospital, Barts Health Institute, London E1 1BB, United Kingdom
| | - Vinay Jasani
- Craniospinal Services, University Hospital of North Midlands NHS Trust, Stoke-on-Trent ST4 6QG, United Kingdom
| | - Syed Aftab
- Spine Department, Royal London Hospital, Barts Health Institute, London E1 1BB, United Kingdom
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Bagenal J, Lee N, Ademuyiwa AO, Nepogodiev D, Ramos-De la Medina A, Biccard B, Lapitan MC, Waweru-Siika W. Surgical research-comic opera no more. Lancet 2023; 402:86-88. [PMID: 37172604 DOI: 10.1016/s0140-6736(23)00856-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023]
Affiliation(s)
| | - Naomi Lee
- National Institute for Health and Care Excellence, London, UK
| | | | - Dmitri Nepogodiev
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Bruce Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and the University of Cape Town, Western Cape, South Africa
| | - Marie Carmela Lapitan
- Institute of Clinical Epidemiology and College of Medicine, National Institutes of Health, University of the Philippines Manila and Philippine General Hospital, Manila, Philippines
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Pak J, Kim TH, Song KJ, Lee SC, Hong KJ, Song SW, Kim DH, Lee SGW. Clinical factors associated with delayed emergency department visit in intracranial traumatic brain injury: from a multicenter injury surveillance registry. Brain Inj 2023; 37:422-429. [PMID: 36529957 DOI: 10.1080/02699052.2022.2158232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Early diagnosis and intervention by visiting the emergency department (ED) are important for traumatic brain injury (TBI). We evaluate the factors associated with delayed ED visits in patients with intracranial TBI. METHODS A retrospective multicenter observational study using the ED-based injury in-depth surveillance database (EDIIS) was designed. Patients with intracranial TBI with an alert mentality at ED presentation from 2014 to 2019 were enrolled. Patients were categorized into four groups according to ED visit time after injury (<1 h, 1-3 h, 3-12 h, and >12 h). ED visits after 12 h were defined as delayed ED visits. The factors associated with delayed ED visits were identified using multivariable logistic regression analysis. RESULTS Among 15,620 patients with TBI enrolled in the final analysis, 2,190 (14.0%) visited the ED 12 h after injury. Multivariable analysis identified the following factors as independent predictors for delayed ED visit such as unintentionally struck by or against an object or unintentional fall as a trauma mechanism, injury during ordinary activities, indoor injury, injury during nighttime, winter season, combined subdural hemorrhage and epidural hemorrhage. CONCLUSION In patients with intracranial TBI with an alert mentality, multiple factors related to patient demographics and injury characteristics were associated with the time interval from injury to ED visit.
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Affiliation(s)
- Jieun Pak
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
| | - Tae Han Kim
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
| | - Seung Chul Lee
- Department of Emergency medicine, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Ki Jeong Hong
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
- Department of Emergency Medicine, Seoul National University Hospital
| | - Sung Wook Song
- Department of Emergency Medicine, Jeju National University College of Medicine
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, South Korea
| | - Stephen Gyung Won Lee
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, South Korea
- Laboratory of Emergency Medical Services, Seoul National University Hospital Biomedical Research Institute, Seoul, South Korea
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10
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Zhao R, Lu B. Flexible template matching for observational study design. Stat Med 2023; 42:1760-1778. [PMID: 36863006 DOI: 10.1002/sim.9698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 02/08/2023] [Accepted: 02/20/2023] [Indexed: 03/04/2023]
Abstract
Matching is a popular design for inferring causal effect with observational data. Unlike model-based approaches, it is a nonparametric method to group treated and control subjects with similar characteristics together, hence to re-create a randomization-like scenario. The application of matched design for real world data may be limited by: (1) the causal estimand of interest; (2) the sample size of different treatment arms. We propose a flexible design of matching, based on the idea of template matching, to overcome these challenges. It first identifies the template group which is representative of the target population, then match subjects from the original data to this template group and make inference. We provide theoretical justification on how it unbiasedly estimates the average treatment effect using matched pairs and the average treatment effect on the treated when the treatment group has a bigger sample size. We also propose using the triplet matching algorithm to improve matching quality and devise a practical strategy to select the template size. One major advantage of matched design is that it allows both randomization-based or model-based inference, with the former being more robust. For the commonly used binary outcome in medical research, we adopt a randomization inference framework of attributable effects in matched data, which allows heterogeneous effects and can incorporate sensitivity analysis for unmeasured confounding. We apply our design and analytical strategy to a trauma care evaluation study.
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Affiliation(s)
- Ruochen Zhao
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Bo Lu
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, Ohio, USA
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11
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Dragon AH, Rowe CJ, Rhodes AM, Pak OL, Davis TA, Ronzier E. Systematic Identification of the Optimal Housekeeping Genes for Accurate Transcriptomic and Proteomic Profiling of Tissues following Complex Traumatic Injury. Methods Protoc 2023; 6:mps6020022. [PMID: 36961042 PMCID: PMC10037587 DOI: 10.3390/mps6020022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/17/2023] [Accepted: 02/19/2023] [Indexed: 02/25/2023] Open
Abstract
Trauma triggers critical molecular and cellular signaling cascades that drive biological outcomes and recovery. Variations in the gene expression of common endogenous reference housekeeping genes (HKGs) used in data normalization differ between tissue types and pathological states. Systematically, we investigated the gene stability of nine HKGs (Actb, B2m, Gapdh, Hprt1, Pgk1, Rplp0, Rplp2, Tbp, and Tfrc) from tissues prone to remote organ dysfunction (lung, liver, kidney, and muscle) following extremity trauma. Computational algorithms (geNorm, Normfinder, ΔCt, BestKeeper, RefFinder) were applied to estimate the expression stability of each HKG or combinations of them, within and between tissues, under both steady-state and systemic inflammatory conditions. Rplp2 was ranked as the most suitable in the healthy and injured lung, kidney, and skeletal muscle, whereas Rplp2 and either Hprt1 or Pgk1 were the most suitable in the healthy and injured liver, respectively. However, the geometric mean of the three most stable genes was deemed the most stable internal reference control. Actb and Tbp were the least stable in normal tissues, whereas Gapdh and Tbp were the least stable across all tissues post-trauma. Ct values correlated poorly with the translation from mRNA to protein. Our results provide a valuable resource for the accurate normalization of gene expression in trauma-related experiments.
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Affiliation(s)
- Andrea H Dragon
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 2081, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, USA
| | - Cassie J Rowe
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 2081, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, USA
| | - Alisha M Rhodes
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 2081, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, USA
| | - Olivia L Pak
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 2081, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, USA
| | - Thomas A Davis
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 2081, USA
| | - Elsa Ronzier
- Cell Biology and Regenerative Medicine Program, Department of Surgery, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 2081, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, Bethesda, MD 20817, USA
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12
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Hosseini M, Shayan L, Yadollahi M, Karajizadeh M. Characteristics of Traumatic Patients Referring to the Emergency Department and their Association with Mortality and Incidence of Surgery Performance. Bull Emerg Trauma 2023; 11:132-137. [PMID: 37525653 PMCID: PMC10387339 DOI: 10.30476/beat.2023.97729.1413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/22/2023] [Accepted: 05/30/2023] [Indexed: 08/02/2023] Open
Abstract
Objective To identify the distinctive features of acutely injured patients who were presented to the emergency department (ED) and their association with mortality and surgical intervention outcomes. Methods This cross-sectional study was conducted on all trauma patients resuscitated in the ED of Shahid Rajaee (Emtiaz) Trauma Hospital (Shiraz, Iran) from May 2018 to June 2019. Demographic information, the mechanism of trauma, trauma type, injured body regions, criteria of abbreviated injury scale (AIS) score, injury severity score (ISS), and surgical intervention were all taken into consideration. The items related to the mortality and surgical performance outcomes among the patients were analyzed. Results Of all 1281 cases, 82.9% were men, and the mean age of the patients was 37.9±19.1 years. The most common mechanism of injury was a car accident, and the thorax was the most prevalent injured area of the body. The majority of the patients had moderate blunt trauma. The mechanism of trauma, ISS, and the severity of head trauma were all significantly correlated with operation interventions. Moreover, age, the mechanism and type of trauma, ISS, and the necessity for the surgery were significantly associated with death occurrence. Additionally, head, thorax, and abdomen trauma were significantly related to a high mortality rate. Conclusion Age, trauma mechanism and type, ISS, and the necessity for surgery were significantly associated with the mortality rate of injured patients. The severity of the trauma, particularly head injuries and the mechanism of damage were important determinants in concern for surgery the necessity.
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Affiliation(s)
- Maryam Hosseini
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leila Shayan
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahnaz Yadollahi
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehrdad Karajizadeh
- Truama Research Center, Shahid Rajaee (Emtiaz) Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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13
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Ebrahimian R, Souri Z, Feizkhah A, Mobayen M, Eslami Kenarsari H, Esmailzadeh M, Ghorbani M, Mirhedayati S, Bagheri Toolaroud P. Evaluation of the Spiral Chest CT Scan Findings in Patients with Multiple Trauma. Bull Emerg Trauma 2023; 11:19-25. [PMID: 36818057 PMCID: PMC9923035 DOI: 10.30476/beat.2023.97214.1402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 12/22/2023] [Accepted: 12/25/2023] [Indexed: 02/24/2023] Open
Abstract
Objective To evaluate the spiral chest computed tomography (CT) scan findings in patients with multiple trauma during the COVID-19 pandemic. Methods This retrospective study was performed on multiple trauma patients admitted to a tertiary hospital in the north of Iran in 2020. All patients with multiple trauma who had undergone a chest spiral CT were included in this study. Furthermore, the data analysis was performed through descriptive and analytical statistics using SPSS software. Results A total of 600 patients were included over the study period. The mean age of patients was 48.2±20.3 years. Of the total, 496 (65.3%) patients had blunt chest injuries, and 104 (34.7%) had penetrating chest injuries. Falling was the most common mechanical cause of chest trauma in 270 patients (45%). Surgical interventions were performed in 110 (18.3%) patients. A total of 276 (46%) patients had chest injuries identified by CT scans. Many patients (15.6%) had ground-glass lung opacity in the CT scan reports. Lung consolidation, pneumothorax, lung contusion, hemothorax, and rib fractures were the most common. Conclusion Due to the high frequency of typical findings in spiral CT scan examinations, obtaining a reliable history of trauma severity, injury mechanism, and a detailed physical examination is recommended before prescribing a CT scan for patients.
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Affiliation(s)
- Ramin Ebrahimian
- Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran,Department of Surgery, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Zoubin Souri
- Department of Radiology, Faculty of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Alireza Feizkhah
- Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran,Department of Medical Physics, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohammadreza Mobayen
- Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Habib Eslami Kenarsari
- Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Mojdeh Esmailzadeh
- Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohsen Ghorbani
- Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Soroush Mirhedayati
- Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Parissa Bagheri Toolaroud
- Burn and Regenerative Medicine Research Center, Guilan University of Medical Sciences, Rasht, Iran,Health Information Management Research Center, Kashan University of Medical Sciences, Kashan, Iran
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14
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Gosselin AR, White NJ, Bargoud CG, Hanna JS, Tutwiler V. Hyperfibrinolysis drives mechanical instabilities in a simulated model of trauma induced coagulopathy. Thromb Res 2022; 220:131-140. [PMID: 36347079 PMCID: PMC10544892 DOI: 10.1016/j.thromres.2022.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/04/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Trauma induced coagulopathy (TIC) is common after severe trauma, increasing transfusion requirements and mortality among patients. TIC has several phenotypes, with primary hyperfibrinolysis being among the most lethal. We aimed to investigate the contribution of hypercoagulation, hemodilution, and fibrinolytic activation to the hyperfibrinolytic phenotype of TIC, by examining fibrin formation in a plasma-based model of TIC. We hypothesized that instabilities arising from TIC will be due primarily to increased fibrinolytic activation rather than hemodilution or tissue factor (TF) induced hypercoagulation. METHODS The influence of TF, hemodilution, fibrinogen consumption, tissue plasminogen activator (tPA), and the antifibrinolytic tranexamic acid (TXA) on plasma clot formation and structure were examined using rheometry, optical properties, and confocal microscopy. These were then compared to plasma samples from trauma patients at risk of developing TIC. RESULTS Combining TF-induced clot formation, 15 % hemodilution, fibrinogen consumption, and tPA-induced fibrinolysis, the clot characteristics and hyperfibrinolysis were consistent with primary hyperfibrinolysis. TF primarily increased fibrin polymerization rates and reduced fiber length. Hemodilution decreased clot optical density but had no significant effect on mechanical clot stiffness. TPA addition induced primary clot lysis as observed mechanically and optically. TXA restored mechanical clot formation but did not restore clot structure to control levels. Patients at risk of TIC showed increased clot formation, and lysis like that of our simulated model. CONCLUSIONS This simulated TIC plasma model demonstrated that fibrinolytic activation is a primary driver of instability during TIC and that clot mechanics can be restored, but clot structure remains altered with TXA treatment.
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Affiliation(s)
- Andrew R Gosselin
- Department of Biomedical Engineering, Rutgers -The State University of New Jersey, Piscataway, NJ, USA
| | - Nathan J White
- Department of Emergency Medicine, Resuscitation Engineering Science Unit, University of Washington School of Medicine, Seattle, WA, USA
| | - Christopher G Bargoud
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Joseph S Hanna
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Valerie Tutwiler
- Department of Biomedical Engineering, Rutgers -The State University of New Jersey, Piscataway, NJ, USA.
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15
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ter Avest E, Carenzo L, Lendrum RA, Christian MD, Lyon RM, Coniglio C, Rehn M, Lockey DJ, Perkins ZB. Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries. Crit Care 2022; 26:184. [PMID: 35725641 PMCID: PMC9210796 DOI: 10.1186/s13054-022-04052-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 06/02/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract Early haemorrhage control and minimizing the time to definitive care have long been the cornerstones of therapy for patients exsanguinating from non-compressible haemorrhage (NCH) after penetrating injuries, as only basic treatment could be provided on scene. However, more recently, advanced on-scene treatments such as the transfusion of blood products, resuscitative thoracotomy (RT) and resuscitative endovascular balloon occlusion of the aorta (REBOA) have become available in a small number of pre-hospital critical care teams. Although these advanced techniques are included in the current traumatic cardiac arrest algorithm of the European Resuscitation Council (ERC), published in 2021, clear guidance on the practical application of these techniques in the pre-hospital setting is scarce. This paper provides a scoping review on how these advanced techniques can be incorporated into practice for the resuscitation of patients exsanguinating from NCH after penetrating injuries, based on available literature and the collective experience of several helicopter emergency medical services (HEMS) across Europe who have introduced these advanced resuscitation interventions into routine practice.
Graphical Abstract ![]()
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16
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Suzuki K, Okada H, Sumi K, Tomita H, Kobayashi R, Ishihara T, Mizuno Y, Yamaji F, Kamidani R, Miura T, Yasuda R, Kitagawa Y, Fukuta T, Suzuki K, Miyake T, Kanda N, Doi T, Yoshida T, Yoshida S, Tetsuka N, Ogura S, Suzuki A. Syndecan-1 as a severity biomarker for patients with trauma. Front Med (Lausanne) 2022; 9:985955. [PMID: 36237551 PMCID: PMC9550865 DOI: 10.3389/fmed.2022.985955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/29/2022] [Indexed: 11/15/2022] Open
Abstract
Tissue injury and hemorrhage induced by trauma lead to degradation of the endothelial glycocalyx, causing syndecan-1 (SDC-1) to be shed into the blood. In this study, we investigated whether serum SDC-1 is useful for evaluating trauma severity in patients. A single-center, retrospective, observational study was conducted at Gifu University Hospital. Patients transported to the emergency room for trauma and subsequently admitted to the intensive care unit from January 2019 to December 2021 were enrolled. A linear regression model was constructed to evaluate the association of serum SDC-1 with injury severity score (ISS) and probability of survival (Ps). A total of 76 trauma patients (54 men and 22 women) were analyzed. ISS was significantly associated with serum SDC-1 level in trauma patients. Among the six body regions defined in the AIS used to calculate the ISS score, “chest” and “abdominal or pelvic contents” were significantly associated with serum SDC-1 level, and “extremities or pelvic girdle” also tended to show an association with serum SDC-1 level. Moreover, increasing serum SDC-1 level was significantly correlated with decreasing Ps. Serum SDC-1 may be a useful biomarker for monitoring the severity of trauma in patients. Further large-scale studies are warranted to verify these results.
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Affiliation(s)
- Keiko Suzuki
- Department of Infection Control, Gifu University Graduate School of Medicine, Gifu, Japan
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Hideshi Okada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
- Hideshi Okada
| | - Kazuyuki Sumi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ryo Kobayashi
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Laboratory of Advanced Medical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Yosuke Mizuno
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Fuminori Yamaji
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ryo Kamidani
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tomotaka Miura
- Department of Infection Control, Gifu University Graduate School of Medicine, Gifu, Japan
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ryu Yasuda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yuichiro Kitagawa
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tetsuya Fukuta
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Kodai Suzuki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takahito Miyake
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Norihide Kanda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Tomoaki Doi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takahiro Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shozo Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
- Department of Abuse Prevention Emergency Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Nobuyuki Tetsuka
- Department of Infection Control, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
- Laboratory of Advanced Medical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
- *Correspondence: Akio Suzuki
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17
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Moussally J, Saha AC, Madden S. TraumaLink: A Community-Based First-Responder System for Traffic Injury Victims in Bangladesh. GLOBAL HEALTH, SCIENCE AND PRACTICE 2022; 10:e2100537. [PMID: 36041838 PMCID: PMC9426980 DOI: 10.9745/ghsp-d-21-00537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 06/01/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Road traffic injuries are a rapidly growing epidemic in low- and middle-income countries (LMICs). However, many countries lack formal prehospital emergency medical services, often leaving victims without access to first aid when it can be most effective in preventing death or disability. METHODS To address the lack of a dedicated prehospital emergency medical system in Bangladesh, we developed TraumaLink, a community-based network of volunteer first responders for traffic injury victims. The service uses an emergency hotline number and 24-hour call center with local first responders who are trained in basic trauma first aid, given essential medical supplies, and dispatched to crash scenes through mobile phone text message notifications. We designed the training curriculum to teach simple lifesaving skills that people with any level of education and no prior medical background could learn and perform. We retrospectively analyzed data originally collected for quality monitoring and evaluation to provide a descriptive analysis of the program's impact. RESULTS During the first 6 years, operations were expanded from a 14-km section of 1 highway to 135 km on 3 national highways, and free care was provided to 3,119 patients involved in 1,544 crashes. All calls to the service received a response, and in 88% of cases, first responders were at the scene in 5 minutes or less. Most patients were young adult men, and 76% of victims transported to the hospital arrived there within 30 minutes of the crash. Assessments of injury severity at the accident scene aligned closely with patient dispositions, reflecting the accuracy of these triage decisions. CONCLUSION The strong community support and rapid, reliable volunteer responses suggest that this flexible and scalable model could be expanded throughout Bangladesh and adapted for other LMICs that face similar challenges with traffic injury victims.
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Affiliation(s)
- Jon Moussally
- Harvard T.H. Chan School of Public Health, Department of Global Health and Population, Boston, MA, USA.
- TraumaLink, Dhaka, Bangladesh
| | | | - Susan Madden
- Harvard T.H. Chan School of Public Health, Department of Global Health and Population, Boston, MA, USA
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18
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Tupetz A, Strand E, Hoque KI, Sultana M, Vissoci JRN, Staton C, Landry MD. Scarf Injury: a qualitative examination of the emergency response and acute care pathway from a unique mechanism of road traffic injury in Bangladesh. BMC Emerg Med 2022; 22:141. [PMID: 35922760 PMCID: PMC9351164 DOI: 10.1186/s12873-022-00698-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 07/18/2022] [Indexed: 12/04/2022] Open
Abstract
Background Road traffic injuries (RTI) are the leading cause of death worldwide in children over 5 and adults aged 18–29. Nonfatal RTIs result in 20–50 million annual injuries. In Bangladesh, a new mechanism of RTI has emerged over the past decade known as a ‘scarf injury.’ Scarf injuries occur when scarves, part of traditional female dress, are caught in the driveshaft of an autorickshaw. The mechanism of injury results in novel, strangulation-like cervical spine trauma. This study aimed to understand the immediate emergency response, acute care pathway, and subsequent functional and health outcomes for survivors of scarf injuries. Methods Key informant interviews were conducted with female scarf injury survivors (n = 12), caregivers (n = 6), and health care workers (n = 15). Themes and subthemes were identified via inductive content analysis, then applied to the three-delay model to examine specific breakdowns in pre-hospital care and provide a basis for future interventions. Findings Over half of the scarf injury patients were between the ages of 10 and 15. All but two were tetraplegic. Participants emphasized less than optimal patient outcomes were due to unawareness of scarf injuries and spinal cord injuries among the general public and health professionals; unsafe and inefficient bystander first aid and transportation; and high cost of acute health care. Conclusions Females in Bangladesh are at significant risk of sustaining serious and life-threatening trauma through scarf injuries in autorickshaws, further worsened through inadequate care along the trauma care pathway. Interventions designed to increase awareness and knowledge of basic SCI care at the community and provider level would likely improve health and functional outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-022-00698-2.
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Affiliation(s)
- Anna Tupetz
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
| | - Eleanor Strand
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
| | | | - Mohsina Sultana
- Center for the Rehabilitation of the Paralyzed (CRP), Savar, Bangladesh.,Directorate of General Health Services (DGHS), Government of Mohakhali, Dhaka, Bangladesh
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
| | - Catherine Staton
- Duke Global Health Institute, Duke University, Durham, NC, USA.,Department of Emergency Medicine, Duke University Medical Center, Durham, NC, USA
| | - Michel D Landry
- Western Norway University of Applied Sciences, Bergen, Norway. .,Virginia Commonwealth University, Richmond, VA, USA.
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19
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Noack L, Bundkirchen K, Xu B, Gylstorff S, Zhou Y, Köhler K, Jantaree P, Neunaber C, Nowak AJ, Relja B. Acute Intoxication With Alcohol Reduces Trauma-Induced Proinflammatory Response and Barrier Breakdown in the Lung via the Wnt/β-Catenin Signaling Pathway. Front Immunol 2022; 13:866925. [PMID: 35663960 PMCID: PMC9159919 DOI: 10.3389/fimmu.2022.866925] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background Trauma is the third leading cause of mortality worldwide. Upon admission, up to 50% of traumatized patients are acutely intoxicated with alcohol, which might lead to aberrant immune responses. An excessive and uncontrolled inflammatory response to injury is associated with damage to trauma-distant organs. We hypothesize that, along with inflammation-induced apoptosis, the activation of the Wnt/β-catenin signaling pathway would cause breakdown of the lung barrier and the development of lung injury after trauma. It remains unclear whether ethanol intoxication (EI) prior to trauma and hemorrhagic shock will attenuate inflammation and organ injury. Methods In this study, 14 male C57BL/6J mice were randomly assigned to two groups and exposed either to EtOH or to NaCl as a control by an oral gavage before receiving a femur fracture (Fx) and hemorrhagic shock, followed by resuscitation (THFx). Fourteen sham animals received either EtOH or NaCl and underwent surgical procedures without THFx induction. After 24 h, oil red O staining of fatty vacuoles in the liver was performed. Histological lung injury score (LIS) was assessed to analyze the trauma-induced RLI. Gene expression of Cxcl1, Il-1β, Muc5ac, Tnf, and Tnfrsf10b as well as CXCL1, IL-1β, and TNF protein levels in the lung tissue and bronchoalveolar lavage fluid were determined by RT-qPCR, ELISA, and immunohistological analyses. Infiltrating polymorphonuclear leukocytes (PMNLs) were examined via immunostaining. Apoptosis was detected by activated caspase-3 expression in the lung tissue. To confirm active Wnt signaling after trauma, gene expression of Wnt3a and its inhibitor sclerostin (Sost) was determined. Protein expression of A20 and RIPK4 as possible modulators of the Wnt signaling pathway was analyzed via immunofluorescence. Results Significant fatty changes in the liver confirmed the acute EI. Histopathology and decreased Muc5ac expression revealed an increased lung barrier breakdown and concomitant lung injury after THFx versus sham. EI prior trauma decreased lung injury. THFx increased not only the gene expression of pro-inflammatory markers but also the pulmonary infiltration with PMNL and apoptosis versus sham, while EI prior to THFx reduced those changes significantly. EI increased the THFx-reduced gene expression of Sost and reduced the THFx-induced expression of Wnt3a. While A20, RIPK4, and membranous β-catenin were significantly reduced after trauma, they were enhanced upon EI. Conclusion These findings suggest that acute EI alleviates the uncontrolled inflammatory response and lung barrier breakdown after trauma by suppressing the Wnt/β-catenin signaling pathway.
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Affiliation(s)
- Laurens Noack
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany
| | | | - Baolin Xu
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany.,Trauma Department, Hannover Medical School, Hannover, Germany
| | - Severin Gylstorff
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany
| | - Yuzhuo Zhou
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany.,Trauma Department, Hannover Medical School, Hannover, Germany
| | - Kernt Köhler
- Institute of Veterinary Pathology, Justus Liebig University Giessen, Giessen, Germany
| | - Phatcharida Jantaree
- Institute of Experimental Internal Medicine, Otto-von-Guericke University, Magdeburg, Germany
| | | | - Aleksander J Nowak
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany
| | - Borna Relja
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany
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20
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Tupetz A, Barcenas LK, Isaacson JE, Nickenig Vissoci JR, Gerald V, Kingazi JR, Mushi I, Peter TA, Staton CA, Mmbaga BT, Bettger JP. "I Don't Do Anything; I'm Just Being Taken Care Of": Experiences of Patients and Their Caregivers Transitioning Back into the Community Following Traumatic Injury in Northern Tanzania. TRAUMA CARE 2022; 2:341-358. [PMID: 37274128 PMCID: PMC10238087 DOI: 10.3390/traumacare2020028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024] Open
Abstract
After discharge from the hospital for traumatic injury, patients and their caregivers face a period of increased vulnerability. This adjustment phase is poorly characterized, especially in low- and middle-income countries. We explored the experiences of patients and their caregivers in Northern Tanzania after hospitalization for a traumatic injury. Patients who received care for traumatic injury at the Kilimanjaro Christian Medical Center and their caregivers were selected as part of a convenience sample from January 2019 to December 2019. Analysts developed a codebook; content and analytic memos were subsequently created. We then applied the biopsychosocial model to further characterize our findings. Participants included 26 patients and 11 caregivers. Patients were mostly middle-aged (mean age 37.7) males (80.8%), residing in urban settings (57.7%), injured in road traffic accidents (65.4%), and who required surgery (69.2%). Most caregivers were female. Seven major themes arose: pain, decreased physical functioning, poor emotional health, lack of support, challenges with daily activities, financial strain, and obstacles to accessing healthcare. This study describes some of the difficulties transitioning back into the community after hospitalization for traumatic injury. Our work demonstrates the importance of mixed methods approaches in characterizing and addressing transitions of care challenges.
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Affiliation(s)
- Anna Tupetz
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | - Loren K. Barcenas
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
| | | | - Joao Ricardo Nickenig Vissoci
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
- Duke Global Health Institute, Duke University, Durham, NC 27710, USA
| | | | | | - Irene Mushi
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | | | - Catherine A. Staton
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, NC 27710, USA
- Duke Global Health Institute, Duke University, Durham, NC 27710, USA
| | - Blandina T. Mmbaga
- Duke Global Health Institute, Duke University, Durham, NC 27710, USA
- Kilimanjaro Christian Medical Center, Moshi, Tanzania
- Paediatric and Child Health Department, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Clinical Trial Department, Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Janet Prvu Bettger
- Duke Global Health Institute, Duke University, Durham, NC 27710, USA
- Duke-Margolis Center for Health Policy, Duke University School of Medicine, Durham, NC 27710, USA
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA
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21
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Sturm R, Haag F, Janicova A, Xu B, Vollrath JT, Bundkirchen K, Dunay IR, Neunaber C, Marzi I, Relja B. Acute alcohol consumption increases systemic endotoxin bioactivity for days in healthy volunteers-with reduced intestinal barrier loss in female. Eur J Trauma Emerg Surg 2022; 48:1569-1577. [PMID: 33839799 PMCID: PMC9192383 DOI: 10.1007/s00068-021-01666-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/01/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Trauma is the most common cause of death among young adults. Alcohol intoxication plays a significant role as a cause of accidents and as a potent immunomodulator of the post-traumatic response to tissue injury. Polytraumatized patients are frequently at risk to developing infectious complications, which may be aggravated by alcohol-induced immunosuppression. Systemic levels of integral proteins of the gastrointestinal tract such as syndecan-1 or intestinal fatty acid binding proteins (FABP-I) reflect the intestinal barrier function. The exact impact of acute alcohol intoxication on the barrier function and endotoxin bioactivity have not been clarified yet. METHODS 22 healthy volunteers received a precisely defined amount of alcohol (whiskey-cola) every 20 min over a period of 4 h to reach the calculated blood alcohol concentration (BAC) of 1‰. Blood samples were taken before alcohol drinking as a control, and after 2, 4, 6, 24 and 48 h after beginning with alcohol consumption. In addition, urine samples were collected. Intestinal permeability was determined by serum and urine values of FABP-I, syndecan-1, and soluble (s)CD14 as a marker for the endotoxin translocation via the intestinal barrier by ELISA. BAC was determined. RESULTS Systemic FABP-I was significantly reduced 2 h after the onset of alcohol drinking, and remained decreased after 4 h. However, at 6 h, FABP-I significantly elevated compared to previous measurements as well as to controls (p < 0.05). Systemic sCD14 was significantly elevated after 6, 24 and 48 h after the onset of alcohol consumption (p < 0.05). Systemic FABP-I at 2 h after drinking significantly correlated with the sCD14 concentration after 24 h indicating an enhanced systemic LPS bioactivity. Women showed significantly lower levels of syndecan-1 in serum and urine and urine for all time points until 6 h and lower FABP-I in the serum after 2 h. CONCLUSIONS Even relative low amounts of alcohol affect the immune system of healthy volunteers, although these changes appear minor in women. A potential damage to the intestinal barrier and presumed enhanced systemic endotoxin bioactivity after acute alcohol consumption is proposed, which represents a continuous immunological challenge for the organism and should be considered for the following days after drinking.
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Affiliation(s)
- Ramona Sturm
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany
| | - Florian Haag
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany
- Experimental Radiology, Department of Radiology and Nuclear Medicine, Otto Von Guericke University, Magdeburg, Germany
| | - Andrea Janicova
- Experimental Radiology, Department of Radiology and Nuclear Medicine, Otto Von Guericke University, Magdeburg, Germany
| | - Baolin Xu
- Experimental Radiology, Department of Radiology and Nuclear Medicine, Otto Von Guericke University, Magdeburg, Germany
| | - Jan Tilmann Vollrath
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany
| | | | - Ildiko Rita Dunay
- Institute of Inflammation and Neurodegeneration, Otto Von Guericke University, Magdeburg, Germany
| | | | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany.
- Experimental Radiology, Department of Radiology and Nuclear Medicine, Otto Von Guericke University, Magdeburg, Germany.
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22
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Al Ani A, Riad Z, Ahmed H, Aboughosiba H, Abuhussein N, Abdulhakim H, Kabeer N, Ibrahim M, Atasi A, Banday V, Makki M, Tamer A, Qassem N. Trauma team training: A key to success. HAMDAN MEDICAL JOURNAL 2022. [DOI: 10.4103/hmj.hmj_40_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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23
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Andrei S, Isac S, Carstea M, Martac C, Mihalcea L, Buzatu C, Ionescu D, Georgescu DE, Droc G. Isolated liver trauma: A clinical perspective in a non-emergency center for liver surgery. Exp Ther Med 2021; 23:39. [PMID: 34849154 PMCID: PMC8613533 DOI: 10.3892/etm.2021.10961] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 09/21/2021] [Indexed: 12/16/2022] Open
Abstract
The management of liver trauma is, currently, still heterogeneous ranging from conservative to major invasive liver resections. When appropriate, these cases should be referred to a regional care center. The objective of this study was to analyze the expertise of a non-emergency center for liver surgery from Romania after initial stabilization in county hospitals. This study is a monocentric, retrospective, observational study, including 12 patients with hepatic trauma after a car accident, admitted between 2015 and 2019. We analyzed various clinical and biochemical data as independent variables, and the main outcome was considered the intensive care unit (ICU) length of stay. Our results revealed that intubation status at admission, norepinephrine infusion during surgery, hyperfibrinogenemia and duration of mechanical ventilation in patients with isolated liver trauma were correlated with prolonged ICU length of stay. Further prospective, more comprehensive studies are needed in order to evaluate the exact prognostic factors in terms of short- and long-term mortality.
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Affiliation(s)
- Stefan Andrei
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Sebastian Isac
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania.,Department of Physiology II and Neurosciences, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Maricica Carstea
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Cristina Martac
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Lucian Mihalcea
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Cristina Buzatu
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania
| | - Dorin Ionescu
- Repartment of Medical Semiology, Discipline of Internal Medicine I and Nephrology, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania.,Department of Nephrology, Bucharest Emergency University Hospital, 050098 Bucharest, Romania
| | - Dragos Eugen Georgescu
- Department of Surgery, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Gabriela Droc
- Department of Anesthesiology and Intensive Care I, 'Fundeni' Clinical Institute, 022328 Bucharest, Romania.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, 'Carol Davila' University of Medicine and Pharmacy, 020021 Bucharest, Romania
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24
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Long Y, Bundkirchen K, Gräff P, Krettek C, Noack S, Neunaber C. Cytological Effects of Serum Isolated from Polytraumatized Patients on Human Bone Marrow-Derived Mesenchymal Stem Cells. Stem Cells Int 2021; 2021:2612480. [PMID: 34876907 PMCID: PMC8645412 DOI: 10.1155/2021/2612480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022] Open
Abstract
Due to their immunomodulatory and regenerative capacity, human bone marrow-derived mesenchymal stem cells (hBMSCs) are promising in the treatment of patients suffering from polytrauma. However, few studies look at the effects of sera from polytraumatized patients on hBMSCs. The aim of this study was to explore changes in hBMSC properties in response to serum from polytrauma patients taken at different time points after the trauma incident. For this, sera from 84 patients with polytrauma (collected between 2010 and 2020 in our department) were used. In order to test the differential influence on hBMSC, sera from the 1st (D1), 5th (D5), and 10th day (D10) after polytrauma were pooled, respectively. As a control, sera from three healthy donors (HS), matched with respect to age and gender to the polytrauma group, were collected. Furthermore, hBMSCs from four healthy donors were used in the experiments. The pooled sera of HS, D1, D5, and D10 were analyzed by multicytokine array for pro-/anti-inflammatory cytokines. Furthermore, the influence of the different sera on hBMSCs with respect to cell proliferation, colony forming unit-fibroblast (CFU-F) assay, cell viability, cytotoxicity, cell migration, and osteogenic and chondrogenic differentiation was analyzed. The results showed that D5 serum significantly reduced hBMSC cell proliferation capacity compared with HS and increased the proportion of dead cells compared with D1. However, the frequency of CFU-F was not reduced in polytrauma groups compared with HS, as well as the other parameters. The serological effect of polytrauma on hBMSCs was related to the time after trauma. It is disadvantageous to use BMSCs in polytraumatized patients at least until the fifth day after polytrauma as obvious cytological changes could be found at that time point. However, it is promising to use hBMSCs to treat polytrauma after five days, combined with the concept of "Damage Control Orthopedics" (DCO).
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Affiliation(s)
- Yazhou Long
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany
| | | | - Pascal Gräff
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany
| | | | - Sandra Noack
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany
| | - Claudia Neunaber
- Trauma Department, Hannover Medical School, 30625 Hannover, Germany
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25
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Clinical Features, Management, and Outcomes of Chest Trauma at a Tertiary-Care Centre in India: A Retrospective Observational Study. ScientificWorldJournal 2021; 2021:8052586. [PMID: 34824560 PMCID: PMC8610654 DOI: 10.1155/2021/8052586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/26/2021] [Accepted: 11/05/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Chest is one of the main sites of injuries in trauma being a part of the torso. Many important organs lie in rib cage. However, data on chest injuries are scarce. Methods A retrospective study was carried out for chest trauma patients including polytrauma (n = 184) from hospital records for five years (2016–2020). Various parameters including demographic profile, mode of injury, management, and outcomes were studied. Results Mean age of patients was 37 ± 16 years with a male to female ratio of 2.4 : 1. Road traffic injuries remained the most common cause of trauma followed by assaults. Most of the patients were managed conservatively (55.43%). Mortality was seen in only 1.63% patients. Conclusion Young male patients are usually affected by trauma. Road traffic injuries are the commonest cause. However, most patients can be managed by conservative treatment and mortality is seen only in polytrauma patients in the present study.
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26
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Shanthakumar D, Payne A, Leitch T, Alfa-Wali M. Trauma Care in Low- and Middle-Income Countries. Surg J (N Y) 2021; 7:e281-e285. [PMID: 34703885 PMCID: PMC8536645 DOI: 10.1055/s-0041-1732351] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 05/21/2021] [Indexed: 11/13/2022] Open
Abstract
Background
Trauma-related injury causes higher mortality than a combination of prevalent infectious diseases. Mortality secondary to trauma is higher in low- and middle-income countries (LMICs) than high-income countries. This review outlines common issues, and potential solutions for those issues, identified in trauma care in LMICs that contribute to poorer outcomes.
Methods
A literature search was performed on PubMed and Google Scholar using the search terms “trauma,” “injuries,” and “developing countries.” Articles conducted in a trauma setting in low-income countries (according to the World Bank classification) that discussed problems with management of trauma or consolidated treatment and educational solutions regarding trauma care were included.
Results
Forty-five studies were included. The problem areas broadly identified with trauma care in LMICs were infrastructure, education, and operational measures. We provided some solutions to these areas including algorithm-driven patient management and use of technology that can be adopted in LMICs.
Conclusion
Sustainable methods for the provision of trauma care are essential in LMICs. Improvements in infrastructure and education and training would produce a more robust health care system and likely a reduction in mortality in trauma-related injuries.
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Affiliation(s)
| | - Anna Payne
- Department of Surgery, Royal London Hospital, London, United Kingdom
| | - Trish Leitch
- Department of Surgery, St George's Hospital, London, United Kingdom
| | - Maryam Alfa-Wali
- Department of Surgery, Royal London Hospital, London, United Kingdom
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27
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Are Trauma Surgery Simulation Courses Beneficial in Low- and Middle-Income Countries—A Systematic Review and Meta-Analysis. TRAUMA CARE 2021. [DOI: 10.3390/traumacare1030012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite trauma-related injuries being a leading cause of death worldwide, low- and middle-income countries (LMICs) lack the infrastructure and resources required to offer immediate surgical care, further perpetuating the risk of morbidity and mortality. In high-income countries, trauma surgery simulation courses are routinely delivered to surgeons, teaching the fundamental skills of operative trauma. This study aimed to assess whether similar courses are beneficial in LMICs and how they can be improved. We performed a systematic review and meta-analysis using MEDLINE, Embase and Google Scholar, analysing studies evaluating trauma surgery simulation in LMICs. The outcomes measured included clinical knowledge improvement, participant confidence and general course-feedback. The review was carried out in-line with PRISMA guidelines. Five studies were included, summating a population of 172 participants. In three studies, meta-analysis showed an overall significant weighted mean improvement of knowledge post-course by 22.91% (95%CI 19.53, 26.29; p < 0.00001; I2 = 0%). One study reported a significant increase in participant confidence for 20/22 of operative skills taught (p < 0.04). We conclude that these courses are beneficial in LMICs; however, further research is necessary to establish the optimum course design, and whether patient outcomes are improved following their implementation. Collaboration between international trauma institutions is essential for closing the educational resource inequality gap between higher- and lower-income countries.
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28
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Crawford R, Kruger D, Moeng M. Shock index as a prognosticator for emergent surgical intervention and mortality in trauma patients in Johannesburg: A retrospective cohort study. Ann Med Surg (Lond) 2021; 69:102710. [PMID: 34429962 PMCID: PMC8365323 DOI: 10.1016/j.amsu.2021.102710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/06/2021] [Accepted: 08/07/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Trauma is the leading cause of morbidity and mortality worldwide with exsanguination being the primary preventable cause through early surgical intervention. We assessed two popular trauma scoring systems, injury severity scores (ISS) and shock index (SI) to determine the optimal cut off values that may predict the need for emergent surgical intervention (ESI) and in-hospital mortality. Methods A retrospective analysis of patient records from a tertiary hospital's trauma unit for the year 2019 was done. Descriptive statistics, univariate and multivariate logistic regression analyses were performed. Receiver operator characteristic (ROC) curve analysis was conducted and area under the curve (AUC) reported for predicting the need for ESI in all study participants, as well as in patients with penetrating injuries alone, based on continuous variables of ISS, SI or a combination of ISS and SI. The Youdin Index was applied to determine the optimal ISS and SI cut off values. Results A total of 1964 patients’ records were included, 89.0% were male and the median age (IQR) was 30 (26–37) years. Penetrating injuries accounted for 65.9% of all injuries. ISS and SI were higher in the ESI group with median (IQR) 11 (10–17) and 0.74 (0.60–0.95), respectively. The overall mortality rate was 4.5%. The optimal cut-off values for ESI and mortality by ISS (AUC) were 9 (0.74) and 12 (0.86) (p = 0.0001), with optimal values for SI (AUC) being 0.72 (0.60), and 0.91 (0.68) (p = 0.0001), respectively. Conclusion ISS and SI are significant, independent prognosticators for the need of ESI and in-hospital mortality. The ISS cut-off of 15 for severe trauma may underestimate the severity of trauma within our local South African population. Our study reports an optimal SI cut off value of ≥0.72 for emergency surgical intervention. At an optimal SI cut off of ≥0.91 for in-hospital mortality, the odds of demise were 6.7 times higher. ISS was a stronger predictor than SI of both ESI and in-hospital mortality in our study.
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Affiliation(s)
- Richard Crawford
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Deirdre Kruger
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maeyane Moeng
- Department of Surgery, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Trauma Unit, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
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29
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Khalil DM, Elmorsy E, Arafa A, Nafady HA, Saleh L. Factors affecting prehospital time delay of the injured patients arriving at the Emergency Department of Beni-Suef University Hospital in Egypt: A cross-sectional study. PLoS One 2021; 16:e0252044. [PMID: 34077438 PMCID: PMC8172024 DOI: 10.1371/journal.pone.0252044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 05/08/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE This study aimed to assess the factors affecting the prehospital time delay of the injured patients arriving at the Emergency Department of Beni-Suef University Hospital in Upper Egypt. MATERIALS AND METHODS In this cross-sectional study, the following data were retrieved from the hospital records of 632 injured patients between 1/1/2018 and 31/3/2018: age, sex, residence, means of transportation to the hospital, prehospital time delay, consciousness level on admission, source of injury, and type of worst injury. RESULTS The prehospital time delay (>one hour) of the injured patients was positively associated with age >60 years and rural residence but inversely associated with consciousness level with odds ratios (95% confidence intervals) of 5.14 (2.26-11.68), 3.49 (2.22-5.48), and 0.56 (0.32-0.96), respectively. CONCLUSION The prehospital time delay of the injured patients arriving at the Emergency Department of Beni-Suef University Hospital in Egypt was associated with old age, rural residence, and consciousness level.
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Affiliation(s)
- Doaa Mahmoud Khalil
- Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
- * E-mail:
| | - Elmorsy Elmorsy
- Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Ahmed Arafa
- Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
- Public Health, Department of Social Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hesham Ahmed Nafady
- Department of General Surgery, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
| | - Lamiaa Saleh
- Department of Public Health and Community Medicine, Faculty of Medicine, Beni-Suef University, Beni-Suef, Egypt
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30
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Marqués CG, Moretti K, Amanullah S, Uwamahoro C, Ndebwanimana V, Garbern S, Naganathan S, Martin K, Niyomiza J, Gjesvik A, Nkeshimana M, Levine AC, Aluisio AR. Association between volume resuscitation & mortality among injured patients at a tertiary care hospital in Kigali, Rwanda. Afr J Emerg Med 2021; 11:152-157. [PMID: 33680737 PMCID: PMC7910191 DOI: 10.1016/j.afjem.2020.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/26/2020] [Accepted: 09/21/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Injuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K). METHODS Data were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS From the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids. CONCLUSIONS Injured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.
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Affiliation(s)
- Catalina González Marqués
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
- Department of Epidemiology and Pediatrics Brown University School of Public Health, Providence, USA
| | - Katelyn Moretti
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
- Department of Epidemiology and Pediatrics Brown University School of Public Health, Providence, USA
| | - Siraj Amanullah
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
- Department of Epidemiology and Pediatrics Brown University School of Public Health, Providence, USA
| | - Chantal Uwamahoro
- Department of Anaesthesia, Emergency Medicine and Critical Care, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Accident and Emergency, University Teaching Hospital of Kigali, Rwanda
| | - Vincent Ndebwanimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Accident and Emergency, University Teaching Hospital of Kigali, Rwanda
| | - Stephanie Garbern
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
| | - Sonya Naganathan
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
| | - Kyle Martin
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
| | - Joseph Niyomiza
- Department of Anaesthesia, Emergency Medicine and Critical Care, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Accident and Emergency, University Teaching Hospital of Kigali, Rwanda
| | - Annie Gjesvik
- Department of Epidemiology and Pediatrics Brown University School of Public Health, Providence, USA
| | - Menelas Nkeshimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Accident and Emergency, University Teaching Hospital of Kigali, Rwanda
| | - Adam C. Levine
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
| | - Adam R. Aluisio
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
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Continuous enteral protease inhibition as a novel treatment for experimental trauma/hemorrhagic shock. Eur J Trauma Emerg Surg 2021; 48:1579-1588. [PMID: 33483765 DOI: 10.1007/s00068-020-01591-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/27/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Trauma and hemorrhagic shock (T/HS) is a major cause of morbidity and mortality. Existing treatment options are largely limited to source control and fluid and blood repletion. Previously, we have shown that enteral protease inhibition improves outcomes in experimental models of T/HS by protecting the gut from malperfusion and ischemia. However, enteral protease inhibition was achieved invasively, by laparotomy and direct injection of tranexamic acid (TXA) into the small intestine. In this study, we tested a minimally invasive method of enteral protease inhibitor infusion in experimental T/HS that can be readily adapted for clinical use. METHODS Wistar rats were exsanguinated to a mean arterial blood pressure (MABP) of 40 mmHg, with laparotomy to induce trauma. Hypovolemia was maintained for 120 min and was followed by reperfusion of shed blood. Animals were monitored for an additional 120 min. A modified orogastric multi-lumen tube was developed to enable rapid enteral infusion of a protease inhibitor solution while simultaneously mitigating risk of reflux aspiration into the airways. The catheter was used to deliver TXA (T/HS + TXA) or vehicle (T/HS) continuously into the proximal small intestine, starting 20 min into the ischemic period. RESULTS Rats treated with enteral protease inhibition (T/HS + TXA) displayed improved outcomes compared to control animals (T/HS), including significantly improved MABP (p = 0.022) and lactate (p = 0.044). Mass spectrometry-based analysis of the plasma peptidome after T/HS indicated mitigation of systemic proteolysis in T/HS + TXA. CONCLUSION Minimally invasive, continuous enteral protease inhibitor delivery improves outcomes in T/HS and is readily translatable to the clinical arena.
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Abstract
Traumatic injuries are a leading cause of death and disability in both military and civilian populations. Given the complexity and diversity of traumatic injuries, novel and individualized treatment strategies are required to optimize outcomes. Cellular therapies have potential benefit for the treatment of acute or chronic injuries, and various cell-based pharmaceuticals are currently being tested in preclinical studies or in clinical trials. Cellular therapeutics may have the ability to complement existing therapies, especially in restoring organ function lost due to tissue disruption, prolonged hypoxia or inflammatory damage. In this article we highlight the current status and discuss future directions of cellular therapies for the treatment of traumatic injury. Both published research and ongoing clinical trials are discussed here.
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Relja B, Yang B, Bundkirchen K, Xu B, Köhler K, Neunaber C. Different experimental multiple trauma models induce comparable inflammation and organ injury. Sci Rep 2020; 10:20185. [PMID: 33214576 PMCID: PMC7678855 DOI: 10.1038/s41598-020-76499-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 10/05/2020] [Indexed: 01/04/2023] Open
Abstract
Multiple injuries appear to be a decisive factor for experimental polytrauma. Therefore, our aim was to compare the inflammatory response and organ damage of five different monotrauma with three multiple trauma models. For this, mice were randomly assigned to 10 groups: Healthy control (Ctrl), Sham, hemorrhagic shock (HS), thoracic trauma (TxT), osteotomy with external fixation (Fx), bilateral soft tissue trauma (bsTT) or laparotomy (Lap); polytrauma I (PT I, TxT + HS + Fx), PT II (TxT + HS + Fx + Lap) and one multi-trauma group (MT, TxT + HS + bsTT + Lap). The inflammatory response and organ damage were quantified at 6 h by analyses of IL-6, IL-1β, IL-10, CXCL1, SAA1, HMGB1 and organ injury. Systemic IL-6 increased in all mono and multiple trauma groups, while CXCL1 increased only in HS, PT I, PT II and MT vs. control. Local inflammatory response was most prominent in HS, PT I, PT II and MT in the liver. Infiltration of inflammatory cells into lung and liver was significant in all multiple trauma groups vs. controls. Hepatic and pulmonary injury was prominent in HS, PT I, PT II and MT groups. These experimental multiple trauma models closely mimic the early post-traumatic inflammatory response in human. Though, the choice of read-out parameters is very important for therapeutic immune modulatory approaches.
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Affiliation(s)
- Borna Relja
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany
| | - Bing Yang
- Trauma Department, Hannover Medical School, Hannover, Germany
| | | | - Baolin Xu
- Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany.,Trauma Department, Hannover Medical School, Hannover, Germany.,Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Kernt Köhler
- Institute of Veterinary Pathology, Justus Liebig University, Giessen, Germany
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Empirical transfusion strategies for major hemorrhage in trauma patients: A systematic review. J Trauma Acute Care Surg 2020; 88:855-865. [PMID: 32459450 DOI: 10.1097/ta.0000000000002685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Major hemorrhage is a significant cause of mortality and morbidity around the world. There is currently no consensus on the best empirical transfusion strategy. The current National Institute for Clinical Excellence (NICE) guidelines suggest a ratio of 1:1 of red blood cells and plasma. The aim of this study is to compare this to alternative strategies identified through review of the available literature with the objective of identifying the best protocol for mortality outcomes and complication rates. METHODS A systematic review of the literature was conducted using four databases. Inclusion and exclusion criteria were applied to produce a suitable list of randomized control trials for review. Critical appraisal of each article was then performed, using a Scottish Intercollegiate Guidelines Network-approved checklist, in duplicate and was subject to further independent scrutiny when required. RESULTS Evidence suggests that early administration of cryoprecipitate within the standard practiced major hemorrhage protocol is associated with a lower risk of mortality. Other strategies suggested a negative impact. Complications including incidence of thromboembolic events, multiple organ failure and sepsis as well as length of stay in hospital following activation of the different protocols and overall transfusion requirements were assessed. No clear optimal protocol was identified from our analysis. CONCLUSION This project demonstrates that there is no significant clarity regarding morbidity and mortality. As a preliminary recommendation, cryoprecipitate supplementation suggests more favorable mortality over the current protocol. Due to the limited sample populations, we recommend the inclusion of retrospective/prospective cohort studies to bolster the statistical power of any future reviews until randomized control trials of sufficient power are available. LEVEL OF EVIDENCE Systematic review, Level III.
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Gerbase FE, Tegner M, Krutzmann ME, Muller VV, Alff JDA, da Silva VB, Sagrilo OP, Linden R, Antunes MV. Blood phosphatidyl ethanol levels as a tool to detect alcohol misuse in trauma patients. Clin Toxicol (Phila) 2020; 59:418-425. [PMID: 33021410 DOI: 10.1080/15563650.2020.1822531] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION There is a strong need for a reliable marker of harmful alcohol consumption to identify injured patients that can benefit from alcohol interventions, and blood phosphatidyl ethanol (PEth) has not previously been tested on this population. This study aims to compare the performance of blood PEth concentration, blood alcohol concentration (BAC) and the Alcohol Use Disorders Identification Test Consumption (AUDIT-C) for the screening of alcohol misuse in trauma patients. METHODS Prospective cross-sectional study of 238 adult patients presenting in the emergency department with any type of trauma. PEth concentration was determined in whole blood by high-performance liquid chromatography with tandem mass spectrometry. Consent, AUDIT-C score and demographic data were obtained. RESULTS The sample consisted of majority male (67.6%), single (46.2%) and employed (66%) patients. The most common type of trauma was traffic collision (63.9%). The mean age was 41.7 years. We found a significant correlation between PEth levels with AUDIT-C score (Spearman's r = 0.654; p < .0001). PEth had an area under the ROC curve of 0.885 to detect hazardous alcohol consumption (AUDIT-C score ≥ 6) and PEth ≥23.9 ng/mL cutoff point provided 91.2% of sensitivity and 78.4% of specificity. Twelve patients reported alcohol abstinence, but had quantifiable levels of PEth. CONCLUSIONS PEth levels and AUDIT-C score had a moderate correlation in our population. PEth was useful to identify 12 cases of underreporting of alcohol consumption habits. PEth shows promising results, but more research is needed to identify the best screening tool for alcohol misuse in trauma patients.
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Affiliation(s)
- Fernando Engel Gerbase
- Postgraduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Novo Hamburgo, Brazil.,Laboratory of Analytical Toxicology, Institute of Health Sciences, Universidade Feevale, Novo Hamburgo, Brazil.,Emergency Department, Novo Hamburgo Municipal Hospital, Novo Hamburgo, Brazil
| | - Mariane Tegner
- Laboratory of Analytical Toxicology, Institute of Health Sciences, Universidade Feevale, Novo Hamburgo, Brazil
| | - Maria Eduarda Krutzmann
- Laboratory of Analytical Toxicology, Institute of Health Sciences, Universidade Feevale, Novo Hamburgo, Brazil
| | - Victória Vendramini Muller
- Laboratory of Analytical Toxicology, Institute of Health Sciences, Universidade Feevale, Novo Hamburgo, Brazil
| | - Jonatan de Andrade Alff
- Laboratory of Analytical Toxicology, Institute of Health Sciences, Universidade Feevale, Novo Hamburgo, Brazil
| | - Vanessa Becher da Silva
- Laboratory of Analytical Toxicology, Institute of Health Sciences, Universidade Feevale, Novo Hamburgo, Brazil
| | | | - Rafael Linden
- Postgraduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Novo Hamburgo, Brazil.,Laboratory of Analytical Toxicology, Institute of Health Sciences, Universidade Feevale, Novo Hamburgo, Brazil
| | - Marina Venzon Antunes
- Postgraduate Program on Toxicology and Analytical Toxicology, Universidade Feevale, Novo Hamburgo, Brazil.,Laboratory of Analytical Toxicology, Institute of Health Sciences, Universidade Feevale, Novo Hamburgo, Brazil
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Developing a Lay First Responder Program in Chad: A 12-Month Follow-Up Evaluation of a Rural Prehospital Emergency Care Program. Prehosp Disaster Med 2020; 35:546-553. [PMID: 32723421 DOI: 10.1017/s1049023x20000977] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The World Health Organization (WHO; Geneva, Switzerland) recommends lay first responder (LFR) programs as a first step toward establishing formal Emergency Medical Services (EMS) in low- and middle-income countries (LMICs) to address injury. There is a scarcity of research investigating LFR program development in predominantly rural settings of LMICs. STUDY OBJECTIVE A pilot LFR program was launched and assessed over 12 months to investigate the feasibility of leveraging pre-existing transportation providers to scale up prehospital emergency care in rural, low-resource settings of LMICs. METHODS An LFR program was established in rural Chad to evaluate curriculum efficacy, using a validated 15-question pre-/post-test to measure participant knowledge improvement. Pre-/post-test score distributions were compared using a Wilcoxon Signed-Rank test. For test evaluation, each pre-test question was mapped to its corresponding post-test analog and compared using McNemar's Chi-Squared Test to examine knowledge acquisition on a by-question basis. Longitudinal prehospital care was evaluated with incident reports, while program cost was tracked using a one-way sensitivity analysis. Qualitative follow-up surveys and semi-interviews were conducted at 12 months, with initial participants and randomly sampled motorcycle taxi drivers, and used a constructivist grounded theory approach to understand the factors motivating continued voluntary participation to inform future program continuity. The consolidated criteria for reporting qualitative research (COREQ) checklist was used to guide design, analysis, and reporting the qualitative results. RESULTS A total of 108 motorcycle taxi participants demonstrated significant knowledge improvement (P <.001) across three of four curricular categories: scene safety, airway and breathing, and bleeding control. Lay first responders treated 71 patients over six months, encountering five deaths, and provided patient transport in 82% of encounters. Lay first responders reported an average confidence score of 8.53/10 (n = 38). In qualitative follow-up surveys and semi-structured interviews, the ability to care for the injured, new knowledge/skills, and the resultant gain in social status and customer acquisition motivated continued involvement as LFRs. Ninety-six percent of untrained, randomly sampled motorcycle taxi drivers reported they would be willing to pay to participate in future training courses. CONCLUSION Lay first responder programs appear feasible and cost-effective in rural LMIC settings. Participants demonstrate significant knowledge acquisition, and after 12 months of providing emergency care, report sustained voluntary participation due to social and financial benefits, suggesting sustainability and scalability of LFR programs in low-resource settings.
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Ribeiro MAF, DE-Campos T, Lima DS, Marttos-Jr AC, Pereira BM. The trauma and acute care surgeon in the COVID-19 pandemic era. Rev Col Bras Cir 2020; 47:e20202576. [PMID: 32428069 DOI: 10.1590/0100-6991e-20202576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 11/22/2022] Open
Abstract
The World Health Organization recognized in March 2020 the existence of a pandemic for the new coronavirus that appeared in China, in late 2019, and whose disease was named COVID-19. In this context, the SBAIT (Brazilian Society of Integrated Care for Traumatized Patients) conducted a survey with 219 trauma and emergency surgeons regarding the availability of personal protective equipment (PPE) and the role of the surgeon in this pandemic by means of an electronic survey. It was observed that surgeons have been acting under inadequate conditions, with a lack of basic supplies as well as more specific equipment such as N95 masks and facial shields for the care of potential victims who may be contaminated. The latter increases the risk of contamination of professionals, resulting in potential losses in the working teams. Immediate measures must be taken to guarantee access to safety equipment throughout the country, since all trauma victims and/or patients with emergency surgical conditions must be treated as potential carriers of COVID-19.
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Affiliation(s)
| | - Tercio DE-Campos
- Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil
| | | | - Antonio C Marttos-Jr
- Ryder Trauma Center, Acute Care & Trauma Surgery, University of Miami, Miami, FL, USA
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38
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Full Steam Ahead. J Trauma Nurs 2020; 27:1-2. [DOI: 10.1097/jtn.0000000000000476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kashani P, Saberinia A. Management of multiple traumas in emergency medicine department: A review. J Family Med Prim Care 2019; 8:3789-3797. [PMID: 31879615 PMCID: PMC6924209 DOI: 10.4103/jfmpc.jfmpc_774_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/16/2019] [Accepted: 10/09/2019] [Indexed: 11/04/2022] Open
Abstract
One of the main causes of adults' disability during their working age is multiple trauma. The process of medical care of patients who are injured seriously is still a challenging job. The primary treatment of these patients in the emergency medicine departments is the most required choice after the wilderness first aid and also would be very required before definitive care in the hospital. The main aim of emergency medicine departments is quick recognition and treatment of injuries which pose severe threat to patients' life in appropriate order of priority. The procedure of primary evaluation in emergency medicine department with the help of medical routine examination and ultrasonography is based on the concept of focused assessment with sonography in trauma (FAST) for identifying spontaneous intraperitoneal hemorrhage. Emergency patients who suffer from massive hematothorax, serious lung and heart traumas, and penetrating traumas to the chest would undergo thoracotomy and patients who have few symptoms of perforated hollow viscous will undergo emergency laparotomy. Based on the trauma severity, emergency treatment could be the way to fast recovery of the structure of injured organ and its function. The subsequent goal, in the acute phase, will concentrate on preventing and stopping bleeding and secondary injuries like painful compartment syndrome or intra-abdominal infections (IAIs). However, the main aim of emergency medicine department in taking care of severely injured patients is the management of airway, protecting circulation and breathing, identification of neurologic problems, and whole body clinical examination with the help of healthcare providers.
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Affiliation(s)
- Parvin Kashani
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Loghman Hakim Hospital, Tehran, Iran
| | - Amin Saberinia
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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40
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Mörs K, Wagner N, Sturm R, Störmann P, Vollrath JT, Marzi I, Relja B. Enhanced pro-inflammatory response and higher mortality rates in geriatric trauma patients. Eur J Trauma Emerg Surg 2019; 47:1065-1072. [PMID: 31875239 DOI: 10.1007/s00068-019-01284-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 12/05/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Age has been associated with increased morbidity and mortality after traumatic injury. Disregarding trauma-related factors, this may be caused by the diminished ability to cope with stressors due to limited reserve, the so-called frailty. Inflammation is assumed to promote frailty, and thus, pro-inflammatory markers may constitute as being predictive factors in geriatric trauma patients (TP). Here, we analyzed the influence of age on systemic inflammatory markers and outcome parameters in TP. PATIENTS AND METHODS 204 TP with injury severity score (ISS) ≥ 16 were included and grouped to younger vs. geriatric, defining an age of 65 as cut-off. ISS, vital signs, physiological parameters, stay at the intensive-care unit (ICU) or in-hospital, and outcome parameters were analyzed. Systemic fibrinogen, interleukin (IL)-6, and IL-10 levels were determined upon admission. A p value < 0.05 was considered statistically significant. RESULTS 43 geriatric and 161 younger TP were included. ISS (24.19 ± 9.59 vs. 26.93 ± 9.68) was comparable between both groups. Abbreviated Injury Scale (AIS) ≥ 3 of head trauma was more prevalent in geriatric TP (74.42 vs. 64.59%). In both groups, there were significantly more male than female patients; however, this disparity was significantly more distinct in younger TP. Geriatric group showed significantly lower shock indices, higher fibrinogen, and lower IL-10 levels (all p < 0.05). A significant spearman´s rank correlation with age was found for fibrinogen (positive correlation, r = 0.364, p < 0.05), and for IL-10 (negative correlation, r = - 0.168, p < 0.05). In-hospital mortality was significantly increased in geriatric TP. CONCLUSIONS An enhanced inflammatory response is associated with higher mortality rates in geriatric trauma patients.
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Affiliation(s)
- Katharina Mörs
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, 60590, Frankfurt, Germany.
| | - Nils Wagner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, 60590, Frankfurt, Germany
| | - Ramona Sturm
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, 60590, Frankfurt, Germany
| | - Philipp Störmann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, 60590, Frankfurt, Germany
| | - Jan Tilmann Vollrath
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, 60590, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, 60590, Frankfurt, Germany
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, 60590, Frankfurt, Germany.,Experimental Radiology, Department of Radiology and Nuclear Medicine, Otto Von Guericke University Magdeburg, 39120, Magdeburg, Germany
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Duran Y, Karaboğa İ. Effect of hesperetin on systemic inflammation and hepatic injury after blunt chest trauma in rats. Biotech Histochem 2019; 95:297-304. [PMID: 31850807 DOI: 10.1080/10520295.2019.1691265] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
We investigated the protective effect of hesperetin on hepatic damage after blunt chest trauma in rats using histological and biochemical methods. We used 18 adult male rats in three groups of six: control, chest trauma and chest trauma + hesperetin. Chest trauma was caused by dropping a metal cylinder onto the right hemithorax. Hesperetin, 100 mg/kg, was administered orally for 7 days. At the end of the seventh day, liver tissue samples were obtained. Serum tumor necrosis factor-alpha (TNF-α), interleukin 1-beta (IL-1β), alanine aminotransferase (AST), aspartate transferase (ALT) and lactate dehydrogenase (LDH) enzyme activities were measured in blood samples taken from the heart. The general structure of liver tissue was investigated using hematoxylin and eosin staining. Nuclear factor kappa beta (Nf-κβ) expression in liver tissue was determined by the indirect immunohistochemical method. Apoptosis was determined using the terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) method. Decreased TNF-α, AST and ALT enzyme activity, fewer histopathological changes and lower Nf-kB expression were observed in the hesperetin treated group compared to the chest trauma group. We also found reduced hepatic apoptosis in the chest trauma + hesperetin group compared to the chest trauma group. Hesperetine inhibits liver damage by reducing proinflammatory cytokines and by suppressing Nf-κβ activity in a blunt chest trauma model in rats.
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Affiliation(s)
- Yasin Duran
- Tekirdag Namık Kemal University, Faculty of Medicine, Department of General Surgery, 59030, Tekirdag, Turkey
| | - İhsan Karaboğa
- Tekirdag Namık Kemal University, School of Health, Department of Emergency and Disaster Management, 59030, Tekirdag, Turkey
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Janicova A, Becker N, Xu B, Wutzler S, Vollrath JT, Hildebrand F, Ehnert S, Marzi I, Störmann P, Relja B. Endogenous Uteroglobin as Intrinsic Anti-inflammatory Signal Modulates Monocyte and Macrophage Subsets Distribution Upon Sepsis Induced Lung Injury. Front Immunol 2019; 10:2276. [PMID: 31632392 PMCID: PMC6779999 DOI: 10.3389/fimmu.2019.02276] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/09/2019] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a serious clinical condition which can cause life-threatening organ dysfunction, and has limited therapeutic options. The paradigm of limiting excessive inflammation and promoting anti-inflammatory responses is a simplified concept. Yet, the absence of intrinsic anti-inflammatory signaling at the early stage of an infection can lead to an exaggerated activation of immune cells, including monocytes and macrophages. There is emerging evidence that endogenous molecules control those mechanisms. Here we aimed to identify and describe the dynamic changes in monocyte and macrophage subsets and lung damage in CL57BL/6N mice undergoing blunt chest trauma with subsequent cecal ligation and puncture. We showed that early an increase in systemic and activated Ly6C+CD11b+CD45+Ly6G- monocytes was paralleled by their increased emigration into lungs. The ratio of pro-inflammatory Ly6ChighCD11b+CD45+Ly6G- to patrolling Ly6ClowCD11b+CD45+Ly6G- monocytes significantly increased in blood, lungs and bronchoalveolar lavage fluid (BALF) suggesting an early transition to inflammatory phenotypes during early sepsis development. Similar to monocytes, the level of pro-inflammatory Ly6ChighCD45+F4/80+ macrophages increased in lungs and BALF, while tissue repairing Ly6ClowCD45+F4/80+ macrophages declined in BALF. Levels of inflammatory mediators TNF-α and MCP-1 in blood and RAGE in lungs and BALF were elevated, and besides their boosting of inflammation via the recruitment of cells, they may promote monocyte and macrophage polarization, respectively, toward the pro-inflammatory phenotype. Neutralization of uteroglobin increased pro-inflammatory cytokine levels, activation of inflammatory phenotypes and their recruitment to lungs; concurrent with increased pulmonary damage in septic mice. In in vitro experiments, the influence of uteroglobin on monocyte functions including migratory behavior, TGF-β1 expression, cytotoxicity and viability were proven. These results highlight an important role of endogenous uteroglobin as intrinsic anti-inflammatory signal upon sepsis-induced early lung injury, which modules the early monocyte/macrophages driven inflammation. Short Summary Blunt chest injury is the third largest cause of death following major trauma, and ongoing excessive pro-inflammatory immune response entails high risk for the development of secondary complications, such as sepsis, with limited therapeutic options. In murine double hit trauma consisting of thoracic trauma and subsequent cecal ligation and puncture, we investigated the cytokine profile, pulmonary epithelial integrity and phenotypic shift of patrolling Ly6ClowCD11b+CD45+Ly6G- monocytes and Ly6ClowCD45+F4/80+ macrophages to pro-inflammatory Ly6ChighCD11b+CD45+Ly6G- monocytes and Ly6ChighCD45+F4/80+ cells in blood, lungs and bronchoalveolar lavage fluid (BALF). Pro-inflammatory mediators and phenotypes were elevated and uteroglobin neutralization led to further increase. Enhanced total protein levels in BALF suggests leakage of respiratory epithelium. In vitro, uteroglobin inhibited the migratory capacity of monocytes and the TGF-β1 expression without affecting the viability. These results highlight an important role of endogenous uteroglobin as an intrinsic anti-inflammatory signal upon sepsis-induced early lung injury, which modulates the early monocyte/macrophages driven inflammation.
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Affiliation(s)
- Andrea Janicova
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany.,Department of Aquatic Ecotoxicology, Goethe University, Frankfurt, Germany.,Department of Radiology and Nuclear Medicine, Experimental Radiology, Otto-von-Guericke University, Magdeburg, Germany
| | - Nils Becker
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany
| | - Baolin Xu
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany
| | - Sebastian Wutzler
- Orthopedic and Trauma Surgery, Helios Horst Schmidt Clinic, Wiesbaden, Germany
| | - Jan Tilmann Vollrath
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany
| | | | - Sabrina Ehnert
- Department of Trauma and Reconstructive Surgery, Siegfried Weller Research Institute, BG Trauma Center Tuebingen, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany
| | - Philipp Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University, Frankfurt, Germany
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Vervoort D, Meuris B, Meyns B, Verbrugghe P. Global cardiac surgery: Access to cardiac surgical care around the world. J Thorac Cardiovasc Surg 2019; 159:987-996.e6. [PMID: 31128897 DOI: 10.1016/j.jtcvs.2019.04.039] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 04/02/2019] [Accepted: 04/10/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Cardiovascular disease is the leading cause of death worldwide, responsible for 17.5 million deaths every year, of which 80% occur in low- and middle-income countries. Some 75% of the world does not have access to cardiac surgery when needed because of lack of infrastructure, human resources, and financial coverage. This study aims to map access to cardiac surgery around the world. METHODS A scoping review was done on access to cardiac surgery for an undifferentiated population. Workforce data were collected from the Cardiothoracic Surgery Network database and used to calculate numbers and ratios of adult and pediatric cardiac surgeons to population. RESULTS A total of 12,180 adult cardiac surgeons and 3858 pediatric cardiac surgeons were listed in the Cardiothoracic Surgery Network in August 2017, equaling 1.64 (0-181.82) adult cardiac surgeons and 0.52 (0-25.97) pediatric cardiac surgeons per million population globally. Large disparities existed between regions, ranging from 0.12 adult cardiac surgeons and 0.08 pediatric cardiac surgeons per million population (sub-Saharan Africa) to 11.12 adult cardiac surgeons and 2.08 pediatric cardiac surgeons (North America). Low-income countries possessed 0.04 adult cardiac surgeons and 0.03 pediatric cardiac surgeons per million population, compared with 7.15 adult cardiac surgeons and 1.67 pediatric cardiac surgeons in high-income countries. CONCLUSIONS This study maps the current global state of access to cardiac surgery. Disparities exist between and within world regions, with a positive correlation between a nation's economic status and access to cardiac surgery. Low early mortality rates in low-resource settings suggest the possibility of high-quality cardiac surgery in low- and middle-income countries. There is the need to increase human and physical resources, while focusing on safety, quality, and efficiency to improve access to cardiac surgery for the 4.5 billion people without.
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Affiliation(s)
- Dominique Vervoort
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Mass.
| | - Bart Meuris
- Department of Cardiac Surgery, UZ Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, UZ Leuven, Leuven, Belgium
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Johnston PF, Padmanaban V, Jalloh S, Balarezo LL, Valenzuela R, Tran A, Sule H, Sifri ZC. Integrating Bleeding Control Training Into Surgical Missions in Low- and Middle-Income Countries. J Surg Res 2019; 241:53-56. [PMID: 31004873 DOI: 10.1016/j.jss.2019.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/04/2019] [Accepted: 03/20/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Basic bleeding control (BCon) techniques can save lives globally but the knowledge is not widespread in low-income countries where trauma is a common cause of death. Short-term surgical missions (STSMs) are an effective route to share this public health initiative around the world. MATERIALS AND METHODS Over 2017-2018, the International Surgical Health Initiative organized STSMs to locations in Sierra Leone, Bangladesh, Peru, and Ghana. The hour-long official American College of Surgeons Basic Bleeding Control course was offered to host participants several times over the course of the mission. Data including number and size of classes, type of trainee, instructors trained, and success rate in demonstrating acquisition of core BCon principles and techniques were collected. RESULTS Over the course of four, week-long STSMs, 748 people were successfully trained in BCon over 27 sessions, with an average of 28 trainees and up to four instructors per class. One-hundred percent of trainees demonstrated acquisition of required skills proficiency. Trainees included health care workers and those in public security roles. CONCLUSIONS Concurrent with a short-term surgical mission, a substantial number of health care providers and would-be bystanders can be trained in BCon in countries most impacted by trauma. Local instructors can be trained to teach BCon independently to sustain the initiative. STSMs are a feasible modality to teach bleeding control techniques to an international audience that does not have rapid access to effective prehospital care.
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Affiliation(s)
- Peter F Johnston
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Vennila Padmanaban
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.
| | - Samba Jalloh
- College of Medicine and Allied Health Sciences, Freetown, Sierra Leone
| | | | - Rolando Valenzuela
- Department of Emergency Medicine, Stony Brook University Medical Center, Stony Brook, New York
| | - Ashley Tran
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Harsh Sule
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Ziad C Sifri
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
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Traumatic injury pattern is of equal relevance as injury severity for experimental (poly)trauma modeling. Sci Rep 2019; 9:5706. [PMID: 30952899 PMCID: PMC6450898 DOI: 10.1038/s41598-019-42085-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 03/21/2019] [Indexed: 01/02/2023] Open
Abstract
This study aims to elaborate the relevance of trauma severity and traumatic injury pattern in different multiple and/or polytrauma models by comparing five singular trauma to two different polytrauma (PT) models with high and one multiple trauma (MT) model with low injury-severity score (ISS). The aim is to provide a baseline for reducing animal harm according to 3Rs by providing less injury as possible in polytrauma modeling. Mice were randomly assigned to 10 groups: controls (Ctrl; n = 15), Sham (n = 15); monotrauma groups: hemorrhagic shock (HS; n = 15), thoracic trauma (TxT; n = 18), osteotomy with external fixation (Fx; n = 16), bilateral soft tissue trauma (bSTT; n = 16) or laparotomy (Lap; n = 16); two PT groups: PT I (TxT + HS + Fx; ISS = 18; n = 18), PT II (TxT + HS + Fx + Lap; ISS = 22; n = 18), and a MT group (TxT + HS + bSTT + Lap, ISS = 13; n = 18). Activity and mortality were assessed. Blood gas analyses and organ damage markers were determined after 6 h. Significant mortality occurred in TxT, PT and MT (11.7%). Activity decreased significantly in TxT, HS, both polytrauma and MT vs. Ctrl/Sham. PT-groups and MT had significantly decreased activity vs. bsTT, Lap or Fx. MT had significantly lower pCO2vs. Ctrl/Sham, Lap or bsTT. Transaminases increased significantly in PT-groups and MT vs. Ctrl, Sham or monotrauma. Traumatic injury pattern is of comparable relevance as injury severity for experimental multiple or (poly)trauma modeling.
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Eguchi A, Franz N, Kobayashi Y, Iwasa M, Wagner N, Hildebrand F, Takei Y, Marzi I, Relja B. Circulating Extracellular Vesicles and Their miR "Barcode" Differentiate Alcohol Drinkers With Liver Injury and Those Without Liver Injury in Severe Trauma Patients. Front Med (Lausanne) 2019; 6:30. [PMID: 30859103 PMCID: PMC6397866 DOI: 10.3389/fmed.2019.00030] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 02/01/2019] [Indexed: 12/16/2022] Open
Abstract
Short Summary: Extracellular vesicles (EVs), released during tissue/cell injury, contain a “barcode” indicating specific microRNAs (miRs) that can uncover their origin. We examined whether systemic EVs possessing hepatic miR-signatures would indicate ongoing liver injury and clinical complications in trauma patients (TP). We grouped the patients of alcoholic drinkers into “alcohol-drinkers with liver injury (LI)” (EtOH with LI) or “alcohol-drinkers without LI” (EtOH w/o LI) and we compared these groups to “non-drinkers” (no EtOH). When we examined patient blood from the EtOH with LI group we found the total number of EVs to be increased, along with an increase in miR-122 and let7f—two EV-associated miRNAs—and several inflammation-associating cytokines, such as interleukin (IL)-6 and IL-33. In contrast, all of the aforementioned readouts were found to be decreased in the EtOH w/o LI group. These novel data demonstrate that hepatocyte damage in alcohol-intoxicated trauma patients presenting with liver injury can be reflected by an increase in circulating serum EVs, their specific miR-“barcode” and the concomitant increase of systemic inflammatory markers IL-6 and IL-33. Anti-inflammatory effect of alcohol-drinking in EtOH w/o LI can be presented by a reduced number of hepato-derived EVs, no upregulation of IL-6 and IL-33, and a miR “barcode” different from patients presenting with liver injury. Background: Alcohol abuse is associated with (neuro)protective effects related to (head) injuries, and with negative effects regarding infection rates and survival in severely injured trauma patients (TP). Extracellular vesicles (EVs), which are released during tissue and/or cell injury, can contain a “barcode” including specific microRNAs (miRs) that uncover their origin. We examined whether EVs with a hepatic miR signature can be systemically measured, and whether they can indicate ongoing liver injury in alcohol-intoxicated TP and foretell clinical complications. Patients/Methods: We enrolled 35 TP and measured blood EVs, IL-6, TNF-alpha, IL-1beta, IL-10 and IL-33, alcohol (ethanol, EtOH) concentration (BAC), GLDH, GGT, AST, ALT, leukocytes, platelets, and bilirubin. Within circulating EVs we measured the expression levels of miR-122, let7f, miR21, miR29a, miR-155, and miR-146a. Patients of alcohol-drinkers were grouped into “alcohol drinkers with liver injury (LI)” (EtOH with LI) or “alcohol drinkers without LI” (EtOH w/o LI) and compared to “non-drinkers” (no EtOH). We assessed systemic injury characteristics and the outcome of hospitalization with regard to sepsis, septic shock, pneumonia, or mortality. Results: EtOH with LI patients had significantly increased rates of pneumonia vs. the EtOH w/o LI group. EVs, IL-6, and IL-33 levels were significantly increased in EtOH with LI vs. EtOH w/o LI group (p < 0.05). EV number correlated positively with ALT and IL-6 (p < 0.0001). Two miRs, miR-122 and let7f, were increased only in the blood EVs from the EtOH with LI group (p < 0.05). Five miRs, miR-122, let7f, miR-21, miR-29a, and miR-146a, were reduced in the blood EVs from the EtOH w/o LI group, vs. no EtOH (p < 0.05). Notably miR-122 correlated significantly with increased bilirubin levels in the EtOH with LI group (p < 0.05). Conclusions: Liver injury in alcohol-intoxicated TP is reflected by increased EV numbers, their specific miR barcode, and the correlated increase of systemic inflammatory markers IL-6 and IL-33. Interestingly, severely injured TP without liver injury were found to have a reduced number of liver-derived EVs, no observed inflammatory infiltration and reduced specific miR “barcode.”
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Affiliation(s)
- Akiko Eguchi
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan.,JST, PRESTO, Saitama, Japan
| | - Niklas Franz
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Yoshinao Kobayashi
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Motoh Iwasa
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Nils Wagner
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Yoshiyuki Takei
- Department of Gastroenterology and Hepatology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
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Franz N, Dieteren S, Köhler K, Mörs K, Sturm R, Marzi I, Perl M, Relja B, Wagner N. Alcohol Binge Reduces Systemic Leukocyte Activation and Pulmonary PMN Infiltration After Blunt Chest Trauma and Hemorrhagic Shock. Inflammation 2018; 42:690-701. [DOI: 10.1007/s10753-018-0927-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Lay First Responder Training in Eastern Uganda: Leveraging Transportation Infrastructure to Build an Effective Prehospital Emergency Care Training Program. World J Surg 2018; 42:2293-2302. [PMID: 29349487 DOI: 10.1007/s00268-018-4467-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Though road traffic injuries (RTIs) are a major cause of mortality in East Africa, few countries have emergency medical services. The aim was to create a sustainable and efficient prehospital lay first responder program, creating a system with lay first responders spread through the 53 motorcycle taxi stages of Iganga Municipality. METHODS One hundred and fifty-four motorcycle taxi riders were taught a first aid curriculum in partnership with a local Red Cross first aid trainer and provided with a first aid kit following WHO guidelines for basic first aid. Pre- and post-survey tests measured first aid knowledge improvement over the course. Post-implementation incident report forms were collected from lay first responders after each patient encounter over 6 months. Follow-up interviews were conducted with 110 of 154 trainees, 9 months post-training. RESULTS Improvement was measured across all five major first aid categories: bleeding control (56.9 vs. 79.7%), scene management (37.6 vs. 59.5%), airway and breathing (43.4 vs. 51.6%), recovery position (13.1 vs. 43.4%), and victim transport (88.2 vs. 94.3%). From the incident report findings, first responders treated 250 victims (82.8% RTI related) and encountered 24 deaths (9.6% of victims). Of the first aid skills, bleeding control and bandaging was used most often (55.2% of encounters). Lay first responders provided transport in 48.3% of encounters. Of 110 lay first responders surveyed, 70 of 76 who had used at least one skill felt "confident" in the care they provided. CONCLUSION A prehospital care system composed of lay first responders can be developed leveraging existing transport organizations, offering a scalable alternative for LMICs, demonstrating usefulness in practice and measurable educational improvements in trauma skills for non-clinical lay responders.
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The Economic and Social Burden of Traumatic Injuries: Evidence from a Trauma Hospital in Port-au-Prince, Haiti. World J Surg 2018; 42:1639-1646. [PMID: 29164295 DOI: 10.1007/s00268-017-4360-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The cost of traumatic injury is unknown in Haiti. This study aims to examine the burden of traumatic injury of patients treated and evaluated at a trauma hospital in the capital city of Port-au-Prince. METHODS A retrospective cross-sectional chart review study was conducted at the Hospital Bernard Mevs Project Medishare for all patients evaluated for traumatic injury from December 2015 to January 2016, as described elsewhere (Zuraik and Sampalis in World J Surg, https://doi.org/10.1007/s00268-017-4088-2 , 2017). Direct medical costs were obtained from patient hospital bills. Indirect and intangible costs were calculated using the human capital approach. RESULTS A total of 410 patients were evaluated for traumatic injury during the study period. Total costs for all patients were $501,706 with a mean cost of $1224. Indirect costs represented 63% of all costs, direct medical costs 19%, and intangible costs 18%. Surgical costs accounted for the majority of direct medical costs (29%). Patients involved in road traffic accidents accounted for the largest number of injuries (41%) and the largest percentage of total costs (51%). Patients with gunshot wounds had the highest total mean costs ($1566). Mean costs by injury severity ranged from $62 for minor injuries, $1269 for serious injuries, to $13,675 for critical injuries. CONCLUSION Injuries lead to a significant economic burden for individuals treated at a semi-private trauma hospital in the capital city of Port-au-Prince, Haiti. Programs aimed at reducing injuries, particularly road traffic accidents, would likely reduce the economic burden to the nation.
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Bashford T, Myint PPN, Win S, Thu M, Naing MM, Burnstein R, Hlaing TT, Brealey E, Hutchinson PJ, Clarkson J. A systems approach to trauma care in Myanmar: from health partnership to academic collaboration. Future Healthc J 2018; 5:171-175. [PMID: 31098561 PMCID: PMC6502594 DOI: 10.7861/futurehosp.5-3-171] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Experience from a variety of disciplines suggests that improving healthcare, particularly in resource-poor environments, can benefit from a systems approach. However, putting this into practice is challenging, especially in the context of an international institutional health partnership. In this article, we outline how a systems approach to the improvement of trauma care has informed both clinical improvement and academic collaboration as part of an ongoing partnership involving Cambridge University Hospitals NHS Foundation Trust, the University of Cambridge, and Cambridge Global Health Partnerships in the UK, and Yangon General Hospital, University of Medicine 1, and the Tropical Health and Education Trust (THET) in Myanmar. Improving and researching trauma care is an exemplar of a systems problem, requiring an understanding of the relevant people, equipment, processes, institutions, and power structures that result in the delivery of care at all points of the patient's journey from injury to rehabilitation. Exploring this in the explicit context of traumatic brain injury is one of the research themes of the NIHR Global Health Research Group on Neurotrauma, allowing systems research to directly inform efforts at practical improvement.
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Affiliation(s)
- Tom Bashford
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, UK
| | - Phyu Phyu Nwe Myint
- NIHR Global Health Research Group on Neurotrauma, University of Medicine 1, Myanmar
| | - Sein Win
- NIHR Global Health Research Group on Neurotrauma, University of Medicine 1, Myanmar
| | - Myat Thu
- NIHR Global Health Research Group on Neurotrauma, University of Medicine 1, Myanmar
| | - Mu Mu Naing
- NIHR Global Health Research Group on Neurotrauma, University of Medicine 1, Myanmar
| | - Rowan Burnstein
- Cambridge-Yangon Trauma Intervention Partnership, Cambridge University Hospitals NHS Trust, UK
| | | | - Evelyn Brealey
- Cambridge Global Health Partnerships, Cambridge University Hospitals NHS Trust, UK
| | - Peter J Hutchinson
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, UK
| | - John Clarkson
- Engineering Design Centre, University of Cambridge, UK
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