ORCID Profile
0000-0001-8023-1957
Current Organisations
University of St Andrews
,
Australian National University
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Publisher: Elsevier BV
Date: 07-2010
Publisher: MDPI AG
Date: 03-11-2021
Abstract: Monoclonal antibodies including trastuzumab, pertuzumab, and antibody-drug conjugates, form the backbone of HER2-positive breast cancer therapy. Unfortunately, an important adverse effect of these agents is cardiotoxicity, occurring in approximately 10% of patients. There is increasing published data regarding prevention strategies for cardiotoxicity, though seldom used in clinical practice. We performed a systematic review and meta-analysis of randomized-controlled trials to evaluate pharmacotherapy for the prevention of monoclonal HER2-directed antibody-induced cardiotoxicity in patients with breast cancer. Online databases were queried from their inception until October 2021. Effects were determined by calculating risk ratios (RRs) and 95% confidence intervals (CI) or mean differences (MD) using random-effects models. We identified five eligible trials. In the three trials (n = 952) reporting data on the primary outcome of cardiotoxicity, there was no clear effect for patients assigned active treatment compared to control (RR = 0.90, 95% CI 0.63 to 1.29, p = 0.57). Effects were similar for ACE-I/ARB and beta-blockers (p homogeneity = 0.50). Active treatment reduced the risk of HER2 therapy interruptions (RR = 0.57, 95% CI 0.43 to 0.77, p 0.001) with similar findings for ACE-I/ARB and beta-blockers (p homogeneity = 0.97). Prophylactic treatment with ACE-I/ARB or beta-blocker therapy may be of value for cardio-protection in patients with breast cancer prescribed monoclonal antibodies. Further, adequately powered randomized trials are required to define the role of routine prophylactic treatment in this patient group.
Publisher: Springer Science and Business Media LLC
Date: 10-07-2008
DOI: 10.1245/S10434-008-0054-4
Abstract: Breast-conserving surgery (BCS) requires clear surgical margins to minimize local recurrence. We sought to identify groups of patients at higher risk of involved margins who might benefit from preoperative counselling and/or more generous excision at the first operation. We reviewed demographic, clinical, radiological and pathological records of all women diagnosed with ductal carcinoma in situ (DCIS) or invasive cancer (IC) through a population-based breast screening program in Melbourne, Australia between 1994 and 2005. A total of 2,160 women were diagnosed with DCIS or IC. We excluded 199 who had mastectomy (TM) as initial procedure or had missing data. Three hundred and thirteen had a diagnostic biopsy. Of 1,648 women who had BCS after a preoperative diagnosis of DCIS or IC, 13.5% had involved margins, 16.6% had close ( 1 mm) margins. Of the patients, 281/1,648 (17.1%) underwent re-excision, of whom 93 (33.1%) had residual disease identified. Mammographic microcalcifications (P < 0.0001), absence of a mammographic mass (P = 0.002), presence of DCIS (P < 0.0001), high tumour grade (P < 0.0001), large size (P < 0.0001), multifocal disease (P < 0.0001) and lobular histology (P = 0.005) were associated with involved margins. Microcalcifications (odds ratio [OR] 1.97), large size (OR 4.22) and multifocal disease (OR 2.85) were independently associated with involved margins. Residual disease was associated with involved margins (P < 0.0001), presence of DCIS (P = 0.05) and large tumour size (P = 0.01). After BCS, patients with mammographic microcalcifications, larger tumour size and multifocal tumours are more likely to have involved margins. Patients with involved margins, large tumour size and/or a DCIS component are more likely to have residual disease on re-excision.
Publisher: Springer Science and Business Media LLC
Date: 13-04-2018
Publisher: Public Library of Science (PLoS)
Date: 04-02-2016
Publisher: Springer Science and Business Media LLC
Date: 08-01-2019
Publisher: Wiley
Date: 08-2017
DOI: 10.1111/JEBM.12256
Abstract: This systematic review aimed to determine the effect of prehospital notification systems for major trauma patients on overall (<30 days) and early (<24 hours) mortality, hospital reception, and trauma team presence (or equivalent) on arrival, time to critical interventions, and length of hospital stay. Experimental and observational studies of prehospital notification compared with no notification or another type of notification in major trauma patients requiring emergency transport were included. Risk of bias was assessed using the Cochrane ACROBAT-NRSI tool. A narrative synthesis was conducted and evidence quality rated using the GRADE criteria. Three observational studies of 72,423 major trauma patients were included. All were conducted in high-income countries in hospitals with established trauma services, with two studies undertaking retrospective analysis of registry data. Two studies reported overall mortality, one demonstrating a reduction in mortality (adjusted odds ratio (OR) 0.61, 95% confidence interval (CI) 0.39 to 0.94, 72,073 participants) and the other demonstrating a nonsignificant change (OR 0.61, 95% CI 0.23 to 1.64, 81 participants). The quality of this evidence was rated as very low. Limited research on the topic constrains conclusive evidence on the effect of prehospital notification on patient-centered outcomes after severe trauma. Composite interventions that combine prehospital notification with effective actions on arrival to hospital such as trauma bay availability, trauma team presence, and early access to definitive management may provide more robust evidence towards benefits of early interventions during trauma reception and resuscitation.
Publisher: Springer Science and Business Media LLC
Date: 16-12-2021
DOI: 10.1007/S12028-021-01400-3
Abstract: Trauma-induced coagulopathy in traumatic brain injury (TBI) remains associated with high rates of complications, unfavorable outcomes, and mortality. The underlying mechanisms are largely unknown. Embedded in the prospective multinational Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, coagulation profiles beyond standard conventional coagulation assays were assessed in patients with isolated TBI within the very early hours of injury. Results from blood s les (citrate/EDTA) obtained on hospital admission were matched with clinical and routine laboratory data of patients with TBI captured in the CENTER-TBI central database. To minimize confounding factors, patients with strictly isolated TBI (iTBI) ( n = 88) were selected and stratified for coagulopathy by routine international normalized ratio (INR): (1) INR 1.2 and (2) INR ≥ 1.2. An INR 1.2 has been well adopted over time as a threshold to define trauma-related coagulopathy in general trauma populations. The following parameters were evaluated: quick’s value, activated partial thromboplastin time, fibrinogen, thrombin time, antithrombin, coagulation factor activity of factors V, VIII, IX, and XIII, protein C and S, plasminogen, D-dimer, fibrinolysis-regulating parameters (thrombin activatable fibrinolysis inhibitor, plasminogen activator inhibitor 1, antiplasmin), thrombin generation, and fibrin monomers. Patients with iTBI with INR ≥ 1.2 ( n = 16) had a high incidence of progressive intracranial hemorrhage associated with increased mortality and unfavorable outcome compared with patients with INR 1.2 ( n = 72). Activity of coagulation factors V, VIII, IX, and XIII dropped on average by 15–20% between the groups whereas protein C and S levels dropped by 20%. With an elevated INR, thrombin generation decreased, as reflected by lower peak height and endogenous thrombin potential (ETP), whereas the amount of fibrin monomers increased. Plasminogen activity significantly decreased from 89% in patients with INR 1.2 to 76% in patients with INR ≥ 1.2. Moreover, D-dimer levels significantly increased from a mean of 943 mg/L in patients with INR 1.2 to 1,301 mg/L in patients with INR ≥ 1.2. This more in-depth analysis beyond routine conventional coagulation assays suggests a counterbalanced regulation of coagulation and fibrinolysis in patients with iTBI with hemostatic abnormalities. We observed distinct patterns involving key pathways of the highly complex and dynamic coagulation system that offer windows of opportunity for further research. Whether the changes observed on factor levels may be relevant and explain the worse outcome or the more severe brain injuries by themselves remains speculative.
Publisher: Springer Science and Business Media LLC
Date: 10-05-2017
Publisher: Wiley
Date: 07-10-2013
DOI: 10.1111/ANS.12401
Abstract: Non-surgical immobilization strategies for type 2 odontoid fractures vary considerably, with some surgeons preferring rigid collars, halothoracic bracing or the Minerva brace. Choice of device should be informed by the effectiveness in achieving union, whilst minimizing mortality and complications. Perform a systematic review evaluating the efficacy of non-surgical interventions for type 2 odontoid fractures. MEDLINE (OvidSP), EMBASE (OvidSP) and The Cochrane Library, ClinicalTrials.gov, Current Controlled Trials. We conducted a systematic review of studies directly comparing the halothoracic brace and cervical collars or the Minerva brace for union, mortality and complications. Studies were appraised for quality and bias, and results were pooled for analysis. Our search identified 1794 citations, 13 of which met inclusion criteria. There were no randomized or prospective studies. All studies were small, retrospective and observational. Our results demonstrate a greater likelihood of developing stable union (osseous and fibrous) relative risk (RR) 1.27 (95% confidence intervals (CI) 1.03 to 1.57 P = 0.03) and airway complications RR 7.52 (95% CI 1.39 to 40.83 P = 0.02) with halothoracic bracing compared with cervical collar. In patients >65, there was a greater risk of airway complications RR 7.50 (0.96-58.36 P = 0.05). No other significant differences were identified. Evidence to support selection of non-surgical immobilization in type 2 odontoid fractures is poor. Osseous union has traditionally been the benchmark for 'successful' treatment however, evidence of association between union and improved outcomes is lacking. We highlight the need for a randomized study to promote evidence-based decision-making in the non-surgical management of this injury.
Publisher: Oxford University Press (OUP)
Date: 22-12-2011
DOI: 10.1002/BJS.7754
Abstract: Valid and reliable measures of trauma system performance are needed to guide improvement activities, benchmarking and public reporting, future investment and research. Traditional measures of in-hospital mortality fail to take into account prehospital and posthospital care, recovery after discharge, and the nature and costs of long-term disability. Drawing on recent systematic reviews, an overview was conducted of existing and emerging trauma care performance indicators. Changes in the nature and purpose of indicators were assessed. Among a large number of existing, mostly locally developed performance indicators, only peer review of deaths has evidence of validity or reliability. The usefulness of the traditional performance measure of in-hospital mortality has been challenged. There is an emerging shift in focus from mortality to non-mortality outcomes, from hospital-based to long-term community-based outcome assessment, and from single measures of trauma centre performance to measures better suited to monitoring the performance of systems of care spanning the entire patient journey. As a result, a new generation of indicators is emerging that are both feasible and potentially more useful for commissioners and payers of population-based services. A global endeavour is now under way to agree on a set of standardized performance indicators that are meaningful to patients, carers, clinicians, managers and service funders, are likely to contribute to desired outcomes, and are valid, reliable and have a strong evidence base.
Publisher: Wiley
Date: 11-12-2018
DOI: 10.1111/ANS.14940
Publisher: Springer Science and Business Media LLC
Date: 29-07-2017
DOI: 10.1007/S00134-017-4895-9
Abstract: In this research agenda on the acute and critical care management of trauma patients, we concentrate on the major factors leading to death, namely haemorrhage and traumatic brain injury (TBI). In haemostasis biology, the results of randomised controlled trials have led to the therapeutic focus moving away from the augmentation of coagulation factors (such as recombinant factor VIIa) and towards fibrinogen supplementation and administration of antifibrinolytics such as tranexamic acid. Novel diagnostic techniques need to be evaluated to determine whether an in idualised precision approach is superior to current empirical practice. The timing and efficacy of platelet transfusions remain in question, while new blood products need to be developed and evaluated, including whole blood variants, lyophilised products and novel red cell storage modalities. The current cornerstones of TBI management are intracranial pressure control, maintenance of cerebral perfusion pressure and avoidance of secondary insults (such as hypotension, hypoxaemia, hyperglycaemia and pyrexia). Therapeutic hypothermia and decompressive craniectomy are controversial therapies. Further research into these strategies should focus on identifying which subgroups of patients may benefit from these interventions. Prediction of the long-term outcome early after TBI remains challenging. Early magnetic resonance imaging has recently been evaluated for predicting the long-term outcome in mild and severe TBI. Novel biomarkers may also help in outcome prediction and may predict chronic neurological symptoms. For trauma in general, rehabilitation is complex and multidimensional, and the optimal timing for commencement of rehabilitation needs investigation. We propose priority areas for clinical trials in the next 10 years.
Publisher: Wiley
Date: 10-2006
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2013
Publisher: Mary Ann Liebert Inc
Date: 15-08-2016
Publisher: Springer Science and Business Media LLC
Date: 25-05-2015
Publisher: Wiley
Date: 04-2002
DOI: 10.1046/J.1445-2197.2002.02367.X
Abstract: The foot complications of diabetes are severe, disabling, costly and common in the Northern Territory. An understanding of the pathogenesis, the disease spectrum and treatment efficacy, however, is poor. The patterns of disease are documented in the present study factors associated with good and poor outcomes are identified and improved management strategies are proposed. All patients presenting to the High Risk Foot Service at Royal Darwin Hospital between March 1997 and March 2000 were included in the present study, and details regarding the status of their feet, their demographics, their treatment and their outcomes were recorded prospectively. Logistic regression analysis was undertaken to determine associations between factors of interest and outcomes of healing and utation. One hundred and twenty-six patients were recorded, 41% of whom had neuropathic ulcers and 63% of whom had severe disease at presentation. Two types of diabetic foot pathology were recognized that are not usually classified: acute injury without neuropathy (10%) and deep soft tissue infection alone (9%).Thirty-seven percent and 23% of patients required minor and major utations, respectively. The total number of hospital bed-days was 5813. Total contact casting was associated with good healing rates in 16 patients. Major utation was associated with ischaemia, severe disease at presentation and increasing age. Patterns of diabetic foot disease which are not commonly recognized are described in the present study the severity and cost of the problem are documented and some factors which lead to poor outcome, such as late presentation, are identified. Attention should be paid, through a multidisciplinary team, to timely referral from primary care, patient education, total contact casts and appropriate revascularization.
Publisher: Cold Spring Harbor Laboratory
Date: 14-09-2020
DOI: 10.1101/2020.09.09.20191031
Abstract: Estimates of seroprevalence of SARS-CoV-2 antibodies have been h ered by inadequate assay sensitivity and specificity. Using an ELISA-based approach to that combines data about IgG responses to both the Nucleocapsid and Spike-receptor binding domain antigens, we show that near-optimal sensitivity and specificity can be achieved. We used this assay to assess the frequency of virus-specific antibodies in a cohort of elective surgery patients in Australia and estimated seroprevalence in Australia to be 0.28% (0 to 0.72%). These data confirm the low level of transmission of SARS-CoV-2 in Australia before July 2020 and validate the specificity of our assay.
Publisher: Informa UK Limited
Date: 18-02-2016
DOI: 10.3109/02699052.2015.1113569
Abstract: Discharge planning for patients with an acquired brain injury (ABI) is considered best practice for assisting the patient and caregiver to successfully transition from hospital to home and is complex because of the long-term care and support needs of the patient. This review aimed to describe and synthesize the perspectives of patients with ABI and their family/caregivers on the transition from hospital to home to better understand opportunities to optimize the process. Electronic medical databases (n = 5) and grey literature published between January-May 2015 were searched to identify qualitative studies on the experience of transition from the hospital to home setting following ABI. Relevant studies were appraised and narratively synthesized. Nine eligible studies that met the inclusion criteria were identified. Two major themes were identified-Engagement and Support. Three underlying sub-themes-poor communication, limited participation and disorganized arrangements for support services-were identified as key contributors to an unsatisfactory experience for patients and their family/caregivers. The transition for patients with an ABI and their family/caregivers was characterized as fragmented and unsatisfactory for supporting a successful return home. This review highlights the importance of tailored education and involvement of the patient and their family/caregiver to increase readiness for returning home and reduce unplanned re-admissions.
Publisher: Mary Ann Liebert Inc
Date: 15-04-2021
Publisher: American Medical Association (AMA)
Date: 11-11-2021
Publisher: Elsevier BV
Date: 2021
Publisher: Mary Ann Liebert Inc
Date: 11-2015
Abstract: To evaluate current practice in the perioperative management of antiplatelets (AP) and anticoagulants (AC) among men undergoing elective transurethral resection of the prostate (TURP), as well as the associated perioperative bleeding and thromboembolic complications. Retrospective review of consecutive elective TURP patients in a single tertiary institution from January 2011 to December 2013 (n = 293). Data on the regular use of AP/AC and the perioperative management approach were collected from patients' electronic medical records. Bleeding and thromboembolic complications were assessed up to 30 days postoperative. Association between AP/AC use and perioperative complications was assessed using the Kruskall-Wallis test (continuous variables) and the Fisher exact test (categoric variables). There were 107/293 (37%) patients receiving long-term AP while there were 25/293 (9%) patients receiving long-term AC. A total of 72/107 (67%) patients ceased AP on an average of 7.6 days preoperatively, while 35/107 (33%) continued receiving AP. Patients with coronary stents (62%) and coronary bypass graft (67%) were significantly more likely to continued receiving AP (P < 0.001). AC was ceased in all patients preoperatively, with 16/25 (64%) receiving enoxaparin bridging. Overall, there were 31 (10%) incidents of bleeding complications and 5 (2%) thromboembolic events. AC users who had enoxaparin bridging had significantly higher risk of bleeding complications (44%), compared with non-AP/AC users (8%), AP users who ceased AP (4%), AP users who continued receiving AP (17%), and AC users who did not receive enoxaparin bridging (0%) (P < 0.001). AC users who received enoxaparin bridging also reported significantly higher thromboembolic complications (17% P < 0.001) and prolonged hospital stay (mean 5.4 days) (P = 0.002), compared with other patients. Perioperative management of AP/AC should be based on the indications and the American College of Chest Physicians thromboembolic risk stratification. Regular AC users who had enoxaparin bridging are at increased risk of both perioperative bleeding and thromboembolic complications.
Publisher: Springer Science and Business Media LLC
Date: 12-05-2020
DOI: 10.1186/S12910-020-00480-8
Abstract: The European Union (EU) aims to optimize patient protection and efficiency of health-care research by harmonizing procedures across Member States. Nonetheless, further improvements are required to increase multicenter research efficiency. We investigated IRB procedures in a large prospective European multicenter study on traumatic brain injury (TBI), aiming to inform and stimulate initiatives to improve efficiency. We reviewed relevant documents regarding IRB submission and IRB approval from European neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI). Documents included detailed information on IRB procedures and the duration from IRB submission until approval(s). They were translated and analyzed to determine the level of harmonization of IRB procedures within Europe. From 18 countries, 66 centers provided the requested documents. The primary IRB review was conducted centrally ( N = 11, 61%) or locally ( N = 7, 39%) and primary IRB approval was obtained after one ( N = 8, 44%), two ( N = 6, 33%) or three ( N = 4, 23%) review rounds with a median duration of respectively 50 and 98 days until primary IRB approval. Additional IRB approval was required in 55% of countries and could increase duration to 535 days. Total duration from submission until required IRB approval was obtained was 114 days (IQR 75–224) and appeared to be shorter after submission to local IRBs compared to central IRBs (50 vs. 138 days, p = 0.0074). We found variation in IRB procedures between and within European countries. There were differences in submission and approval requirements, number of review rounds and total duration. Research collaborations could benefit from the implementation of more uniform legislation and regulation while acknowledging local cultural habits and moral values between countries.
Publisher: Springer Science and Business Media LLC
Date: 02-08-2015
DOI: 10.1007/S00268-014-2663-3
Abstract: Few guidelines exist for the initial management of wounds in disaster settings. As wounds sustained are often contaminated, there is a high risk of further complications from infection, both local and systemic. Healthcare workers with little to no surgical training often provide early wound care, and where resources and facilities are also often limited, and clear appropriate guidance is needed for early wound management. We undertook a systematic review focusing on the nature of wounds in disaster situations, and the outcomes of wound management in recent disasters. We then presented the findings to an international consensus panel with a view to formulating a guideline for the initial management of wounds by first responders and subsequent healthcare personnel as they deploy. We included 62 studies in the review that described wound care challenges in a erse range of disasters, and reported high rates of wound infection with multiple causative organisms. The panel defined a guideline in which the emphasis is on not closing wounds primarily but rather directing efforts toward cleaning, debridement, and dressing wounds in preparation for delayed primary closure, or further exploration and management by skilled surgeons. Good wound care in disaster settings, as outlined in this article, can be achieved with relatively simple measures, and have important mortality and morbidity benefits.
Publisher: Wiley
Date: 30-03-2015
Publisher: John Wiley & Sons, Ltd
Date: 12-09-2012
Publisher: Elsevier BV
Date: 04-2015
Publisher: Elsevier BV
Date: 2022
Publisher: Elsevier BV
Date: 11-2012
DOI: 10.1016/J.BJPS.2012.05.004
Abstract: Plastic surgeons and other doctors who perform cosmetic procedures face relatively high risks of malpractice claims and complaints. In particular, alleged problems with the consent process abound in this area, but little is known about the clinical circumstances of these cases. We reviewed 481 malpractice claims and serious health care complaints resolved in Australia between 2002 and 2008 that alleged failures in the informed consent process for cosmetic and other procedures. We identified all "cases" involving cosmetic procedures and reviewed them in-depth. We calculated their frequency, and described the treatments, allegations, and outcomes involved. A total of 16% (77/481) of the legal disputes over informed consent involved cosmetic procedures. In 70% (54/77) of these cases, patients alleged that the doctor failed to disclose risks of a particular complication, in 39% patients claimed that potential lack of benefit was not explained, and in 26% patients allegations centred on the process by which consent was sought. Five treatment types-liposuction, breast augmentation, face/neck lifts, eye/brow lifts, and rhinoplasty/septoplasty-featured in 70% (54/77) of the cases. Scarring (30/77) and the need for reoperation (18/77) were among the most prevalent adverse health outcomes at issue. A mix of factors "supercharges" the informed consent process for cosmetic procedures. Doctors who deliver these procedures should take special care to canvas the risks and possible outcomes that matter most to patients.
Publisher: BMJ
Date: 07-2017
Publisher: Wiley
Date: 21-01-2013
DOI: 10.1111/ANS.12070
Abstract: Patients taking warfarin are often given interim anticoagulation in the perioperative period. Institutional guidelines that use low-molecular-weight heparin (LMWH) 'bridging' while the international normalized ratio (INR) is sub-therapeutic are often based on the American College of Chest Physicians Anticoagulation Guidelines. This study aims to identify if patients at a tertiary referral hospital were anticoagulated in line with these guidelines, and the incidence and nature of bleeding and thromboembolic complications. A retrospective review of the Alfred Hospital General Surgical and 'Hospital at Home' databases was conducted, identifying patients who underwent elective general surgical procedures and received bridging anticoagulation with enoxaparin. Demographics, indication for anticoagulation, bleeding and thromboembolism rates were recorded. Thromboembolic risk was estimated. The study identified 108 patients. Three-quarters of all patients were anticoagulated with LMWH doses in accordance with the guidelines. Thirty of the 108 patients suffered bleeding complications. This group was younger, weighed less, received higher doses of enoxaparin and were at higher predicted risk of thromboembolism than non-bleeding patients. Wound haematoma, rectal bleeding and intra-abdominal bleeding were the most frequent complications. The peak time of bleeding was 3.5 days after surgery. Twelve patients returned to theatre, 13 were readmitted and 3 received blood transfusion. One patient suffered pulmonary emboli on the first post-operative day. LMWH bridging therapy when prescribed appropriately is associated with low rates of inpatient thromboembolism in elective general surgical patients within our institution, but an unexpectedly high rate of bleeding complications.
Publisher: Journal of Neurosurgery Publishing Group (JNSPG)
Date: 05-2021
Abstract: The aim of this paper was to evaluate the prevalence of postconcussive symptoms and their relation to health-related quality of life (HRQOL) in pediatric and adolescent patients with mild traumatic brain injury (mTBI) who received head CT imaging during initial assessment. Patients aged between 5 and 21 years with mTBI (Glasgow Coma Scale scores 13–15) and available Rivermead Post Concussion Questionnaire (RPQ) at 6 months of follow-up in the multicenter, prospectively collected CENTER-TBI (Collaborative European NeuroTrauma Effectiveness Research in TBI) study were included. The prevalence of postconcussive symptoms was assessed, and the occurrence of postconcussive syndrome (PSC) based on the ICD-10 criteria, was analyzed. HRQOL was compared in patients with and without PCS using the Quality of Life after Brain Injury (QOLIBRI) questionnaire. A total of 196 adolescent or pediatric mTBI patients requiring head CT imaging were included. High-energy trauma was prevalent in more than half of cases (54%), abnormalities on head CT scans were detected in 41%, and admission to the regular ward or intensive care unit was necessary in 78%. Six months postinjury, 36% of included patients had experienced at least one moderate or severe symptom on the RPQ. PCS was present in 13% of adolescents and children when considering symptoms of at least moderate severity, and those patients had significantly lower QOLIBRI total scores, indicating lower HRQOL, compared with young patients without PCS (57 vs 83 points, p 0.001). Adolescent and pediatric mTBI patients requiring head CT imaging show signs of increased trauma severity. Postconcussive symptoms are present in up to one-third of those patients, and PCS can be diagnosed in 13% 6 months after injury. Moreover, PCS is significantly associated with decreased HRQOL.
Publisher: Springer Science and Business Media LLC
Date: 06-02-2019
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2014
Publisher: Frontiers Media SA
Date: 18-08-2022
DOI: 10.3389/FNEUR.2022.861688
Abstract: Spine injury is highly prevalent in patients with poly-trauma, but data on the co-occurrence of spine trauma in patients with traumatic brain injury (TBI) are scarce. In this study, we used the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) database to assess the prevalence, characteristics, and outcomes of patients with TBI and a concurrent traumatic spinal injury (TSI). Data from the European multi-center CENTER-TBI study were analyzed. Adult patients with TBI (≥18 years) presenting with a concomitant, isolated TSI of at least serious severity (Abbreviated Injury Scale AIS ≥3) were included. For outcome analysis, comparison groups of TBI patients with TSI and systemic injuries (non-isolated TSI) and without TSI were created using propensity score matching. Rates of mortality, unfavorable outcomes (Glasgow Outcome Scale Extended GOSe & 5), and full recovery (GOSe 7–8) of all patients and separately for patients with only mild TBI (mTBI) were compared between groups at 6-month follow-up. A total of 164 (4%) of the 4,254 CENTER-TBI core study patients suffered from a concomitant isolated TSI. The median age was 53 [interquartile range (IQR): 37–66] years and 71% of patients were men. mTBI was documented in 62% of cases, followed by severe TBI (26%), and spine injuries were mostly cervical (63%) or thoracic (31%). Surgical spine stabilization was performed in 19% of cases and 57% of patients were admitted to the ICU. Mortality at 6 months was 11% and only 36% of patients regained full recovery. There were no significant differences in the 6-month rates of mortality, unfavorable outcomes, or full recovery between TBI patients with and without concomitant isolated TSI. However, concomitant non-isolated TSI was associated with an unfavorable outcome and a higher mortality. In patients with mTBI, a negative association with full recovery could be observed for both concomitant isolated and non-isolated TSI. Rates of mortality, unfavorable outcomes, and full recovery in TBI patients with and without concomitant, isolated TSIs were comparable after 6 months. However, in patients with mTBI, concomitant TSI was a negative predictor for a full recovery. These findings might indicate that patients with moderate to severe TBI do not necessarily exhibit worse outcomes when having a concomitant TSI, whereas patients with mTBI might be more affected.
Publisher: Wiley
Date: 06-2004
Publisher: Elsevier BV
Date: 04-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 15-03-2017
Abstract: The Glasgow Coma Scale (GCS) characterizes patients with diminished consciousness. In a recent systematic review, we found overall adequate reliability across different clinical settings, but reliability estimates varied considerably between studies, and methodological quality of studies was overall poor. Identifying and understanding factors that can affect its reliability is important, in order to promote high standards for clinical use of the GCS. The aim of this systematic review was to identify factors that influence reliability and to provide an evidence base for promoting consistent and reliable application of the GCS. A comprehensive literature search was undertaken in MEDLINE, EMBASE, and CINAHL from 1974 to July 2016. Studies assessing the reliability of the GCS in adults or describing any factor that influences reliability were included. Two reviewers independently screened citations, selected full texts, and undertook data extraction and critical appraisal. Methodological quality of studies was evaluated with the consensus-based standards for the selection of health measurement instruments checklist. Data were synthesized narratively and presented in tables. Forty-one studies were included for analysis. Factors identified that may influence reliability are education and training, the level of consciousness, and type of stimuli used. Conflicting results were found for experience of the observer, the pathology causing the reduced consciousness, and intubation/sedation. No clear influence was found for the professional background of observers. Reliability of the GCS is influenced by multiple factors and as such is context dependent. This review points to the potential for improvement from training and education and standardization of assessment methods, for which recommendations are presented.
Publisher: Springer Science and Business Media LLC
Date: 09-08-2022
DOI: 10.1038/S41526-022-00219-2
Abstract: Astronauts in a microgravity environment will experience significant changes in their cardiopulmonary system. Up until now, there has always been the reassurance that they have real-time contact with experts on Earth. Mars crew however will have gaps in their communication of 20 min or more. In silico experiments are therefore needed to assess fitness to fly for those on future space flights to Mars. In this study, we present an open-source controlled lumped mathematical model of the cardiopulmonary system that is able simulate the short-term adaptations of key hemodynamic parameters to an active stand test after being exposed to microgravity. The presented model is capable of adequately simulating key cardiovascular hemodynamic changes—over a short time frame—during a stand test after prolonged spaceflight under different gravitational conditions and fluid loading conditions. This model can form the basis for further exploration of the ability of the human cardiovascular system to withstand long-duration space flight and life on Mars.
Publisher: AMPCo
Date: 2006
DOI: 10.5694/J.1326-5377.2006.TB00085.X
Abstract: Contributing to health services research, implementation and effective health policy-making.
Publisher: Springer Science and Business Media LLC
Date: 20-06-2019
DOI: 10.1007/S00268-019-05039-2
Abstract: The completeness of a trauma registry's data is essential for its valid use. This study aimed to evaluate the extent of missing data in a new multicentre trauma registry in India and to assess the association between data completeness and potential predictors of missing data, particularly mortality. The proportion of missing data for variables among all adults was determined from data collected from 19 April 2016 to 30 April 2017. In-hospital physiological data were defined as missing if any of initial systolic blood pressure, heart rate, respiratory rate, or Glasgow Coma Scale were missing. Univariable logistic regression and multivariable logistic regression, using manual stepwise selection, were used to investigate the association between mortality (and other potential predictors) and missing physiological data. Data on the 4466 trauma patients in the registry were analysed. Out of 59 variables, most (n = 51 86.4%) were missing less than 20% of observations. There were 808 (18.1%) patients missing at least one of the first in-hospital physiological observations. Hospital death was associated with missing in-hospital physiological data (adjusted OR 1.4 95% CI 1.02-2.01 p = 0.04). Other significant associations with missing data were: patient arrival time out of hours, hospital of care, 'other' place of injury, and specific injury mechanisms. Assault/homicide injury intent and occurrence of chest X-ray were associated with not missing any of first in-hospital physiological variables. Most variables were well collected. Hospital death, a proxy for more severe injury, was associated with missing first in-hospital physiological observations. This remains an important limitation for trauma registries.
Publisher: Informa UK Limited
Date: 19-08-2010
DOI: 10.3109/02699052.2010.506865
Abstract: To report the clinical use of the QOLIBRI, a disease-specific measure of health-related quality-of-life (HRQoL) after traumatic brain injury (TBI). The QOLIBRI, with 37 items in six scales (cognition, self, daily life and autonomy, social relationships, emotions and physical problems) was completed by 795 patients in six languages (Finnish, German, Italian, French, English and Dutch). QOLIBRI scores were examined by variables likely to be influenced by rehabilitation interventions and included socio-demographic, functional outcome, health status and mental health variables. The QOLIBRI was self-completed by 73% of participants and 27% completed it in interview. It was sensitive to areas of life amenable to intervention, such as accommodation, work participation, health status (including mental health) and functional outcome. The QOLIBRI provides information about patient's subjective perception of his/her HRQoL which supplements clinical measures and measures of functional outcome. It can be applied across different populations and cultures. It allows the identification of personal needs, the prioritization of therapeutic goals and the evaluation of in idual progress. It may also be useful in clinical trials and in longitudinal studies of TBI recovery.
Publisher: Mary Ann Liebert Inc
Date: 15-05-2021
Abstract: The International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticoid Randomisation After Significant Head injury (CRASH) prognostic models predict functional outcome after moderate and severe traumatic brain injury (TBI). We aimed to assess their performance in a contemporary cohort of patients across Europe. The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) core study is a prospective, observational cohort study in patients presenting with TBI and an indication for brain computed tomography. The CENTER-TBI core cohort consists of 4509 TBI patients available for analyses from 59 centers in 18 countries across Europe and Israel. The IMPACT validation cohort included 1173 patients with GCS ≤12, age ≥14, and 6-month Glasgow Outcome Scale-Extended (GOSE) available. The CRASH validation cohort contained 1742 patients with GCS ≤14, age ≥16, and 14-day mortality or 6-month GOSE available. Performance of the three IMPACT and two CRASH model variants was assessed with discrimination (area under the receiver operating characteristic curve AUC) and calibration (comparison of observed vs. predicted outcome rates). For IMPACT, model discrimination was good, with AUCs ranging between 0.77 and 0.85 in 1173 patients and between 0.80 and 0.88 in the broader CRASH selection (
Publisher: BMJ
Date: 07-2002
Abstract: To examine the role of specialist outreach in supporting primary health care and overcoming the barriers to health care faced by the indigenous population in remote areas of Australia, and to examine issues affecting its sustainability. A process evaluation of a specialist outreach service, using health service utilisation data and interviews with health professionals and patients. The Top End of Australia's Northern Territory, where Darwin is the capital city and the major base for hospital and specialist services. In the rural and remote areas outside Darwin there are many small, predominantly indigenous communities, which are greatly disadvantaged by a severe burden of disease and limited access to medical care. Seventeen remote health practitioners, five specialists undertaking outreach, five regional health administrators, and three patients from remote communities. The barriers faced by many remote indigenous people in accessing specialist and hospital care are substantial. Outreach delivery of specialist services has overcome some of the barriers relating to distance, communication, and cultural inappropriateness of services and has enabled an over fourfold increase in the number of consultations with people from remote communities. Key issues affecting sustainability include: an adequate specialist base an unmet demand from primary care integration with, accountability to and capacity building for a multidisciplinary framework centred in primary care good communication visits that are regular and predictable funding and coordination that recognises responsibilities to both hospitals and the primary care sector and regular evaluation. In a setting where there is a disadvantaged population with inadequate access to medical care, specialist outreach from a regional centre can provide a more equitable means of service delivery than hospital based services alone. A sustainable outreach service that is organised appropriately, responsive to local community needs, and has an adequate regional specialist base can effectively integrate with and support primary health care processes. Poorly planned and conducted outreach, however, can draw resources away and detract from primary health care.
Publisher: Elsevier BV
Date: 07-2018
DOI: 10.1016/J.BJA.2018.03.020
Abstract: The Standardising Endpoints for Perioperative Medicine group was established to derive an appropriate set of endpoints for use in clinical trials related to anaesthesia and perioperative medicine. Anaesthetic or analgesic technique during cancer surgery with curative intent may influence the risk of recurrence or metastasis. However, given the current equipoise in the existing literature, prospective, randomised, controlled trials are necessary to test this hypothesis. As such, a cancer subgroup was formed to derive endpoints related to research in onco-anaesthesia based on a current evidence base, international consensus and expert guidance. We undertook a systematic review to identify measures of oncological outcome used in the oncological, surgical, and wider literature. A multiround Delphi consensus process that included up to 89 clinician-researchers was then used to refine a recommended list of endpoints. We identified 90 studies in a literature search, which were the basis for a preliminary list of nine outcome measures and their definitions. A further two were added during the Delphi process. Response rates for Delphi rounds one, two, and three were 88% (n=9), 82% (n=73), and 100% (n=10), respectively. A final list of 10 defined endpoints was refined and developed, of which six secured approval by ≥70% of the group: cancer health related quality of life, days alive and out of hospital at 90 days, time to tumour progression, disease-free survival, cancer-specific survival, and overall survival (and 5-yr overall survival). Standardised endpoints in clinical outcomes studies will support benchmarking and pooling (meta-analysis) of trials. It is therefore recommended that one or more of these consensus-derived endpoints should be considered for inclusion in clinical trials evaluating a causal effect of anaesthesia-analgesia technique on oncological outcomes.
Publisher: Elsevier BV
Date: 09-2015
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2011
Publisher: Mary Ann Liebert Inc
Date: 04-2020
Abstract: Traumatic brain injury (TBI) is currently classified as mild, moderate, or severe TBI by trichotomizing the Glasgow Coma Scale (GCS). We aimed to explore directions for a more refined multidimensional classification system. For that purpose, we performed a hypothesis-free cluster analysis in the Collaborative European NeuroTrauma Effectiveness Research for TBI (CENTER-TBI) database: a European all-severity TBI cohort (
Publisher: Mary Ann Liebert Inc
Date: 15-09-2021
Publisher: Elsevier BV
Date: 12-2012
DOI: 10.1016/J.JCRC.2012.07.010
Abstract: Quality improvement (QI) is a central tenant of trauma center accreditation in most countries, but its effectiveness is largely unknown. We sought to explore opportunities for improving trauma QI. We performed a qualitative research study using grounded theory analyses of interviews with medical directors and program managers from 75 verified trauma centers s led from the United States (n = 51), Canada (n = 14), and Australasia (Australia and New Zealand [n = 10]) to explore experiences with trauma QI activities and identify opportunities for improvement. Most trauma centers indicated that they perceived trauma QI to be important and devoted personnel for QI (data entry, data analyst, educator, nurse practitioner). Programs identified 5 principal opportunities to improve trauma QI: (1) ensure resource adequacy (human resources, registry maintenance, financial support, institutional support), (2) encourage stakeholder participation (engagement, communication, coordination), (3) ensure clinical relevance, (4) incorporate evidence-based tools, and (5) require provider and QI program accountability. Quality improvement programs exist as accreditation requirements in most centers. However, trauma QI practices depend on a range of local and regional factors, and concrete opportunities for improvement that address impact and sustainability exist.
Publisher: Springer Science and Business Media LLC
Date: 17-01-2019
Publisher: Wiley
Date: 23-03-2018
DOI: 10.1111/ANS.14479
Abstract: The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality. Retrospective comparison of adult primary admissions (Glasgow Coma Scale 2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay. One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79% P = 0.7 and age: 34 (18-88) versus 33 (18-85) P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8) P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75) P = 0.09), prehospital hypotension (15.4% versus 11.7% P = 0.5) and desaturation (14.6% versus 17.5% P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6) P = 0.04) and more often successful PETI (85% versus 22% P < 0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3% P = 0.34 OR = 0.84 95% CI: 0.38-1.86 P = 0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect = 1.58 95% CI: 1.30-1.92 P < 0.05). Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay.
Publisher: Elsevier BV
Date: 09-2012
Publisher: Wiley
Date: 02-08-2023
DOI: 10.1111/ANAE.16104
Abstract: Postoperative systemic inflammation is strongly associated with surgical outcomes, but its relationship with patient‐centred outcomes is largely unknown. Detection of excessive inflammation and patient and surgical factors associated with adverse patient‐centred outcomes should inform preventative treatment options to be evaluated in clinical trials and current clinical care. This retrospective cohort study analysed prospectively collected data from 3000 high‐risk, elective, major abdominal surgery patients in the restrictive vs. liberal fluid therapy for major abdominal surgery (RELIEF) trial from 47 centres in seven countries from May 2013 to September 2016. The co‐primary endpoints were persistent disability or death up to 90 days after surgery, and quality of recovery using a 15‐item quality of recovery score at days 3 and 30. Secondary endpoints included: 90‐day and 1‐year all‐cause mortality septic complications acute kidney injury unplanned admission to intensive care/high dependency unit and total intensive care unit and hospital stays. Patients were assigned into quartiles of maximum postoperative C‐reactive protein concentration up to day 3, after multiple imputations of missing values. The lowest (reference) group, quartile 1, C‐reactive protein ≤ 85 mg.l ‐1 , was compared with three inflammation groups: quartile 2 85 mg.l ‐1 to 140 mg.l ‐1 quartile 3 140 mg.l ‐1 to 200 mg.l ‐1 and quartile 4 200 mg.l ‐1 to 587 mg.l ‐1 . Greater postoperative systemic inflammation had a higher adjusted risk ratio (95%CI) of persistent disability or death up to 90 days after surgery, quartile 4 vs. quartile 1 being 1.76 (1.31–2.36), p 0.001. Increased inflammation was associated with increasing decline in risk‐adjusted estimated medians (95%CI) for quality of recovery, the quartile 4 to quartile 1 difference being ‐14.4 (‐17.38 to ‐10.71), p 0.001 on day 3, and ‐5.94 (‐8.92 to ‐2.95), p 0.001 on day 30. Marked postoperative systemic inflammation was associated with increased risk of complications, poor quality of recovery and persistent disability or death up to 90 days after surgery.
Publisher: MDPI AG
Date: 18-01-2022
Abstract: Epigenetic therapies remain a promising, but still not widely used, approach in the management of patients with cancer. To date, the efficacy and use of epigenetic therapies has been demonstrated primarily in the management of haematological malignancies, with limited supportive data in solid malignancies. The most studied epigenetic therapies in breast cancer are those that target DNA methylation and histone modification however, none have been approved for routine clinical use. The majority of pre-clinical and clinical studies have focused on triple negative breast cancer (TNBC) and hormone-receptor positive breast cancer. Even though the use of epigenetic therapies alone in the treatment of breast cancer has not shown significant clinical benefit, these therapies show most promise in use in combinations with other treatments. With improving technologies available to study the epigenetic landscape in cancer, novel epigenetic alterations are increasingly being identified as potential biomarkers of response to conventional and epigenetic therapies. In this review, we describe epigenetic targets and potential epigenetic biomarkers in breast cancer, with a focus on clinical trials of epigenetic therapies. We describe alterations to the epigenetic landscape in breast cancer and in treatment resistance, highlighting mechanisms and potential targets for epigenetic therapies. We provide an updated review on epigenetic therapies in the pre-clinical and clinical setting in breast cancer, with a focus on potential real-world applications. Finally, we report on the potential value of epigenetic biomarkers in diagnosis, prognosis and prediction of response to therapy, to guide and inform the clinical management of breast cancer patients.
Publisher: Elsevier BV
Date: 10-2014
DOI: 10.1016/J.INJURY.2014.06.025
Abstract: Knowledge about the functional consequences of lower limb long bone fractures is helpful to inform patients, clinicians and employers about their recovery process and prognosis. This study aims to describe the epidemiology and health outcomes of femoral and tibial shaft fractures treated at two level I trauma centres, by comparing the differences between patients with delayed union or nonunion and patients with union. An analysis of registry data over two years, supplemented with medical record review, was conducted. Fracture healing was retrospectively assessed by clinical and radiological evidence of union, and the need for surgical intervention. SF-12 scores, and work and pain status were prospectively recorded at six and twelve months post injury. 285 fractures progressed to union and 138 fractures developed delayed union or nonunion. There was a significant difference between the two cohorts with regards to the mechanism of injury, association with multi-trauma, open fractures, grade of Gustilo classification, patient fund source, smoking status and presence of comorbidities. The SF-12 physical component score was less than 50 at both six and twelve months with improvement in the union group, but not in the delayed union or nonunion group. 72% of patients with union had returned to work at one year, but 54% continued to have pain. The difference compared to patients with delayed union or nonunion was significant. Even patients whose fractures unite in the expectant time-frame will have residual physical disability. Patients with delayed union or nonunion have still poorer outcomes, including ongoing problems with returning to work and pain. It is important to educate patients about their injury so that they have realistic expectations. This is particularly relevant given that the patients most likely to sustain femoral or tibial shaft fractures are working-age healthy adults, and up to a third of fractures may develop delayed union or nonunion. Despite modern treatment, the patient-reported outcomes of lower limb long bone shaft fractures do not return to normal at one year. Patients with delayed union or nonunion can expect poorer outcomes.
Publisher: SAGE Publications
Date: 10-2004
Abstract: People in remote Aboriginal communities in the Northern Territory have greater morbidity and mortality than other Australians, but face considerable barriers when accessing hospital-based specialist services. The Specialist Outreach Service, which began in 1997, was a novel policy initiative to improve access by providing a regular multidisciplinary visiting specialist services to remote communities. It led to two interesting juxtapositions: that of “state of the art” specialist services alongside under-resourced primary care in remote and relatively traditional Aboriginal communities and that of attempts to develop an evidence base for the effectiveness of outreach, while meeting the short-term evaluative requirements of policy-makers. In this essay, first we describe the development of the service in the Northern Territory and its initial process evaluation. Through a Cochrane systematic review we then summarise the published research on the effectiveness of specialist outreach in improving access to tertiary and hospital-based care. Finally we describe the findings of an observational population-based study of the use of specialist services and the impact of outreach to three remote communities over 11 years. Specialist outreach improves access to specialist care and may lessen the demand for both outpatient and inpatient hospital care. Specialist outreach is, however, dependent on well-functioning primary care. According to the way in which outreach is conducted and the service is organised, it can either support primary care or it can hinder primary care and, as a result, reduce its own effectiveness.
Publisher: MDPI AG
Date: 17-02-2021
Abstract: Systemic treatment of hormone receptor-positive (HR+) breast cancer is undergoing a renaissance, with a number of targeted therapies including CDK4/6, mTOR, and PI3K inhibitors now approved for use in combination with endocrine therapies. The increased use of targeted therapies has changed the natural history of HR+ breast cancers, with the emergence of new escape mechanisms leading to the inevitable progression of disease in patients with advanced cancers. The identification of new predictive and pharmacodynamic biomarkers to current standard-of-care therapies and discovery of new therapies is an evolving and urgent clinical challenge in this setting. While traditional, routinely measured biomarkers such as estrogen receptors (ERs), progesterone receptors (PRs), and human epidermal growth factor receptor 2 (HER2) still represent the best prognostic and predictive biomarkers for HR+ breast cancer, a significant proportion of patients either do not respond to endocrine therapy or develop endocrine resistant disease. Genomic tests have emerged as a useful adjunct prognostication tool and guide the addition of chemotherapy to endocrine therapy. In the treatment-resistant setting, mutational profiling has been used to identify ESR1, PIK3CA, and AKT mutations as predictive molecular biomarkers to newer therapies. Additionally, pharmacodynamic biomarkers are being increasingly used and considered in the metastatic setting. In this review, we summarise the current state-of-the-art therapies prognostic, predictive, and pharmacodynamic molecular biomarkers and how these are impacted by emerging therapies for HR+ breast cancer.
Publisher: Wiley
Date: 20-11-2023
DOI: 10.1002/CAM4.5468
Abstract: There is robust trial evidence for improved overall survival (OS) with immunotherapy in advanced solid organ malignancies. The real‐world long‐term survival data and the predictive variables are not yet known. Our aim was to evaluate factors associated with 3‐year and 5‐year OS for patients treated with immune checkpoint inhibitors (ICIs). We performed a retrospective study of patients who received ICIs as management of advanced solid organ malignancies in two tertiary Australian oncology centres from 2012–2017. Data pertaining to clinical characteristics, metastatic disease burden, immune‐related adverse events (IRAEs) and tumour responses were collected and their relationship to survival examined. In this analysis of 264 patients, 202 (76.5%) had melanoma, 46 (17.4%) had non‐small cell lung cancer (NSCLC), 12 (4.5%) had renal cell carcinoma (RCC) and 4 (1.5%) had mesothelioma. The 5‐year OS rates were 42.1% in patients with melanoma, 19.6% with NSCLC, 75% with RCC, and none of the mesothelioma patients were alive at 5 years. In multivariate analysis, an ECOG score of 0 (Hazard ratio [HR] 0.39 95% confidence interval [CI] 0.23–0.66 p 0.001) and the occurrence of IRAE's of any grade (HR 0.61 95% CI 0.37–0.95 p = 0.05) were associated with better 5‐year survival. The presence of bone metastases (HR 1.62 95% CI 1.03–2.82 p = 0.05) and liver metastases (HR 1.76 95% CI 1.07–2.89 p = 0.03) were associated with worse 5‐year survival. These results support the long‐term benefits of immunotherapy that in some patients, extend to at least 5 years. ECOG performance status of 0 and the occurrence of irAEs are associated with better long‐term survival. Survival is significantly influenced by metastatic site and cancer type. These predictive clinical correlates aid discussions and planning in the delivery of ICIs to patients.
Publisher: Wiley
Date: 28-09-2018
Publisher: Mary Ann Liebert Inc
Date: 10-2009
Abstract: Recent calls have been made for the inclusion of health-related quality of life (HRQoL) in traumatic brain injury studies. This study reports the impact of TBI on traditional measures (general health, depression, social isolation, labor force participation), self-assessed health function status using the SF-36 version 2 (SF-36V2), and self-assessed health preference using two generic utility instruments, the assessment of quality of life (AQoL) and the SF6D. A random s le of TBI cases (n = 66) was drawn from a trauma registry and matched (gender, age, education, and relationship status) with non-trauma-exposed cases from a population health survey. All participants were interviewed and the two cohorts compared. When compared with matched comparators, TBI cases experienced worse general health, elevated probabilities of depression, social isolation, and worse labor force participation rates. The TBI-cohort reported worse health status on the SF-36V2. The most affected areas were social function, role emotion, and mental health (effect sizes -0.70 to -0.86). The reported utility values indicative of a HRQoL between 13 and 24% worse than their non-TBI contemporaries (effect sizes -0.80 to -0.81). The findings suggest that TBI has long-term consequences across all aspects of peoples' lives, and that these consequences can be self-assessed using generic instruments. The challenge is to provide and evaluate long-term services targeted at the life areas that those with TBI find particularly difficult.
Publisher: Mary Ann Liebert Inc
Date: 15-04-2021
Publisher: Wiley
Date: 15-06-2011
Publisher: Elsevier BV
Date: 08-2015
Publisher: Springer Science and Business Media LLC
Date: 21-10-2014
Publisher: Wiley
Date: 11-1998
Publisher: Wiley
Date: 10-2004
Publisher: Elsevier BV
Date: 09-2016
DOI: 10.1016/J.CLINEURO.2016.06.012
Abstract: Head injury commonly presents in association with torso or limb injuries, especially in blunt trauma mechanisms. Stopping life-threatening thoraco-abdominal hemorrhage and preventing secondary brain injury are time critical priorities. Although simultaneous operative management by multiple teams has been common practice in the recent wars in Iraq and Afghanistan, simultaneous surgery is rare in most civilian settings. Nevertheless, situations arise whereby simultaneous craniotomy and chest or abdominal surgery is necessary to prevent mortality or reduce severe morbidity. We discuss two recent cases at our level one trauma centre, the challenges that surgeons and the operating room staff face and propose that with appropriate planning this surgical capability can be integrated into the systems of contemporary advanced trauma units.
Publisher: Springer Science and Business Media LLC
Date: 09-03-2011
Publisher: Elsevier BV
Date: 04-2023
Publisher: AMPCo
Date: 06-2008
Publisher: Public Library of Science (PLoS)
Date: 07-08-2012
Publisher: Springer Science and Business Media LLC
Date: 12-2018
Publisher: Springer Science and Business Media LLC
Date: 27-07-2022
DOI: 10.1186/S13054-022-04079-W
Abstract: While the Glasgow coma scale (GCS) is one of the strongest outcome predictors, the current classification of traumatic brain injury (TBI) as ‘mild’, ‘moderate’ or ‘severe’ based on this fails to capture enormous heterogeneity in pathophysiology and treatment response. We hypothesized that data-driven characterization of TBI could identify distinct endotypes and give mechanistic insights. We developed an unsupervised statistical clustering model based on a mixture of probabilistic graphs for presentation ( 24 h) demographic, clinical, physiological, laboratory and imaging data to identify subgroups of TBI patients admitted to the intensive care unit in the CENTER-TBI dataset ( N = 1,728). A cluster similarity index was used for robust determination of optimal cluster number. Mutual information was used to quantify feature importance and for cluster interpretation. Six stable endotypes were identified with distinct GCS and composite systemic metabolic stress profiles, distinguished by GCS, blood lactate, oxygen saturation, serum creatinine, glucose, base excess, pH, arterial partial pressure of carbon dioxide, and body temperature. Notably, a cluster with ‘moderate’ TBI (by traditional classification) and deranged metabolic profile, had a worse outcome than a cluster with ‘severe’ GCS and a normal metabolic profile. Addition of cluster labels significantly improved the prognostic precision of the IMPACT (International Mission for Prognosis and Analysis of Clinical trials in TBI) extended model, for prediction of both unfavourable outcome and mortality (both p 0.001). Six stable and clinically distinct TBI endotypes were identified by probabilistic unsupervised clustering. In addition to presenting neurology, a profile of biochemical derangement was found to be an important distinguishing feature that was both biologically plausible and associated with outcome. Our work motivates refining current TBI classifications with factors describing metabolic stress. Such data-driven clusters suggest TBI endotypes that merit investigation to identify bespoke treatment strategies to improve care. Trial registration The core study was registered with ClinicalTrials.gov, number NCT02210221 , registered on August 06, 2014, with Resource Identification Portal (RRID: SCR_015582).
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2013
Publisher: Elsevier BV
Date: 07-2006
Publisher: American Medical Association (AMA)
Date: 09-2021
Publisher: Mary Ann Liebert Inc
Date: 20-05-2012
Abstract: Knowledge of the breadth, nature, and volume of traumatic brain injury (TBI) and spinal cord injury (SCI) research can aid in research planning. This study aimed to provide an overview of existing TBI and SCI research to inform identification of knowledge translation (KT), systematic review (SR), and primary research opportunities. Topics and relevant articles from three large neurotrauma evidence resources were synthesized: the Global Evidence Mapping (GEM) Initiative (129 topics and 1644 articles), the Acquired Brain Injury Evidence-Based Review (ERABI 152 topics and 732 articles), and the Spinal Cord Injury Rehabilitation Evidence (SCIRE) Project (297 topics and 1650 articles). A de-duplicated dataset of SRs, randomized controlled trials (RCTs), and other studies identified by these projects was created. In all, 145 topics were identified (66 TBI and 79 SCI), yielding 3466 research articles (1256 TBI and 2210 SCI). Topics with KT potential included cognitive therapies for TBI and prevention/management of urinary tract problems post-SCI, which accounted for 17% and 18%, respectively, of the TBI and SCI yield. Topics that may require SR included management of raised intracranial pressure in TBI, and ventilation and intermittent positive pressure interventions following SCI. Topics for which primary research may be needed included pharmacological therapies for neurological recovery post-TBI, and management of sleep-disordered breathing post-SCI. There was a larger volume of non-intervention (epidemiological) studies in SCI than in TBI. This comprehensive overview of TBI and SCI research can aid funding agencies, researchers, clinicians, and other stakeholders in prioritizing and planning TBI and SCI research.
Publisher: Wiley
Date: 11-2007
Publisher: Elsevier BV
Date: 02-2022
Publisher: Wiley
Date: 04-2001
DOI: 10.1046/J.1442-9071.2001.D01-5.X
Abstract: To assess the visual outcomes and quality of life after cataract surgery in Aborig nal people and compare them with a case-matched population of non-Aborginal people living in remote and rural areas in the Top End of the Northern Territory. Patients living in remote areas of the Top End of the Northern Territory who underwent cataract surgery between 1994 and 1999 were identified from records at the three major hospitals in the region. Eighty-three patients were included in the study. Each patient underwent a complete ocular assessment and then was administered a standardized, field-tested, 12-item questionnaire concerning visual function. This was analyzed and the results of the Aboriginal and matched non-Aboriginal populations compared. Sixty one Aboriginal and 22 non-Aboriginal people from a total of 295 patients who underwent cataract surgery were included in the study. The two study groups were closely matched by sex, age at the time of surgery, time of follow up from surgery and the number who had undergone bilateral surgeryThe median preoperative visual acuity for the Aboriginal group was 6/60 against 6/24 of the non-Aboriginal group. After surgery, at the time of follow up, 26% of eyes in Aboriginal patients did not correct to 6/12 or better with pinhole approximation. Posterior capsule opacities were the most common principal postoperative cause for a deterioration of visual acuity in both groups. Postoperatve trauma was a common cause for a low best-corrected visual acuity n the Aboriginal group but not in the non-Aboriginal group. The majority (75.5%) of Aboriginal patients were satisfied with their operated eyes. Patients who were dissatisfied all had a visual acuity worse than 6/36. Aborigina patients reported worse visual function than did those in the non-Aboriginal group. Cataract surgery has a beneficial effect on the visual acuity and quality of life of Aboriginal and non-Aboriginal people. As compared to their non-Aboriginal counterparts, most Aboriginal people underwent surgery when they were legally blind, had a lower level of attained postoperative visual acuity and a high incidence of uncorrected refractive errors and posterior capsular opacification requiring laser capsulotomy. The positive mpact of cataract surgery on the lives of the majority of Aboriginal patients is highlighted, as is the need for continued postoperative follow up.
Publisher: Springer Science and Business Media LLC
Date: 24-07-2021
Publisher: Springer Science and Business Media LLC
Date: 12-2015
Publisher: Wiley
Date: 21-10-2008
Publisher: Informa UK Limited
Date: 11-2013
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2014
Publisher: Wiley
Date: 10-1997
DOI: 10.1111/J.1445-2197.1997.TB07109.X
Abstract: Wounds are a common problem, particularly in the elderly population. The scale of wound problems in hospital is largely unknown because wounds are widely dispersed. The present study examined the point prevalence of hospital wounds and undertook a pressure ulcer risk assessment of all patients on one day. All 360 inpatients were surveyed and thoroughly examined. A risk scale for pressure sore development, the Norton score, was applied. When wounds were found, information was collected to determine their aetiology. Forty leg ulcers, 40 pressure sores, 85 surgical wounds and seven other types of wounds were found. Most leg ulcer and pressure sore cases were admitted for other reasons. The Norton score did not predict all cases of pressure ulceration. A total of 52% of wounds did not qualify for additional funding under current funding criteria. The prevalence of non-surgical wounds in Heidelberg Repatriation Hospital was easily underestimated. Wound care management can be optimized by staff education and protocol design, early identification of troublesome wounds and of at-risk patients, and a cross-sectional approach that incorporates wound-management teams.
Publisher: Elsevier BV
Date: 04-2015
Publisher: Springer Science and Business Media LLC
Date: 31-10-2016
DOI: 10.1007/S00268-016-3759-8
Abstract: Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries. From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with erse economic and geographic contexts. Primary end points were adherence to process of care measures secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability. Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation (p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses. Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in erse settings.
Publisher: Public Library of Science (PLoS)
Date: 18-02-2014
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2009
DOI: 10.1002/CHP.20034
Abstract: In recent years increasing attention has been paid to issues of professionalism in surgery and the content and structure of continuing professional development for surgeons however, little attention has been paid to interprofessional education (IPE) in surgical training. Imagining the form(s) of IPE and/or continuing interprofessional education (CIPE) programs within surgical training requires serious attention to 2 fundamental issues--the discourses of professionalism in surgery and the professional culture of surgery, as shaped and expressed within the clinical setting. We explore the possibility that concepts of professionalism within surgery may be in conflict with the tenets of interprofessionalism held by other health and medical professionals. We believe that if any rapprochement is to occur between the concept of professionalism in surgical training (and within the everyday clinical culture of surgical subspecialties groups and their professional institutions) and broader discourses of interprofessionalism circulating within health care institutions, there is a pressing need to understand and deconstruct this conflict from the point of view of surgery.
Publisher: Elsevier BV
Date: 06-2013
DOI: 10.1016/J.INJURY.2013.02.003
Abstract: The burden of injury is greatest in developing countries. Trauma systems have reduced mortality in developed countries and trauma registries are known to be integral to monitoring and improving trauma care. There are relatively few trauma registries in developing countries and no reviews describing the experience of each registry. The aim of this study was to examine the collective published experience of trauma registries in developing countries. A structured review of the literature was performed. Relevant abstracts were identified by searching databases for all articles regarding a trauma registry in a developing country. A tool was used to abstract trauma registry details, including processes of data collection and analysis. There were 84 articles, 76 of which were sourced from 47 registries. The remaining eight articles were perspectives. Most were from Iran, followed by China, Jamaica, South Africa and Uganda. Only two registries used the Injury Severity Score (ISS) to define inclusion criteria. Most registries collected data on variables from all five variable groups (demographics, injury event, process of care, injury severity and outcome). Several registries collected data for less than a total of 20 variables. Only three registries measured disability using a score. The most commonly used scores of injury severity were the ISS, followed by Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and the K ala Trauma Score (KTS). Amongst the small number of trauma registries in developing countries, there is a large variation in processes. The implementation of trauma systems with trauma registries is feasible in under-resourced environments where they are desperately needed.
Publisher: Wiley
Date: 12-2010
DOI: 10.1111/J.1742-6723.2010.01355.X
Abstract: Clinical practice guidelines for haemodynamically unstable patients with pelvic fractures were initiated in February 2005 at our level 1 trauma centre. The purpose of the present study was to evaluate guideline adherence and outcome of guideline performance. In a retrospective clinical study all patients admitted with a pelvic fracture from August 2003 to March 2007 were identified from a prospective trauma registry database. Medical records of all patients were reviewed. Patients with pelvic fractures associated with haemodynamic instability were included. Patients were ided into two groups: preguideline and postguideline. The two groups were compared. Main outcome measurements were 24 h fluid requirement, total blood transfusion, length of stay in ICU and hospital, and mortality rate. Of the 210 patients with pelvic fractures, 32 patients met the inclusion criteria. Preguideline group consisted of 13 and postguideline group 19 patients. Non-invasive pelvic stabilization was applied significantly more postguideline (92.3% vs 33.3%, P= 0.004). Focused abdominal sonography for trauma and pelvic angiography/embolization have been used significantly more in the postguideline group (5 vs 14, P= 0.046 and 0 vs 6, P= 0.025, respectively). There was no significant difference in 24 h fluid requirement, total blood transfusion, length of stay in ICU and hospital, and mortality rate between the two groups. The introduction of guidelines has influenced the approach to haemodynamically unstable patients with pelvic fractures. Multiple factors can potentially influence the strict adherence to the guideline. Care provided can still be improved by addressing the challenges in guideline performance.
Publisher: Massachusetts Medical Society
Date: 26-04-2007
DOI: 10.1056/NEJMSA064508
Publisher: Springer Science and Business Media LLC
Date: 11-12-2020
DOI: 10.1007/S12028-020-01151-7
Abstract: Trauma-induced coagulopathy in patients with traumatic brain injury (TBI) is associated with high rates of complications, unfavourable outcomes and mortality. The mechanism of the development of TBI-associated coagulopathy is poorly understood. This analysis, embedded in the prospective, multi-centred, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, aimed to characterise the coagulopathy of TBI. Emphasis was placed on the acute phase following TBI, primary on subgroups of patients with abnormal coagulation profile within 4 h of admission, and the impact of pre-injury anticoagulant and/or antiplatelet therapy. In order to minimise confounding factors, patients with isolated TBI (iTBI) ( n = 598) were selected for this analysis. Haemostatic disorders were observed in approximately 20% of iTBI patients. In a subgroup analysis, patients with pre-injury anticoagulant and/or antiplatelet therapy had a twice exacerbated coagulation profile as likely as those without premedication. This was in turn associated with increased rates of mortality and unfavourable outcome post-injury. A multivariate analysis of iTBI patients without pre-injury anticoagulant therapy identified several independent risk factors for coagulopathy which were present at hospital admission. Glasgow Coma Scale (GCS) less than or equal to 8, base excess (BE) less than or equal to − 6, hypothermia and hypotension increased risk significantly. Consideration of these factors enables early prediction and risk stratification of acute coagulopathy after TBI, thus guiding clinical management.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2014
Publisher: Wiley
Date: 09-2011
DOI: 10.5694/MJA11.10379
Abstract: To describe the frequency, characteristics, and outcomes of medicolegal disputes over informed consent. Retrospective review and analysis of negligence claims against doctors insured by Avant Mutual Group Limited and complaints lodged with the Office of the Health Services Commissioner of Victoria that alleged failures in the informed consent process and were adjudicated between 1 January 2002 and 31 December 2008. Case frequency (by medical specialty), type of allegation, type of treatment. A total of 481 cases alleged deficiencies in the informed consent process (218 of 1898 conciliated complaints [11.5%] 263 of 7846 negligence claims [3.4%]). 57% of these cases were against surgeons. Plastic surgeons experienced dispute rates that were more than twice those of any other specialty or subspecialty group. 92% of cases (442/481) involved surgical procedures and 16% (77/481) involved cosmetic procedures. The primary allegation in 71% of cases was that the clinician failed to mention or properly explain risks of complications. Five treatment types - procedures on reproductive organs (12% of cases), procedures on facial features excluding eyes (12%), prescription medications (8%), eye surgery (7%) and breast surgery (7%) - accounted for 46% of all cases. The typical dispute over informed consent involves an operation, often cosmetic, and allegations that a particular complication was not properly disclosed. With Australian courts now looking to patient preferences in setting legal standards of care for risk disclosure, medicolegal disputes provide valuable insights for targeting both quality improvement efforts and risk management activities.
Publisher: Springer Science and Business Media LLC
Date: 07-08-2012
Publisher: Springer Science and Business Media LLC
Date: 06-09-2017
Publisher: Elsevier BV
Date: 04-2019
Publisher: Elsevier BV
Date: 2017
DOI: 10.1016/J.HLC.2017.02.014
Abstract: Atrial fibrillation (AF) is the most frequent complication of surgery performed on cardiopulmonary bypass (CPB) and recent work associates CPB with postoperative inflammation. We have shown that all tissue injury releases mitochondrial damage associated molecular patterns (mtDAMPs) including mitochondrial DNA (mtDNA). This can act as a direct, early activator of neutrophils (PMN), eliciting a systemic inflammatory response syndrome (SIRS) while suppressing PMN function. Neutrophil Extracellular Traps (NETs) are crucial to host defence. They carry out NETosis wherein webs of granule proteins and chromatin trap and kill bacteria. We hypothesised that surgery performed on CPB releases mtDAMPs into the circulation. Molecular patterns thus mobilised during CPB might then participate in the pathogenesis of SIRS and predict postoperative complications like AF [1]. We prospectively studied 16 patients undergoing elective operations on CPB. Blood was s led preoperatively, at the end of CPB and on days 1-2 postoperatively. Plasma s les were analysed for mtDNA. Neutrophil IL-6 gene expression was studied to assess induction of SIRS. Neutrophils were also assayed for the presence of neutrophil extracellular traps (NETs/NETosis). These biologic findings were then correlated to clinical data and compared in patients with and without postoperative AF (POAF). Mitochondrial DNA was significantly elevated following CPB (six-fold increase post-CPB, p=0.008 and five-fold increase days 1-2, p=0.02). Patients with POAF showed greater increases in mtDNA post-CPB than those without. Postoperative AF was seen in all patients with a ≥2-fold increase of mtDNA (p=0.037 vs. <2-fold). Neutrophil IL-6 gene transcription increased postoperatively demonstrating SIRS that was greatest days 1-2 (p=0.039). Neutrophil extracellular trap (NET) formation was markedly suppressed in the post-CPB state. Mitochondrial DNA is released by CPB surgery and is associated with POAF. IL-6 gene expression increases after CPB, demonstrating the evolution of postoperative SIRS. Lastly, cardiac surgery on CPB also suppressed PMN NETosis. Taken together, our data suggest that mtDNA released during surgery on CPB, may be involved in the pathogenesis of SIRS and related postoperative inflammatory events like POAF and infections. Mitochondrial DNA may therefore prove to be an early biomarker for postoperative complications with the degree of association to be determined in appropriately sized studies. If mtDNA is directly involved in cardiac inflammation, mtDNA-induced toll-like receptor-9 (TLR9) signalling could also be targeted therapeutically.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2011
Publisher: American Medical Association (AMA)
Date: 11-04-2010
DOI: 10.1001/ARCHOPHTHALMOL.2010.319
Abstract: To examine how mydriasis and the medical qualifications of photographers who take retinal photographs influence the accuracy of screening for diabetic retinopathy (DR). Our meta-analysis included studies that measured the sensitivity and specificity of tests designed to detect any DR, sight-threatening DR, or macular edema. Using random-effects logistic regression, we examined the effect of variations in mydriatic status and in medical qualifications of photographers on sensitivity and specificity. Only the category of "any DR" had sufficient consistency in definition, number of studies (n = 20), and number of assessments (n = 40) for meta-analysis. Variations in mydriatic status did not significantly influence sensitivity (odds ratio [OR], 0.89 95% confidence interval [CI], 0.56-1.41 P = .61) or specificity (OR, 0.94 95% CI, 0.57-1.54 P = .80). Variations in medical qualifications of photographers did not significantly influence sensitivity (OR, 1.25 95% CI, 0.31-5.12 P = .75). Specificity of detection of any DR was significantly higher for screening methods that use a photographer with specialist medical or eye qualifications (OR, 3.86 95% CI, 1.78-8.37 P = .001). Outreach screening is an effective alternative to on-site specialist examination. It has potential to increase screening coverage of high-risk patients with DR in remote and resource-poor settings without the risk of missing DR and the opportunity to prevent vision loss. Our analysis was confined to the presence or absence of DR. Future studies should use consistent DR classification schemes to facilitate further analysis.
Publisher: Elsevier BV
Date: 04-2021
Publisher: Springer Science and Business Media LLC
Date: 11-02-2019
Publisher: AMPCo
Date: 16-05-2005
DOI: 10.5694/J.1326-5377.2005.TB00023.X
Abstract: It takes humility to walk along the path towards better Aboriginal health.
Publisher: Massachusetts Medical Society
Date: 13-07-2023
Publisher: Mary Ann Liebert Inc
Date: 15-04-2021
Publisher: Springer Science and Business Media LLC
Date: 06-12-2021
DOI: 10.1007/S12028-021-01386-Y
Abstract: In traumatic brain injury (TBI), large between-center differences in treatment and outcome for patients managed in the intensive care unit (ICU) have been shown. The aim of this study is to explore if European neurotrauma centers can be clustered, based on their treatment preference in different domains of TBI care in the ICU. Provider profiles of centers participating in the Collaborative European Neurotrauma Effectiveness Research in TBI study were used to assess correlations within and between the predefined domains: intracranial pressure monitoring, coagulation and transfusion, surgery, prophylactic antibiotics, and more general ICU treatment policies. Hierarchical clustering using Ward’s minimum variance method was applied to group data with the highest similarity. Heat maps were used to visualize whether hospitals could be grouped to uncover types of hospitals adhering to certain treatment strategies. Provider profiles were available from 66 centers in 20 different countries in Europe and Israel. Correlations within most of the predefined domains varied from low to high correlations (mean correlation coefficients 0.2–0.7). Correlations between domains were lower, with mean correlation coefficients of 0.2. Cluster analysis showed that policies could be grouped, but hospitals could not be grouped based on their preference. Although correlations between treatment policies within domains were found, the failure to cluster hospitals indicates that a specific treatment choice within a domain is not a proxy for other treatment choices within or outside the domain. These results imply that studying the effects of specific TBI interventions on outcome can be based on between-center variation without being substantially confounded by other treatments. We do not report the results of a health care intervention.
Publisher: Springer Science and Business Media LLC
Date: 13-05-2016
Publisher: Elsevier BV
Date: 05-2012
DOI: 10.1016/J.JCLINEPI.2012.04.002
Abstract: We present a multistep process for identifying priority research areas in rehabilitation and long-term care of traumatic brain-injured (TBI) patients. In particular, we aimed to (1) identify which stakeholders should be involved (2) identify what methods are appropriate (3) examine different criteria for the generation of research priority areas and (4) test the feasibility of linkage and exchange among researchers, decision makers, and other potential users of the research. Potential research questions were identified and developed using an initial scoping meeting and preliminary literature search, followed by a facilitated mapping workshop and an online survey. Identified research questions were then prioritized against specific criteria (clinical importance, novelty, and controversy). Existing evidence was then mapped to the high-priority questions using usual processes for search, screening, and selection. A broad range of stakeholders were then brought together at a forum to identify priority research themes for future research investment. Using clinical and research leaders, smaller targeted planning workshops prioritized specific research projects for each of the identified themes. Twenty-six specific questions about TBI rehabilitation were generated, 14 of which were high priority. No one method identified all high-priority questions. Methods that relied solely on the views of clinicians and researchers identified fewer high-priority questions compared with methods that used broader stakeholder engagement. Evidence maps of these high-priority questions yielded a number of evidence gaps. Priority questions and evidence maps were then used to inform a research forum, which identified 12 priority themes for future research. Our research demonstrates the value of a multistep and multimethod process involving many different types of stakeholders for prioritizing research to improve the rehabilitation outcomes of people who have suffered TBI. Enhancing stakeholder representation can be augmented using a combination of methods and a process of linkage and exchange. This process can inform decisions about prioritization of research areas.
Publisher: Elsevier BV
Date: 10-2019
DOI: 10.1016/J.INJURY.2019.04.003
Abstract: Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM. This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop. There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9 95% CI:2.5-47.6, p < 0.001). This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients.
Publisher: Springer Science and Business Media LLC
Date: 20-05-2015
DOI: 10.1007/S00268-014-2638-4
Abstract: The unmet global burden of surgical disease is substantial. Currently, two billion people do not have access to emergency and essential surgical care. This results in unnecessary deaths from injury, infection, complications of pregnancy, and abdominal emergencies. Inadequately treated surgical disease results in disability, and many children suffer deformity without corrective surgery. A consensus meeting was held between representatives of Surgical and Anaesthetic Colleges and Societies to obtain agreement about which indicators were the most appropriate and credible. The literature and state of national reporting of perioperative mortality rates was reviewed by the authors. There is a need for a credible national and/or regional indicator that is relevant to emergency and essential surgical care. We recommend introducing the perioperative mortality rate (POMR) as an indicator of access to and safety of surgery and anaesthesia. POMR should be measured at two time periods: death on the day of surgery and death before discharge from hospital or within 30 days of the procedure, whichever is sooner. The rate should be expressed as the number of deaths (numerator) over the number of procedures (denominator). The option of before-discharge or 30 days is practical for those low- to middle-income countries where postdischarge follow-up is likely to be incomplete, but it allows those that currently can report 30-day mortality rates to continue to do so. Clinical interpretation of POMR at a hospital or health service level will be facilitated by risk stratification using age, urgency (elective and emergency), procedure rocedure group, and the American Society of Anesthesiologists grade. POMR should be reported as a health indicator by all countries and regions of the world. POMR reporting is feasible, credible, achieves a consensus of acceptance for reporting at national level. Hospital and Service level POMR requires interpretation using simple measures of risk adjustment such as urgency, age, the condition being treated or the procedure being performed and ASA status.
Publisher: Springer Science and Business Media LLC
Date: 20-06-2009
DOI: 10.1007/S00268-009-0103-6
Abstract: Saltwater crocodiles are formidable predators in northern Australia, and crocodile attacks on humans are not rare. With recent deaths highlighting this as a public health issue, an evidence-based discourse about effective methods of minimizing the danger to humans is needed. Using the Haddon Matrix for injury prevention, approaches to minimizing crocodile associated death and injury were sought. Possibilities for harm minimization before, during and after a crocodile attack are identified, and their merits appraised. The importance of excellent prehospital and surgical and critical care is emphasized. A combination of behavior adaptation, mutual respect, and minimizing contact will be the key to minimizing the harm from attacks, and excellent medical and surgical care will always be necessary for those unfortunate to be victims but fortunate to survive.
Publisher: Springer Science and Business Media LLC
Date: 10-09-2020
DOI: 10.1007/S00415-020-10174-1
Abstract: The original version of this article unfortunately contained a mistake.
Publisher: Springer Science and Business Media LLC
Date: 21-03-2014
DOI: 10.1186/S13049-021-00930-1
Abstract: Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients. Patients with moderate and severe TBI (Glasgow Coma Scale 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively. A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90). Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation.
Publisher: BMJ
Date: 09-09-2015
DOI: 10.1136/EMERMED-2015-205053
Abstract: Implementation research aims to increase the uptake of research findings into clinical practice to improve the quality of healthcare. This scoping systematic study aims to assess the volume and scope of implementation research in emergency medicine (EM) to obtain an overview and inform future implementation research. Studies were identified by searching electronic databases and reference lists of included studies for the years 2002, 2007 and 2012. Titles/abstracts were screened, full papers checked and data extracted by one author, with a random s le checked by a second author. A total of 3581 citations were identified with 197 eligible papers included. The number of papers significantly increased over time from 26 in 2002 to 77 in 2007 and 94 in 2012 (p<0.05). Eighty-two (42%) focused on identifying evidence-practice gaps, 77 (39%) evaluated the effectiveness of implementation interventions and 38 (19%) explored barriers and enablers to change. Only two papers explicitly stated that theory was used. Five of the 77 effectiveness studies used a randomised design and few provided sufficient detail about the intervention undergoing evaluation. Although there was a significant increase in the number of implementation research papers, most studies focused on identifying evidence-practice gaps or used weak study designs to evaluate the effects of implementation interventions. Recommendations for improving implementation research in EM include identifying barriers and enablers to implementation, using theory in areas where proven important gaps exist, improving the reporting of the content of interventions and using rigorous study designs to evaluate their effectiveness.
Publisher: Springer Science and Business Media LLC
Date: 28-06-2016
DOI: 10.1007/S00268-016-3614-Y
Abstract: Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care. We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures. The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p < 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures. Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.
Publisher: Mary Ann Liebert Inc
Date: 04-2019
Abstract: Observer variability in local radiological reading is a major concern in large-scale multi-center traumatic brain injury (TBI) studies. A central review process has been advocated to minimize this variability. The aim of this study is to compare central with local reading of TBI imaging datasets and to investigate the added value of central review. A total of 2050 admission computed tomography (CT) scans from subjects enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study were analyzed for seven main CT characteristics. Kappa statistics were used to calculate agreement between central and local evaluations and a center-specific analysis was performed. The McNemar test was used to detect whether discordances were significant. Central interobserver and intra-observer agreement was calculated in a subset of patients. Good agreement was found between central and local assessment for the presence or absence of structural pathology (CT+, CT-, κ = 0.73) and most CT characteristics (κ = 0.62 to 0.71), except for traumatic axonal injury lesions (κ = 0.37). Despite good kappa values, discordances were significant in four of seven CT characteristics (i.e., midline shift, contusion, traumatic subarachnoid hemorrhage, and cisternal compression p = 0.0005). Central reviewers showed substantial to excellent interobserver and intra-observer agreement (κ = 0.73 to κ = 0.96), contrasted by considerable variability in local radiological reading. Compared with local evaluation, a central review process offers a more consistent radiological reading of acute CT characteristics in TBI. It generates reliable, reproducible data and should be recommended for use in multi-center TBI studies.
Publisher: Elsevier BV
Date: 2011
DOI: 10.1016/J.INJURY.2011.10.011
Abstract: A high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) is currently recognised as the standard of care in some centres during massive transfusion post trauma. The aim of this study was to test whether the presumption of benefit held true for severely injured patients who received a massive transfusion, but did not present with acute traumatic coagulopathy. Data collected in The Alfred Trauma Registry over a 6 year period were reviewed. Included patients were sub-grouped by a high FFP:PRBC ratio (≥1:2) in the first 4 h and compared to patients receiving a lower ratio. Outcomes studied were associations with mortality, hours in the intensive care unit and hours of mechanical ventilation. Of 4164 eligible patients, 374 received a massive transfusion and 179 (49.7%) patients who did not have coagulopathy were included for analysis. There were 66 patients who received a high ratio of FFP:PRBC, and were similar in demographics and presentation to 113 patients who received a lower ratio. There was no significant difference in mortality between the two groups (p=0.80), and the FFP:PRBC ratio was not significantly associated with mortality, ICU length of stay or mechanically ventilated hours. A small proportion of major trauma patients received a massive blood transfusion in the absence of acute traumatic coagulopathy. Aggressive FFP transfusion in this group of patients was not associated with significantly improved outcomes. FFP transfusion carries inherent risks with substantial costs and the population most likely to benefit from a high FFP:PRBC ratio needs to be clearly defined.
Publisher: Springer Science and Business Media LLC
Date: 13-05-2004
Publisher: Wiley
Date: 03-2010
DOI: 10.1111/J.1445-2197.2010.05209.X
Abstract: There has been a shift from operative to conservative management of splenic injuries in the last two decades, but the current practice in Australia is not known. This study aims to determine the profile of splenic injury in major trauma victims and the approach to treatment in Victoria for the last 2 years. A review of prospectively collected data from the Victorian State Trauma Registry (VSTR) from July 2005 to June 2007 was conducted. Demographic data, details of the event, clinical observations, management and associated outcomes were extracted from the database. The patients were categorized into four groups according to management (conservative, splenectomy, embolization and repair) and were compared accordingly. Multivariate binary logistic regression was performed to identify predictors of treatment (conservative versus splenectomy) on arrival. Of the 318 major trauma patients with splenic injuries, 186 (59%) were treated conservatively, 103 (32%) with splenectomy, 17 (5%) with arterial embolization and 12 (4%) with repair. Of these, 14 (14%) splenectomy cases and 2 (12%) embolization cases did not receive their respective treatments within 24 h. The severity of the spleen injury (as measured by the Abbreviated Injury Scale (AIS)) and age were identified as significant independent predictors of the form of treatment provided. In Victoria, conservative management is the preferred approach in patients with minor (AIS = 2) to moderate (AIS = 3) splenic injuries. The low rates of embolization warrant further research into whether splenectomy is overused.
Publisher: CSIRO Publishing
Date: 2012
DOI: 10.1071/AH11064
Abstract: Objectives. Health policy making is complex, but can be informed by evidence of what works, including systematic reviews. We aimed to inform the work of the Cochrane Effective Practice and Organisation of Care (EPOC) Group by identifying systematic review topics relevant to Australian health policy makers and exploring whether existing Cochrane reviews address these topics. Methods. We interviewed 30 senior policy makers from State and Territory Government Departments of Health to identify topics considered important for systematic reviews within the scope of health services research, including professional, financial, organisational and regulatory interventions to improve professional practice and the organisation of services. We then looked for existing Cochrane reviews relevant to these topics. Results. Eighty-five priority topics were identified by policy makers, including advanced practice roles, care for Indigenous Australians, care for chronic disease, coordinating across jurisdictions, admission avoidance, and eHealth. Sixty published Cochrane reviews address these issues, and 34 additional reviews are in progress. Thirty-four topics are yet to be addressed. Conclusions. This survey has identified questions for which Australian policy makers have indicated a need for systematic reviews. Further, it has confirmed that existing reviews do address issues of importance to policy makers, with the potential to inform policy processes. What is known about the topic? Evidence-informed policy making is a complex process, requiring integration of relevant evidence in the context of multiple influences, inputs and priorities. Communication between policy makers and researchers is likely to increase the availability of relevant research evidence for policy, and improve its uptake into action. The Cochrane Effective Practice and Organisation of Care Group produces systematic reviews in areas intersecting with key policy responsibilities, including professional, financial, organisational and regulatory interventions designed to improve health professional practice and the organisation of healthcare services, and seeks to engage with policy makers to identify their research priorities. What does this paper add? This study surveyed Australian health policy makers from each of the Australian State and Territory Government Departments of Health, and identified 85 policy questions for which they considered systematic reviews of the evidence would be useful. Relevant to these topics, 60 existing published Cochrane systematic reviews were identified, as well as 34 reviews in progress, and 34 topics not yet addressed. The study also identified those published reviews that could not reach definitive conclusions, indicating that more primary research is required. What are the implications for practitioners? For researchers, areas of need for new systematic reviews have been identified. For policy makers, a suite of relevant systematic reviews have been identified that may be of use in policy processes.
Publisher: Springer Science and Business Media LLC
Date: 03-08-2021
DOI: 10.1038/S41598-021-94401-3
Abstract: Plasma fibrinogen is an important coagulation factor and susceptible to post-translational modification by oxidants. We have reported impairment of fibrin polymerization after exposure to hypochlorous acid (HOCl) and increased methionine oxidation of fibrinogen in severely injured trauma patients. Molecular dynamics suggests that methionine oxidation poses a mechanistic link between oxidative stress and coagulation through protofibril lateral aggregation by disruption of AαC domain structures. However, experimental evidence explaining how HOCl oxidation impairs fibrinogen structure and function has not been demonstrated. We utilized polymerization studies and two dimensional-nuclear magnetic resonance spectrometry (2D-NMR) to investigate the hypothesis that HOCl oxidation alters fibrinogen conformation and T 2 relaxation time of water protons in the fibrin gels. We have demonstrated that both HOCl oxidation of purified fibrinogen and addition of HOCl-oxidized fibrinogen to plasma fibrinogen solution disrupted lateral aggregation of protofibrils similarly to competitive inhibition of fibrin polymerization using a recombinant AαC fragment (AαC 419–502). DOSY NMR measurement of fibrinogen protons demonstrated that the diffusion coefficient of fibrinogen increased by 17.4%, suggesting the oxidized fibrinogen was more compact and fast motion in the prefibrillar state. 2D-NMR analysis reflected that water protons existed as bulk water (T 2 ) and intermediate water (T 2i ) in the control plasma fibrin. Bulk water T 2 relaxation time was increased twofold and correlated positively with the level of HOCl oxidation. However, T 2 relaxation of the oxidized plasma fibrin gels was dominated by intermediate water. Oxidation induced thinner fibers, in which less water is released into the bulk and water fraction in the hydration shell was increased. We have confirmed that T 2 relaxation is affected by the self-assembly of fibers and stiffness of the plasma fibrin gel. We propose that water protons can serve as an NMR signature to probe oxidative rearrangement of the fibrin clot.
Publisher: Mary Ann Liebert Inc
Date: 19-10-2020
Publisher: Elsevier BV
Date: 09-2023
Publisher: Mary Ann Liebert Inc
Date: 06-2020
Abstract: The aim of this study is to investigate the prognostic value of using the National Institute of Neurological Disorders and Stroke (NINDS) standardized imaging-based pathoanatomic descriptors for the evaluation and reporting of acute traumatic brain injury (TBI) lesions. For a total of 3392 patients (2244 males and 1148 females, median age = 51 years) enrolled in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, we extracted 96 Common Data Elements (CDEs) from the structured reports, spanning all three levels of pathoanatomic information (i.e., 20 "basic," 60 "descriptive," and 16 "advanced" CDE variables per patient). Six-month clinical outcome scores were dichotomized into favorable (Glasgow Outcome Scale Extended [GOS-E] = 5-8) versus unfavorable (GOS-E = 1-4). Regularized logistic regression models were constructed and compared using the optimism-corrected area under the curve (AUC). An abnormality was reported for the majority of patients (64.51%). In 79.11% of those patients, there was at least one coexisting pathoanatomic lesion or associated finding. An increase in lesion severity, laterality, and volume was associated with more unfavorable outcomes. Compared with the full set of pathoanatomic descriptors (i.e., all three categories of information), reporting "basic" CDE information provides at least equal discrimination between patients with favorable versus unfavorable outcome (AUC = 0.8121 vs. 0.8155, respectively). Addition of a selected subset of "descriptive" detail to the basic CDEs could improve outcome prediction (AUC = 0.8248). Addition of "advanced" or "emerging/exploratory" information had minimal prognostic value. Our results show that the NINDS standardized-imaging based pathoanatomic descriptors can be used in large-scale studies and provide important insights into acute TBI lesion patterns. When used in clinical predictive models, they can provide excellent discrimination between patients with favorable and unfavorable 6-month outcomes. If further validated, our findings could support the development of structured and itemized templates in routine clinical radiology.
Publisher: BMJ
Date: 10-05-2022
Abstract: Following traumatic brain injury (TBI), the clinical focus is often on disability. However, patients’ perceptions of well-being can be discordant with their disability level, referred to as the ‘disability paradox’. We aimed to examine the relationship between disability and health-related quality of life (HRQoL) following TBI, while taking variation in personal, injury-related and environment factors into account. We used data from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury study. Disability was assessed 6 months post-injury by the Glasgow Outcome Scale-Extended (GOSE). HRQoL was assessed by the SF-12v2 physical and mental component summary scores and the Quality of Life after Traumatic Brain Injury overall scale. We examined mean total and domain HRQoL scores by GOSE. We quantified variance in HRQoL explained by GOSE, personal, injury-related and environment factors with multivariable regression. Six-month outcome assessments were completed in 2075 patients, of whom 78% had mild TBI (Glasgow Coma Scale 13–15). Patients with severe disability had higher HRQoL than expected on the basis of GOSE alone, particularly after mild TBI. Up to 50% of patients with severe disability reported HRQoL scores within the normative range. GOSE, personal, injury-related and environment factors explained a limited amount of variance in HRQoL (up to 29%). Contrary to the idea that discrepancies are unusual, many patients with poor functional outcomes reported well-being that was at or above the boundary considered satisfactory for the normative s le. These findings challenge the idea that satisfactory HRQoL in patients with disability should be described as ‘paradoxical’ and question common views of what constitutes ‘unfavourable’ outcome.
Publisher: Elsevier BV
Date: 04-2015
Publisher: Elsevier BV
Date: 03-2011
Publisher: SAGE Publications
Date: 06-11-2013
Abstract: Retrospective review on clinical-quality trauma registry prospective data. To identify early predictors of suboptimal health status in polytrauma patients with spine injuries. A retrospective review on a prospective cohort was performed on spine-injured polytrauma patients with successful discharge from May 2009 to January 2011. The Short Form 12-Questionnaire Health Survey (SF-12) was used in the health status assessment of these patients. Univariate and multivariate logistic regression models were applied to investigate the effects of the Injury Severity Score, age, blood sugar level, vital signs, brain trauma severity, comorbidities, coagulation profile, spine trauma-related neurologic status, and spine injury characteristics of the patients. The SF-12 had a 52.3% completion rate from 915 patients. The patients who completed the SF-12 were younger, and there were fewer patients with severe spinal cord injuries (American Spinal Injury Association classifications A, B, and C). Other comparison parameters were satisfactorily matched. Multivariate logistic regression revealed five early predictive factors with statistical significance ( p ≤ 0.05). They were (1) tachycardia (odds ratio [OR] = 1.88 confidence interval [CI] = 1.11 to 3.19), (2) hyperglycemia (OR = 2.65 CI = 1.51 to 4.65), (3) multiple chronic comorbidities (OR = 2.98 CI = 1.68 to 5.26), and (4) thoracic spine injuries (OR = 1.54 CI = 1.01 to 2.37). There were no independent early predictive factors identified for suboptimal mental health-related qualify of life outcomes. Early independent risk factors predictive of suboptimal physical health status identified in a level 1 trauma center in polytrauma patients with spine injuries were tachycardia, hyperglycemia, multiple chronic medical comorbidities, and thoracic spine injuries. Early spine trauma risk factors were shown not to predict suboptimal mental health status outcomes.
Publisher: Mary Ann Liebert Inc
Date: 24-02-2023
Publisher: Springer Science and Business Media LLC
Date: 06-11-2018
Publisher: Springer Science and Business Media LLC
Date: 13-04-2012
DOI: 10.1007/S00268-012-1593-1
Abstract: Quality Improvement (QI) programs have been shown to be a valuable tool to strengthen care of severely injured patients, but little is known about them in low and middle income countries (LMIC). We sought to explore opportunities to improve trauma QI activities in LMIC, focusing on the Asia-Pacific region. We performed a mixed methods research study using both inductive thematic analysis of a meeting convened at the Royal Australasian College of Surgeons, Melbourne, Australia, November 21-22, 2010 and a pre-meeting survey to explore experiences with trauma QI activities in LMIC. Purposive s ling was employed to invite participants with demonstrated leadership in trauma care to provide erse representation of organizations and countries within Asia-Pacific. A total of 22 experts participated in the meeting and reported that trauma QI activities varied between countries and organizations: morbidity and mortality conferences (56 %), monitoring complications (31 %), preventable death studies (25 %), audit filters (19 %), and statistical methods for analyzing morbidity and mortality (6 %). Participants identified QI gaps to include paucity of reliable/valid injury data, lack of integrated trauma QI activities, absence of standards of care, lack of training in QI methods, and varying cultures of quality and safety. The group highlighted barriers to QI: limited engagement of leaders, organizational ersity, limited resources, heavy clinical workload, and medico-legal concerns. Participants proposed establishing the Asia-Pacific Trauma Quality Improvement Network (APTQIN) as a tool to facilitate training and dissemination of QI methods, injury data management, development of pilot QI projects, and advocacy for quality trauma care. Our study provides the first description of trauma QI practices, gaps in existing practices, and barriers to QI in LMIC of the Asia-Pacific region. In this study we identified opportunities for addressing these challenges, and that work will be supported by APTQIN.
Publisher: Elsevier BV
Date: 09-2012
Publisher: Springer Science and Business Media LLC
Date: 13-01-2014
Publisher: Elsevier BV
Date: 08-2021
Publisher: Frontiers Media SA
Date: 07-08-2018
Publisher: BMJ
Date: 19-11-2012
DOI: 10.1136/BMJ.E7133
Publisher: Springer Science and Business Media LLC
Date: 23-06-2015
DOI: 10.1038/SC.2015.86
Abstract: Literature review/semi-structured interviews. To develop a spinal cord injury (SCI) research strategy for Australia and New Zealand. Australia. The National Trauma Research Institute Forum approach of structured evidence review and stakeholder consultation was employed. This involved gathering from published literature and stakeholder consultation the information necessary to properly consider the challenge, and synthesising this into a briefing document. A research strategy 'roadmap' was developed to define the major steps and key planning questions to consider next, evidence from published SCI research strategy initiatives was synthesised with information from four one-on-one semi-structured interviews with key SCI research stakeholders to create a research strategy framework, articulating six key themes and associated activities for consideration. These resources, combined with a review of SCI prioritisation literature, were used to generate a list of draft principles for discussion in a structured stakeholder dialogue meeting. The research strategy roadmap and framework informed discussion at a structured stakeholder dialogue meeting of 23 participants representing key SCI research constituencies, results of which are published in a companion paper. These resources could also be of value in other research strategy or planning exercises. This project was funded by the Victorian Transport Accident Commission and the Australian and New Zealand Spinal Cord Injury Network.
Publisher: Elsevier BV
Date: 08-2019
Publisher: Springer Science and Business Media LLC
Date: 23-06-2015
DOI: 10.1038/SC.2015.85
Abstract: This is a rapid evidence review. The objective of this study was to gain an overview of the volume, nature and findings of studies regarding priorities for spinal cord injury (SCI) research. A worldwide literature search was conducted. Six medical literature databases and Google Scholar were searched for reviews in which the primary aim was to identify SCI research priorities. Two systematic reviews were identified-one of quantitative and one of qualitative studies. The quality of the reviews was variable. Collectively, the reviews identified 31 primary studies 24 quantitative studies totalling 5262 participants and 7 qualitative studies totalling 120 participants. Despite the difference in research paradigms, there was convergence in review findings in the areas of body impairments and relationships. The vast majority of literature within the reviews focused on the SCI patient perspective. The reviews inform specific research topics and highlight other important research considerations, most notably those pertaining to SCI patients' perspectives on quality of life, which may be of use in determining meaningful research outcome measures. The views of other SCI research stakeholders such as researchers, clinicians, policymakers, funders and carers would help shape a bigger picture of SCI research priorities, ultimately optimising research outputs and translation into clinical practice and health policy change. Review findings informed subsequent activities in developing a regional SCI research strategy, as described in two companion papers. This project was funded by the Victorian Transport Accident Commission and the Australian and New Zealand SCI Network.
Publisher: BMJ
Date: 03-2020
DOI: 10.1136/BMJOPEN-2019-034253
Abstract: The optimal size of the health workforce for children’s surgical care around the world remains poorly defined. The goal of this study was to characterise the surgical workforce for children across Brazil, and to identify associations between the surgical workforce and measures of childhood health. This study is an ecological, cross-sectional analysis using data from the Brazil public health system ( Sistema Único de Saúde ). We collected data on the surgical workforce (paediatric surgeons, general surgeons, anaesthesiologists and nursing staff), perioperative mortality rate (POMR) and under-5 mortality rate (U5MR) across Brazil for 2015. We performed descriptive analyses, and identified associations between the workforce and U5MR using geospatial analysis (Getis-Ord-Gi analysis, spatial cluster analysis and linear regression models). There were 39 926 general surgeons, 856 paediatric surgeons, 13 243 anaesthesiologists and 103 793 nurses across Brazil in 2015. The U5MR ranged from 11 to 26 deaths/1000 live births and the POMR ranged from 0.11–0.17 deaths/100 000 children across the country. The surgical workforce is inequitably distributed across the country, with the wealthier South and Southeast regions having a higher workforce density as well as lower U5MR than the poorer North and Northeast regions. Using linear regression, we found an inverse relationship between the surgical workforce density and U5MR. An U5MR of 15 deaths/1000 births across Brazil is associated with a workforce level of 5 paediatric surgeons, 200 surgeons, 100 anaesthesiologists or 700 nurses/100 000 children. We found wide disparities in the surgical workforce and childhood mortality across Brazil, with both directly related to socioeconomic status. Areas of increased surgical workforce are associated with lower U5MR. Strategic investment in the surgical workforce may be required to attain optimal health outcomes for children in Brazil, particularly in rural regions.
Publisher: Hindawi Limited
Date: 21-01-2017
DOI: 10.1111/HSC.12327
Abstract: Adults with moderate to severe traumatic brain injury (TBI) rely on assistance from paid and unpaid caregivers upon return to the community. An inability to move independently makes these adults highly dependent on caregivers for transfers and manual handling tasks. Evidence-based guidelines are therefore important to ensure that caregivers and people in the community are protected and that practices are standard and consistent. This study commenced with a rapid review of evidence-based recommendations between 2000 and 2015 pertaining to transfers and manual handling in people with TBI and ended with a structured stakeholder dialogue that reflected upon this evidence and gathered perspectives on how to address key issues in community-based manual handling following TBI. Three relevant guidelines were identified, providing nine recommendations encompassing assessment of the person's ability to assist caregivers, manual handling and appropriate equipment use. Due to the low number of recommendations and low level of supporting evidence, these recommendations alone could not provide comprehensive guidance. Three systematic reviews and two primary studies were also identified, and these suggest that comprehensive training programmes in transfers and manual handling tasks are effective. Further to this, a structured stakeholder dialogue was conducted, which revealed six major themes - (i) comprehensive risk assessment, (ii) presence of two caregivers, (iii) provision of training, (iv) home environment modification, (v) equipment, and (vi) policy implementation context. Recommendations for health professionals include providing information packs to caregivers, risk assessment and mitigation for those at high risk, and strategies to prevent and minimise injury in caregivers. Development of comprehensive guidance for caregivers in transfers and manual handling in people with moderate to severe TBI living in the community is a hidden but important priority.
Publisher: Elsevier BV
Date: 06-2020
Publisher: Wiley
Date: 11-07-2010
DOI: 10.1111/J.1742-6723.2010.01303.X
Abstract: A low case incidence and variable skill level prompted the development of a credentialing programme and specific surgical training in resuscitative thoracotomy for emergency physicians at The Alfred, a Level 1 Adult Victorian Major Trauma Service. A review of the incidence of traumatic pericardial t onade and the objectives of resuscitative thoracotomy were undertaken. A training programme involving pre-reading of a 17 page teaching manual, a 40 min didactic lecture and a 2 h surgical skills station using anaesthetized pigs were developed. The specific indication for resuscitative thoracotomy for this programme is ultrasound demonstrated cardiac t onade secondary to blunt or penetrating truncal trauma in a haemodynamically unstable patient with a systolic blood pressure of less than 70 mmHg despite pleural decompression and intravenous volume replacement. Cardiac electrical activity must be present. The primary aims of resuscitative thoracotomy taught are release of cardiac t onade, control of haemorrhage and access for internal cardiac massage. Emergency physicians working in high-volume Trauma Centres are expected to diagnose cardiac t onade and on occasion decompress the pericardium. Specific training in the procedure should be undertaken.
Publisher: AMPCo
Date: 05-2001
DOI: 10.5694/J.1326-5377.2001.TB143400.X
Abstract: To identify barriers faced by Aboriginal people from remote communities in the Northern Territory (NT) when accessing hospital-based specialist medical services, and to evaluate the impact of the Specialist Outreach Service (SOS) on these barriers. Combined quantitative and qualitative study. Remote Aboriginal communities in the "Top End" of the NT, 1993-1999 (spanning the introduction of the SOS in 1997). 25 remote health practitioners, patients and SOS specialists. Numbers of consultations with specialists average cost per consultation perceived barriers to accessing hospital-based outpatient care and perceived impact of specialist outreach on these barriers. Perceived barriers included geographic remoteness, poor doctor-patient communication, poverty, cultural differences, and the structure of the health service. Between 1993 and 1999, there were 5,184 SOS and non-SOS outreach consultations in surgical specialties. Intensive outreach practice (as in gynaecology and ophthalmology) increased total consultations by up to 441% and significantly reduced the number of transfers to hospital outpatient clinics (P< 0.001). Average cost per consultation was $277 for SOS consultations, compared with $450 at Royal Darwin Hospital and $357 at the closest regional hospital. Outreach has reduced barriers relating to distance, communication and cultural differences, and potentially bolsters existing primary healthcare services. When compared with hospital-based outpatient services alone, outreach is a more accessible, appropriate and efficient method of providing specialist medical services to remote Aboriginal communities in the NT.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2003
Publisher: Wiley
Date: 09-06-2011
DOI: 10.1111/J.1365-2753.2011.01695.X
Abstract: Rural and remote surgical practice presents unique barriers to the uptake of the evidence-based medicine (EBM) paradigm. As medical and education institutions around Australia develop practices and support for EBM, there are growing questions about how EBM is situated in the rural and remote context. The Monash University Department of Surgery at Monash Medical Centre implemented a study to explore the current understandings, attitudes and practices of rural surgeons towards the EBM paradigm. Descriptive survey of rural surgeons based in a tertiary care environment. The overall results of the survey demonstrate that: (1) rural surgeons have a good understanding of EBM (2) EBM evidence is somewhat useful but not very important to clinical decision making and (3) while rural surgeons are relatively confident in most sources listed, they are most confident in their own judgment and clinical practice guidelines, and least confident in telephone contact with colleagues. Rural surgeons' understanding, usage and confidence in EBM purports that rural surgeons have contradictory, ambivalent and complex views of the EBM paradigm and its place in rural surgical practice. Professional isolation and context specificity are important to consider when extending the EBM paradigm to rural surgical practice and understanding the EBM uptake in the rural surgery context.
Publisher: Wiley
Date: 16-06-2022
DOI: 10.5694/MJA2.51610
Publisher: Elsevier BV
Date: 04-2015
Publisher: Springer Science and Business Media LLC
Date: 16-12-2022
DOI: 10.1186/S12913-022-08908-0
Abstract: Despite existing guidelines for managing mild traumatic brain injury (mTBI), evidence-based treatments are still scarce and large-scale studies on the provision and impact of specific rehabilitation services are needed. This study aimed to describe the provision of rehabilitation to patients after complicated and uncomplicated mTBI and investigate factors associated with functional outcome, symptom burden, and TBI-specific health-related quality of life (HRQOL) up to six months after injury. Patients ( n = 1379) with mTBI from the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study who reported whether they received rehabilitation services during the first six months post-injury and who participated in outcome assessments were included. Functional outcome was measured with the Glasgow Outcome Scale – Extended (GOSE), symptom burden with the Rivermead Post Concussion Symptoms Questionnaire (RPQ), and HRQOL with the Quality of Life after Brain Injury – Overall Scale (QOLIBRI-OS). We examined whether transition of care (TOC) pathways, receiving rehabilitation services, sociodemographic (incl. geographic), premorbid, and injury-related factors were associated with outcomes using regression models. For easy comparison, we estimated ordinal regression models for all outcomes where the scores were classified based on quantiles. Overall, 43% of patients with complicated and 20% with uncomplicated mTBI reported receiving rehabilitation services, primarily in physical and cognitive domains. Patients with complicated mTBI had lower functional level, higher symptom burden, and lower HRQOL compared to uncomplicated mTBI. Rehabilitation services at three or six months and a higher number of TOC were associated with unfavorable outcomes in all models, in addition to pre-morbid psychiatric problems. Being male and having more than 13 years of education was associated with more favorable outcomes. Sustaining major trauma was associated with unfavorable GOSE outcome, whereas living in Southern and Eastern European regions was associated with lower HRQOL. Patients with complicated mTBI reported more unfavorable outcomes and received rehabilitation services more frequently. Receiving rehabilitation services and higher number of care transitions were indicators of injury severity and associated with unfavorable outcomes. The findings should be interpreted carefully and validated in future studies as we applied a novel analytic approach. ClinicalTrials.gov NCT02210221.
Publisher: Informa UK Limited
Date: 17-10-2020
DOI: 10.1080/09638288.2020.1832589
Abstract: There is conflicting literature on the effect of post- utation pain on quality of life (QOL) and no available literature on the relationship of pain medications to QOL of utees in pain. The aims of the study were to compare QOL in lower limb utees with significant pain to those with minimal pain and compare QOL in utees on multiple pain medications (≥3 and/or ≥ 40 mg morphine equivalent/day) to those on minimal. Cross-sectional study of utees ( Post- utation pain was common (69%), but only 13% of the participants were using more pain medications. High-pain interference and poor self-efficacy were associated with poorer QOL after adjusting for age, gender and cause of utation. High medication use was associated with high-pain interference and poor self-efficacy, but there was minimal correlation between pain scores and medication usage ( Post- utation pain continues to be a major determinant of QOL in lower limb utees, but the role of pain medications on an utee's QOL remains unclear.IMPLICATIONS FOR REHABILITATIONAn utee's QOL is affected by the severity of their post- utation pain even beyond six months post their utation.An utee with more pain may not necessarily take more pain medications to manage their pain. The amount of pain medications taken may not influence their self-reported QOL.Pain and QOL assessment should be integrated into routine clinical evaluation of adult utees. Standardized screening tools and/or formative assessment can be utilized for assessing QOL.
Publisher: Elsevier BV
Date: 03-2021
DOI: 10.1016/J.HLC.2021.08.008
Abstract: Postoperative pneumonia is a major cause of morbidity and mortality following cardiac surgery. The inflammatory response to cardiac surgery has been widely studied, but specific mechanisms for postoperative pneumonia have not been determined. Tranexamic acid is renowned for its effect on bleeding but can also modulate inflammatory processes. Cardiac surgery is known to release mitochondrial DAMPs (mtDAMPs) and is linked to postoperative inflammation and atrial fibrillation. We speculated that mtDAMPs might be related to postoperative pneumonia and that this might be modulated by tranexamic acid. Forty-one (41) patients from the Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial were studied. Levels of mitochondrial DNA, matrix metallopeptidase 9 (MMP-9) and neutrophil elastase (NE) were determined in plasma preoperatively, at 24 and 72 hours post-surgery and correlated with clinical outcome. mtDNA was significantly elevated postoperatively in the placebo and tranexamic acid (TXA) groups. Neutrophil elastase increased immediately postoperatively and at 24 hours. MMP-9 was elevated in the placebo group early postoperatively and in the TXA group at the immediate postoperative time point and after 24 hours. Six (6) of the 41 (14.6%) patients subsequently developed pneumonia. mtDNA levels were significantly increased at the early postoperative period and the 24-hour time point in patients with pneumonia. Cardiac surgery releases mtDNA, increases MMP-9 and NE and this was not influenced by TXA. Inflammation postoperatively might be linked to pneumonia since mtDNA was further elevated in these patients. Due to the low number of in iduals developing pneumonia, further studies are warranted to clearly identify whether TXA impacts on the inflammatory response in postoperative pneumonia.
Publisher: Elsevier BV
Date: 05-2020
Publisher: Elsevier BV
Date: 09-2007
Publisher: University Library System, University of Pittsburgh
Date: 04-2011
Publisher: Springer Science and Business Media LLC
Date: 17-09-2014
Publisher: Life Science Alliance, LLC
Date: 21-03-2023
Abstract: Povidone-iodine (PVP-I) inactivates a broad range of pathogens. Despite its widespread use over decades, the safety of PVP-I remains controversial. Its extended use in the current SARS-CoV-2 virus pandemic urges the need to clarify safety features of PVP-I on a cellular level. Our investigation in epithelial, mesothelial, endothelial, and innate immune cells revealed that the toxicity of PVP-I is caused by diatomic iodine (I 2 ), which is rapidly released from PVP-I to fuel organic halogenation with fast first-order kinetics. Eukaryotic toxicity manifests at below clinically used concentrations with a threshold of 0.1% PVP-I (wt/vol), equalling 1 mM of total available I 2 . Above this threshold, membrane disruption, loss of mitochondrial membrane potential, and abolition of oxidative phosphorylation induce a rapid form of cell death we propose to term iodoptosis. Furthermore, PVP-I attacks lipid rafts, leading to the failure of tight junctions and thereby compromising the barrier functions of surface-lining cells. Thus, the therapeutic window of PVP-I is considerably narrower than commonly believed. Our findings urge the reappraisal of PVP-I in clinical practice to avert unwarranted toxicity whilst safeguarding its benefits.
Publisher: BMJ
Date: 05-2021
Abstract: Clinical trials of immunotherapy have excluded patients with pre-existing autoimmune disease. While the safety and efficacy of single agent ipilimumab and anti-PD1 antibodies in patients with autoimmune disease has been examined in retrospective studies, no data are available for combination therapy which has significantly higher toxicity risk. We sought to establish the safety and efficacy of combination immunotherapy for patients with advanced melanoma and pre-existing autoimmune diseases. We performed a retrospective study of patients with advanced melanoma and pre-existing autoimmune disease who received combination ipilimumab and anti-PD1 at 10 international centers from March 2015 to February 2020. Data regarding the autoimmune disease, treatment, toxicity and outcomes were examined in patients. Of the 55 patients who received ipilimumab and anti-PD1, the median age was 63 years (range 23–83). Forty-six were treated with ipilimumab and nivolumab and nine with ipilimumab and pembrolizumab. Eighteen patients (33%) had a flare of their autoimmune disease including 4 of 7 with rheumatoid arthritis, 3 of 6 with psoriasis, 5 of 10 with inflammatory bowel disease, 3 of 19 with thyroiditis, 1 of 1 with Sjogren’s syndrome, 1 of 1 with polymyalgia and 1 of 1 with Behcet’s syndrome and psoriasis. Eight (44%) patients ceased combination therapy due to flare. Thirty-seven patients (67%) had an unrelated immune-related adverse event (irAE), and 20 (36%) ceased combination immunotherapy due to irAEs. There were no treatment-related deaths. Patients on immunosuppression (OR 4.59 p=0.03) had a higher risk of flare. The overall response rate was 55%, with 77% of responses ongoing. Median progression free survival and overall survival were 10 and 24 months, respectively. Patients on baseline immunosuppression had an overall survival of 11 months (95% CI 3.42 to 18.58) compared with 31 months without (95% CI 20.89 to 41.11, p=0.005). In patients with pre-existing autoimmune disease, not on immunosuppression and advanced melanoma, combination ipilimumab and anti-PD1 has similar efficacy compared with previously reported trials. There is a risk of flare of pre-existing autoimmune disorders, particularly in patients with inflammatory bowel disease and rheumatologic conditions, and patients on baseline immunosuppression.
Publisher: Mary Ann Liebert Inc
Date: 15-01-2018
Abstract: Our aim was to describe current approaches and to quantify variability between European intensive care units (ICUs) in patients with traumatic brain injury (TBI). Therefore, we conducted a provider profiling survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. The ICU Questionnaire was sent to 68 centers from 20 countries across Europe and Israel. For this study, we used ICU questions focused on 1) hemoglobin target level (Hb-TL), 2) coagulation management, and 3) deep venous thromboembolism (DVT) prophylaxis. Seventy-eight participants, mostly intensivists and neurosurgeons of 66 centers, completed the ICU questionnaire. For ICU-patients, half of the centers (
Publisher: Wiley
Date: 08-2011
DOI: 10.1111/J.1553-2712.2011.01134.X
Abstract: The objective was to provide an overview of the recommendations and quality of evidence-based clinical practice guidelines (CPGs) for the emergency management of mild traumatic brain injury (mTBI), with a view to informing best practice and improving the consistency of recommendations. Electronic searches of health databases (MEDLINE, EMBASE, The Cochrane Library, PsycINFO), CPG clearinghouse websites, CPG developer websites, and Internet search engines up to January 2010 were conducted. CPGs were included if 1) they were published in English and freely accessible, 2) their scope included the management of mTBI in the emergency department (ED), 3) the date of last search was within the past 10 years (2000 onward), 4) systematic methods were used to search for evidence, and 5) there was an explicit link between the recommendations and the supporting evidence. Four authors independently assessed the quality of the included CPGs using the Appraisal of Guidelines, Research and Evaluation (AGREE) Instrument. The authors extracted and categorized recommendations according to initial clinical assessment, imaging, management, observation, discharge planning, and patient information and follow-up. The search identified 18 potential CPGs, of which six met the inclusion criteria. The included CPGs varied in scope, target population, size, and guideline development processes. Four CPGs were assessed as "strongly recommended." The majority of CPGs did not provide information about the level of stakeholder involvement (mean AGREE standardized domain score = 57%, range = 25% to 81%), nor did they address the organizational/cost implications of applying the recommendations or provide criteria for monitoring and review of recommendations in practice (mean AGREE standardized domain score = 46.6%, range = 19% to 94%). Recommendations were mostly consistent in terms of the use of the Glasgow Coma Scale (GCS) score (adult and pediatric) to assess the level of consciousness, initial assessment criteria, the use of computed tomography (CT) scanning as imaging investigation of choice, and the provision of patient information. The CPGs defined mTBI in a variety of ways and described different rules to determine the need for CT scanning and therefore used different criteria to identify high-risk patients. Higher-quality CPGs for mTBI are consistent in their recommendations about assessment, imaging, and provision of patient information. There is not, however, an agreed definition of mTBI, and the quality of future CPGs could be improved with better reporting of stakeholder involvement, procedures for updating, and greater consideration of the applicability of the recommendations (cost implications, monitoring procedures). Nevertheless, guideline developers may benefit from adapting existing CPGs to their local context rather than investing in developing CPGs de novo.
Publisher: SAGE Publications
Date: 06-2012
Abstract: The establishment of a spine trauma registry collecting both spine column and spinal cord data should improve the evidential basis for clinical decisions. This is a report on the pilot of a spine trauma registry including development of a minimum dataset. A minimum dataset consisting of 56 data items was created using the modified Delphi technique. A pilot study was performed on 104 consecutive spine trauma patients recruited by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Data analysis and collection methodology were reviewed to determine its feasibility. Minimum dataset collection aided by a dataset dictionary was uncomplicated (average of 5 minutes per patient). Data analysis revealed three significant findings: (1) a peak in the 40 to 60 years age group (2) premorbid functional independence in the majority of patients and (3) significant proportion being on antiplatelet or anticoagulation medications. Of the 141 traumatic spine fractures, the thoracolumbar segment was the most frequent site of injury. Most were neurologically intact (89%). Our study group had satisfactory 6-month patient-reported outcomes. The minimum dataset had high completion rates, was practical and feasible to collect. This pilot study is the basis for the development of a spine trauma registry at the Level 1 trauma center.
Publisher: Elsevier BV
Date: 05-2013
DOI: 10.1016/J.JCLINEPI.2012.06.017
Abstract: To identify high-priority research questions for osteoarthritis systematic reviews with consideration of health equity and the social determinants of health (SDH). We consulted with experts and conducted a literature search to identify a priority-setting method that could be adapted to address the health equity and SDH. We selected the Global Evidence Mapping priority-setting method, and through consultations and consensus, we adapted the method to meet our objectives. This involves developing an evidence map of the existing systematic reviews on osteoarthritis conducting one face-to-face workshop with patients and another one with clinicians, researchers, and patients and conducting an online survey of patients to rank the top 10 research questions. We piloted the adapted method with the Cochrane Musculoskeletal Review Group to set research priorities for osteoarthritis. Our focus was on systematic reviews: we identified 34 high-priority research questions for osteoarthritis systematic reviews. Prevention and self-management interventions, mainly diet and exercise, are top priorities for osteoarthritis systematic reviews. Evaluation against our predefined objectives showed that this method did prioritize SDH (50% of the research questions considered SDH). There were marked gaps: no high-priority topics were identified for access to care until patients had advanced disease-lifestyle changes once the disease was diagnosed. This method was felt feasible if conducted annually. We confirmed the utility of an adapted priority-setting method that is feasible and considers SDH. Further testing of this method is needed to assess whether considerations of health equity are prioritized and involve disadvantaged groups of the population.
Publisher: Springer Science and Business Media LLC
Date: 29-04-2019
DOI: 10.1007/S00068-019-01142-0
Abstract: Early identification of trauma patients at risk of developing acute traumatic coagulopathy (ATC) is important for initiating appropriate, coagulopathy-focused treatment. A clinical ATC prediction tool is a quick, simple method to evaluate risk. The COAST score was developed and validated in Australia but is yet to be validated on a European population. We validated the ability of the COAST score to predict coagulopathy and adverse bleeding-related outcomes on a large European trauma population. The COAST score was modified and applied to a retrospective cohort of trauma patients from the German Trauma Registry (TR-DGU). The primary outcome was coagulopathy defined as INR > 1.5 or aPTT > 60 s. Secondary outcomes were massive transfusion, blood product requirements, urgent surgery and mortality. The cohort included adult trauma patients with Injury Severity Score > 15 treated in Germany/Austria in 2012-2016. 15,370 cases were included, of which 10.9% were coagulopathic. The COAST score performed with sensitivity 21.6% and specificity 94.2% at a threshold of COAST ≥ 3. The AUROC was 0.625 (95% CI 0.61-0.64). The COAST score also identified patients who had more massive transfusions (15.3% v 1.6%), more emergency surgery (49.6% v 28.2%), and higher early (21.7% v 5.4%) and total in-hospital mortality (38.1% v 14.5%). This large retrospective study demonstrated that the modified COAST score predicts coagulopathy with low sensitivity but high specificity. A positive COAST score identified a group of patients with bleeding-related adverse outcomes. This score appears adequate to act as an inclusion criterion for clinical trials targeting ATC.
Publisher: Springer Science and Business Media LLC
Date: 05-08-2021
Publisher: Elsevier BV
Date: 02-2016
Publisher: Elsevier BV
Date: 07-2015
DOI: 10.1016/J.SURG.2015.03.024
Abstract: The proportion of patients who die during or after surgery, otherwise known as the perioperative mortality rate (POMR), is a credible indicator of the safety and quality of operative care. Its accuracy and usefulness as a metric, however, particularly one that enables valid comparisons over time or between jurisdictions, has been limited by lack of a standardized approach to measurement and calculation, poor understanding of when in relation to surgery it is best measured, and whether risk-adjustment is needed. Our aim was to evaluate the value of POMR as a global surgery metric by addressing these issues using 4, large, mixed, surgical datasets that represent high-, middle-, and low-income countries. We obtained data from the New Zealand National Minimum Dataset, the Geelong Hospital patient management system in Australia, and purpose-built surgical databases in Pietermaritzburg, South Africa, and Port Moresby, Papua New Guinea. For each site, we calculated the POMR overall as well as for nonemergency and emergency admissions. We assessed the effect of admission episodes and procedures as the denominator and the difference between in-hospital POMR and POMR, including postdischarge deaths up to 30 days. To determine the need for risk-adjustment for age and admission urgency, we used univariate and multivariate logistic regression to assess the effect on relative POMR for each site. A total of 1,362,635 patient admissions involving 1,514,242 procedures were included. More than 60% of admissions in Pietermaritzburg and Port Moresby were emergencies, compared with less than 30% in New Zealand and Geelong. Also, Pietermaritzburg and Port Moresby had much younger patient populations (P < .001). A total of 8,655 deaths were recorded within 30 days, and 8-20% of in-hospital deaths occurred on the same day as the first operation. In-hospital POMR ranged approximately 9-fold, from 0.38 per 100 admissions in New Zealand to 3.44 per 100 admissions in Pietermaritzburg. In New Zealand, in-hospital 30-day POMR underestimated total 30-day POMR by approximately one third. The difference in POMR if procedures were used instead of admission episodes ranged from 7 to 70%, although this difference was less when central line and pacemaker insertions were excluded. Age older than 65 years and emergency admission had large, independent effects on POMR but relatively little effect in multivariate analysis on the relative odds of in-hospital death at each site. It is possible to collect POMR in countries at all level of development. Although age and admission urgency are strong, independent associations with POMR, a substantial amount of its variance is site-specific and may reflect the safety of operative and anesthetic facilities and processes. Risk-adjustment is desirable but not essential for monitoring system performance. POMR varies depending on the choice of denominator, and in-hospital deaths appear to underestimate 30-day mortality by up to one third. Standardized approaches to reporting and analysis will strengthen the validity of POMR as the principal indicator of the safety of surgery and anesthesia care.
Publisher: American College of Physicians
Date: 04-12-2007
DOI: 10.7326/0003-4819-147-11-200712040-00012
Abstract: The prospect of improving care through increasing professionalism has been gaining momentum among physician organizations. Although there have been efforts to define and promote professionalism, few data are available on physician attitudes toward and conformance with professional norms. To ascertain the extent to which practicing physicians agree with and act consistently with norms of professionalism. National survey using a stratified random s le. Medical care in the United States. 3504 practicing physicians in internal medicine, family practice, pediatrics, surgery, anesthesiology, and cardiology. Attitudes and behaviors were assessed by using indicators for each domain of professionalism developed by the American College of Physicians and the American Board of Internal Medicine. Of the eligible s led physicians, 1662 responded, yielding a 58% weighted response rate (adjusting for noneligible physicians). Ninety percent or more of the respondents agreed with specific statements about principles of fair distribution of finite resources, improving access to and quality of care, managing conflicts of interest, and professional self-regulation. Twenty-four percent disagreed that periodic recertification was desirable. Physician behavior did not always reflect the standards they endorsed. For ex le, although 96% of respondents agreed that physicians should report impaired or incompetent colleagues to relevant authorities, 45% of respondents who encountered such colleagues had not reported them. Our measures of behavior did not capture all activities that may reflect on the norms in question. Furthermore, behaviors were self-reported, and the results may not be generalizable to physicians in specialties not included in the study. Physicians agreed with standards of professional behavior promulgated by professional societies. Reported behavior, however, did not always conform to those norms.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2012
Publisher: Elsevier BV
Date: 12-2008
Publisher: Wiley
Date: 22-11-2017
Publisher: Springer Science and Business Media LLC
Date: 12-2009
Publisher: Springer Science and Business Media LLC
Date: 11-07-2014
Publisher: Springer Science and Business Media LLC
Date: 17-06-2011
Publisher: Springer Science and Business Media LLC
Date: 10-05-2022
DOI: 10.1038/S41467-022-30227-5
Abstract: Complex metabolic disruption is a crucial aspect of the pathophysiology of traumatic brain injury (TBI). Associations between this and systemic metabolism and their potential prognostic value are poorly understood. Here, we aimed to describe the serum metabolome (including lipidome) associated with acute TBI within 24 h post-injury, and its relationship to severity of injury and patient outcome. We performed a comprehensive metabolomics study in a cohort of 716 patients with TBI and non-TBI reference patients (orthopedic, internal medicine, and other neurological patients) from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) cohort. We identified panels of metabolites specifically associated with TBI severity and patient outcomes. Choline phospholipids (lysophosphatidylcholines, ether phosphatidylcholines and sphingomyelins) were inversely associated with TBI severity and were among the strongest predictors of TBI patient outcomes, which was further confirmed in a separate validation dataset of 558 patients. The observed metabolic patterns may reflect different pathophysiological mechanisms, including protective changes of systemic lipid metabolism aiming to maintain lipid homeostasis in the brain.
Publisher: Elsevier BV
Date: 02-2011
DOI: 10.1016/J.JOCN.2010.06.015
Abstract: The Quality of Life after Brain Injury (QOLIBRI) is a new international instrument for assessing quality of life after traumatic brain injury (TBI). We report first use and validation. Patients previously admitted with TBI to the Royal Melbourne Hospital, Melbourne, Australia, were randomly s led (n=66, 61% response rate) and administered the QOLIBRI. Fifty-five re-completed it at 2-week follow-up. QOLIBRI scales (with two exceptions) met standard criteria for internal consistency, homogeneity and test-re-test reliability. Correlations with the Assessment of Quality of Life, Short Form-36 version 2 and the Satisfaction with Life Scale were moderate. The QOLIBRI was sensitive to the Glasgow Outcome Scale - Extended scores, Hospital Anxiety and Depression scale, and measures of social isolation (Friendship Scale). There was evidence that further refinement may improve the QOLIBRI. The QOLIBRI should be considered as an outcome measure by clinicians and researchers conducting treatment trials, rehabilitation studies or epidemiological surveys into the treatment or sequelae of trauma.
Publisher: Elsevier BV
Date: 08-2022
Publisher: Springer Science and Business Media LLC
Date: 11-2006
Publisher: Elsevier BV
Date: 07-2022
Publisher: Wiley
Date: 09-08-2011
DOI: 10.1111/J.1742-6723.2011.01455.X
Abstract: The early management of patients who have sustained traumatic brain injury is aimed at preventing secondary brain injury through avoidance of cerebral hypoxia and hypoperfusion. Especially in hypotensive patients, it has been postulated that hypertonic crystalloids and colloids might support mean arterial pressure more effectively by expanding intravascular volume without causing problematic cerebral oedema. We conducted a systematic review to investigate if hypertonic saline or colloids result in better outcomes than isotonic crystalloid solutions, as well as to determine the safety of minimal volume resuscitation, or delayed versus immediate fluid resuscitation during prehospital care for patients with traumatic brain injury. We identified nine randomized controlled trials and one cohort study examined the effects of hypertonic solutions (with or without colloid added) for prehospital fluid resuscitation. None has reported better survival and functional outcomes over the use of isotonic crystalloids. The only trial of restrictive resuscitation strategies was underpowered to demonstrate its safety compared with aggressive early fluid resuscitation in head injured patients, and maintenance of cerebral perfusion remains the top priority.
Publisher: Elsevier BV
Date: 10-2020
Publisher: Cambridge University Press (CUP)
Date: 16-05-2014
DOI: 10.1017/S1355617714000447
Abstract: Severe traumatic brain injury (TBI) in older age is associated with high rates of mortality. However, little is known about outcome following mild TBI (mTBI) in older age. We report on a prospective cohort study investigating 3 month outcome in older age patients admitted to hospital-based trauma services. First, 50 mTBI older age patients and 58 orthopedic controls were compared to 123 community control participants to evaluate predisposition and general trauma effects on cognition. Specific brain injury effects were subsequently evaluated by comparing the orthopedic control and mTBI groups. Both trauma groups had significantly lower performances than the community group on prospective memory ( d =0.82 to 1.18), attention set-shifting ( d =−0.61 to −0.69), and physical quality of life measures ( d =0.67 to 0.84). However, there was only a small to moderate but non-significant difference in the orthopedic control and mTBI group performances on the most demanding task of prospective memory ( d =0.37). These findings indicate that, at 3 months following mTBI, older adults are at risk of poor cognitive performance but this is substantially accounted for by predisposition to injury or general multi-system trauma. ( JINS , 2014, 20 , 1–9)
Publisher: Wiley
Date: 05-2009
DOI: 10.3322/CAAC.20018
Abstract: The authors systematically reviewed the association between provider case volume and mortality in 101 publications involving greater than 1 million patients with esophageal, gastric, hepatic, pancreatic, colon, or rectal cancer, of whom more than 70,000 died. The majority of studies addressed the relation between hospital surgical case volume and short-term perioperative mortality. Few studies addressed surgeon case volume or evaluated long-term survival outcomes. Common methodologic limitations were failure to control for potential confounders, post hoc categorization of provider volume, and unit of analysis errors. A significant volume effect was evident for the majority of gastrointestinal cancers with each doubling of hospital case volume, the odds of perioperative death decreased by 0.1 to 0.23. The authors calculated that between 10 and 50 patients per year, depending on cancer type, needed to be moved from a "low-volume" hospital to a "high-volume" hospital to prevent 1 additional volume-associated perioperative death. Despite this, approximately one-third of all analyses did not find a significant volume effect on mortality. The heterogeneity of results from in idual studies calls into question the validity of case volume as a proxy for care quality, and leads the authors to conclude that more direct quality measures and the validity of their use to inform policy should also be explored.
Publisher: Wiley
Date: 20-10-2003
Publisher: Oxford University Press (OUP)
Date: 16-09-2011
DOI: 10.1002/BJS.7688
Publisher: Springer Science and Business Media LLC
Date: 02-2023
Publisher: Massachusetts Medical Society
Date: 14-06-2018
Publisher: Elsevier BV
Date: 06-2012
DOI: 10.1016/J.INJURY.2012.11.022
Abstract: Trauma registries are central to the implementation of effective trauma systems. However, differences between trauma registry datasets make comparisons between trauma systems difficult. In 2005, the collaborative Australian and New Zealand National Trauma Registry Consortium began a process to develop a bi-national minimum dataset (BMDS) for use in Australasian trauma registries. This study aims to describe the steps taken in the development and preliminary evaluation of the BMDS. A working party comprising sixteen representatives from across Australasia identified and discussed the collectability and utility of potential BMDS fields. This included evaluating existing national and international trauma registry datasets, as well as reviewing all quality indicators and audit filters in use in Australasian trauma centres. After the working party activities concluded, this process was continued by a number of interested in iduals, with broader feedback sought from the Australasian trauma community on a number of occasions. Once the BMDS had reached a suitable stage of development, an email survey was conducted across Australasian trauma centres to assess whether BMDS fields met an ideal minimum standard of field collectability. The BMDS was also compared with three prominent international datasets to assess the extent of dataset overlap. Following this, the BMDS was encapsulated in a data dictionary, which was introduced in late 2010. The finalised BMDS contained 67 data fields. Forty-seven of these fields met a previously published criterion of 80% collectability across respondent trauma institutions the majority of the remaining fields either could be collected without any change in resources, or could be calculated from other data fields in the BMDS. However, comparability with international registry datasets was poor. Only nine BMDS fields had corresponding, directly comparable fields in all the national and international-level registry datasets evaluated. A draft BMDS has been developed for use in trauma registries across Australia and New Zealand. The email survey provided strong indications of the utility of the fields contained in the BMDS. The BMDS has been adopted as the dataset to be used by an ongoing Australian Trauma Quality Improvement Program.
Publisher: Elsevier BV
Date: 03-2022
Publisher: Mary Ann Liebert Inc
Date: 10-2020
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2017
Publisher: Springer Science and Business Media LLC
Date: 20-10-2022
Publisher: American Medical Association (AMA)
Date: 22-11-2006
Abstract: Whether physicians have a professional responsibility to address health-related issues beyond providing care to in idual patients has been vigorously debated. Yet little is known about practicing physicians' attitudes about or the extent to which they participate in public roles, which we defined as community participation, political involvement, and collective advocacy. To determine the importance physicians assign to public roles, their participation in related activities, and sociodemographic and practice factors related to physicians' rated levels of importance and activity. Mail survey conducted between November 2003 and June 2004 of 1662 US physicians engaged in direct patient care selected from primary care specialties (family practice, internal medicine, pediatrics) and 3 non-primary care specialties (anesthesiology, general surgery, cardiology). Rated importance of community participation, political involvement, collective advocacy, and relevant self-reported activities encompassing the previous 3 years rated importance of physician action on different issues. Community participation, political involvement, and collective advocacy were rated as important by more than 90% of respondents, and a majority rated community participation and collective advocacy as very important. Nutrition, immunization, substance abuse, and road safety issues were rated as very important by more physicians than were access-to-care issues, unemployment, or illiteracy. Two thirds of respondents had participated in at least 1 of the 3 types of activities in the previous 3 years. Factors independently related to high overall rating of importance (civic-mindedness) included age, female sex, underrepresented race/ethnicity, and graduation from a non-US or non-Canadian medical school. Civic mindedness, medical specialty, practice type, underrepresented race/ethnicity, preceptors of physicians in training, rural practice, and graduation from a non-US or non-Canadian medical school were independently related to civic activity. Public roles are definable entities that have widespread support among physicians. Civic-mindedness is associated primarily with sociodemographic factors, but civic action is associated with specialty and practice-based factors.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2017
Publisher: Elsevier BV
Date: 07-2021
Publisher: Elsevier BV
Date: 09-2020
Publisher: Public Library of Science (PLoS)
Date: 21-06-2018
Publisher: MDPI AG
Date: 28-09-2019
Abstract: Background and objectives: Prompt identification of patients with acute traumatic coagulopathy (ATC) is necessary to expedite appropriate treatment. An early clinical prediction tool that does not require laboratory testing is a convenient way to estimate risk. Prediction models have been developed, but none are in widespread use. This systematic review aimed to identify and assess accuracy of prediction tools for ATC. Materials and Methods: A search of OVID Medline and Embase was performed for articles published between January 1998 and February 2018. We searched for prognostic and predictive studies of coagulopathy in adult trauma patients. Studies that described stand-alone predictive or associated factors were excluded. Studies describing prediction of laboratory-diagnosed ATC were extracted. Performance of these tools was described. Results: Six studies were identified describing four different ATC prediction tools. The COAST score uses five prehospital variables (blood pressure, temperature, chest decompression, vehicular entrapment and abdominal injury) and performed with 60% sensitivity and 96% specificity to identify an International Normalised Ratio (INR) of .5 on an Australian single centre cohort. TICCS predicted an INR of .3 in a small Belgian cohort with 100% sensitivity and 96% specificity based on admissions to resuscitation rooms, blood pressure and injury distribution but performed with an Area under the Receiver Operating Characteristic (AUROC) curve of 0.700 on a German trauma registry validation. Prediction of Acute Coagulopathy of Trauma (PACT) was developed in USA using six weighted variables (shock index, age, mechanism of injury, Glasgow Coma Scale, cardiopulmonary resuscitation, intubation) and predicted an INR of .5 with 73.1% sensitivity and 73.8% specificity. The Bayesian network model is an artificial intelligence system that predicted a prothrombin time ratio of .2 based on 14 clinical variables with 90% sensitivity and 92% specificity. Conclusions: The search for ATC prediction models yielded four scoring systems. While there is some potential to be implemented effectively in clinical practice, none have been sufficiently externally validated to demonstrate associations with patient outcomes. These tools remain useful for research purposes to identify populations at risk of ATC.
Publisher: Elsevier BV
Date: 12-2013
DOI: 10.1016/J.INJURY.2013.04.009
Abstract: There is a paucity of research into the outcomes and complications of cervical spine immobilisation (hard collar or halothoracic brace) in older people. To identify morbidity and mortality outcomes using geriatric medicine assessment techniques following cervical immobilisation in older people with isolated cervical spine fractures. We identified participants using an injury database. We completed a questionnaire measuring pre-admission medical co-morbidities and functional independence. We recorded the surgical plan and all complications. A further questionnaire was completed three months later recording complications and functional independence. Sixteen patients were recruited over a three month period. Eight were immobilised with halothoracic brace, 8 with external hard collar. Three deaths occurred during the study. Lower respiratory tract infection was the most common complication (7/16) followed by delirium (6/16). Most patients were unable to return home following the acute admission, requiring sub-acute care on discharge. The majority of patients were from home prior to a fall, 6/16 were residing there at 3 months. Most participants had an increase in their care needs at 3 months. There was no difference in the type or incidence of complications between the different modes of immobilisation. Geriatric medicine assessment techniques identified the morbidity and functional impairment associated with cervical spine immobilisation. This often results in a prolonged length of stay in supported care. This small pilot study recommends a larger study over a longer period using geriatric medicine assessment techniques to better define the issues.
Publisher: Wiley
Date: 11-2007
Publisher: American Medical Association (AMA)
Date: 07-01-2004
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2013
Publisher: Wiley
Date: 04-2014
Abstract: Following findings of the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial, tranexamic acid (TxA) use post trauma is becoming widespread. However, issues of generalisability, applicability and predictability beyond the context of study sites remain unresolved. Internal and external validity of the CRASH-2 trial are currently lacking and therefore incorporation of TxA into routine trauma resuscitation guidelines appears premature. The Pre-hospital Antifibrinolytics for Traumatic Coagulopathy and Haemorrhage (PATCH)-Trauma study is a National Health and Medical Research Council-funded randomised controlled trial of early administration of TxA in severely injured patients likely to have acute traumatic coagulopathy. The study population chosen has high mortality and morbidity and is potentially most likely to benefit from TxA's known mechanisms of action. This and further trials involving appropriate s le populations are required before evidence based guidelines on TxA use during trauma resuscitation can be developed.
Publisher: Mary Ann Liebert Inc
Date: 15-08-2020
Publisher: Elsevier BV
Date: 12-2017
DOI: 10.1016/J.EUF.2017.03.008
Abstract: Radical prostatectomy (RP) is one of the most complex urological procedures performed. Higher surgical volume has been found previously to be associated with better patient outcomes and reduced costs to the health care system. This has resulted in some regionalization of care toward high-volume facilities and providers however, the preponderance of RPs is still performed at low-volume institutions. To provide an updated systematic review of the association of hospital and surgeon volume on patient and system outcomes after RP, including robot-assisted RP. A systematic review of literature was undertaken, searching PubMed (1959-2016) for original articles. Selection criteria included RP, hospital and/or surgeon volumes as predictor variables, categorization of hospital and/or surgeon volumes, and measurable end points. Overall 49 publications fulfilled the inclusion criteria. Most of the studies demonstrated that higher-volume surgeries are associated with better outcomes including reduced mortality, morbidity, postoperative complications, length of stay, readmission, and cost-associated factors. The volume-outcome relationship is maintained in robotic surgery. Eleven studies assessed hospital and surgeon volume simultaneously, and findings reflect that neither is an independent predictor variable affecting outcomes. The studies varied in how volume cutoffs were categorized as well as how the volume-outcome relationship was methodologically evaluated. Contemporary evidence continues to support the relationship between high-volume surgeries with improved RP outcomes. Recent studies demonstrate that the volume-outcome relationship applies to robot-assisted RP and may be applied for potential cost savings in health care. An increase in the number of international studies suggests reproducibility of the association. Although regionalization of surgical care remains a contentious issue, there is an increasing body of evidence that short-term outcomes are improved at high-volume centers for RP. This systematic review of the latest literature found that higher surgical volume was associated with improved outcomes for radical prostatectomy.
Publisher: Elsevier BV
Date: 09-2012
Publisher: Springer Science and Business Media LLC
Date: 27-05-2011
Publisher: Peter Lang D
Date: 18-04-2017
Publisher: Springer Science and Business Media LLC
Date: 12-11-2015
DOI: 10.1007/S00134-015-4124-3
Abstract: The Glasgow Coma Scale (GCS) provides a structured method for assessment of the level of consciousness. Its derived sum score is applied in research and adopted in intensive care unit scoring systems. Controversy exists on the reliability of the GCS. The aim of this systematic review was to summarize evidence on the reliability of the GCS. A literature search was undertaken in MEDLINE, EMBASE and CINAHL. Observational studies that assessed the reliability of the GCS, expressed by a statistical measure, were included. Methodological quality was evaluated with the consensus-based standards for the selection of health measurement instruments checklist and its influence on results considered. Reliability estimates were synthesized narratively. We identified 52 relevant studies that showed significant heterogeneity in the type of reliability estimates used, patients studied, setting and characteristics of observers. Methodological quality was good (n = 7), fair (n = 18) or poor (n = 27). In good quality studies, kappa values were ≥0.6 in 85%, and all intraclass correlation coefficients indicated excellent reliability. Poor quality studies showed lower reliability estimates. Reliability for the GCS components was higher than for the sum score. Factors that may influence reliability include education and training, the level of consciousness and type of stimuli used. Only 13% of studies were of good quality and inconsistency in reported reliability estimates was found. Although the reliability was adequate in good quality studies, further improvement is desirable. From a methodological perspective, the quality of reliability studies needs to be improved. From a clinical perspective, a renewed focus on training/education and standardization of assessment is required.
Publisher: Wiley
Date: 03-1996
DOI: 10.1111/J.1445-2197.1996.TB01150.X
Abstract: Leg ulcers are common and are often the cause of a long hospital admission. However, little information is available on the efficacy and efficiency of inpatient leg ulcer management. The inpatient management of leg ulceration was examined and areas for improvement were sought. The management of patients admitted to a teaching hospital with a primary diagnosis of leg ulceration was examined, the costs estimated and areas for improvement identified. A retrospective analysis of 174 admissions to Heidelberg Repatriation Hospital between 1 January 1991 and 31 December 1992 was performed. Of 119 patients, 61 had ulcers due to arterial disease and 34 due to venous disease. Over 2 years, leg ulcers accounted for 5259 inpatient bed days, a mean of 44.2 days per patient. The estimated cost exceeded $2,750,000, averaging over $12,000 per admission. Thirty-three percent of patients had no recorded investigations into the cause of their ulcer and fewer than 50% had documented improvement at discharge. Leg ulcers are costly due to their extended treatment on an inpatient basis. Unfortunately, hospital admission does not guarantee optimal wound healing rates. A leg ulcer protocol is proposed to minimize inpatient stay and improve investigation and management in an outpatient or community setting.
Publisher: Mary Ann Liebert Inc
Date: 12-2021
Abstract: Men and women differ in outcomes following mild traumatic brain injury (TBI). In the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study, we previously found that women had worse 6-month functional outcome (Glasgow Outcome Score Extended [GOSE]), health-related quality of life (HRQoL), and mental health following mild TBI. The aim of this study was to investigate whether those differences were mediated by psychiatric history, gender-related sociodemographic variables, or by care pathways. We analyzed sex/gender differences in 6-month GOSE, generic and TBI-specific HRQoL, and post-concussion and mental health symptoms using three sets of mediators: psychiatric history, sociodemographic variables (living alone, living with children, education and employment status/job category), and care-pathways (referral to study hospital and discharge destination after emergency department) while controlling for a substantial number of potential confounders (pre-injury health and injury-related characteristics). We included 1842 men and 1022 women (16+) with a Glasgow Coma Score 13-15, among whom 83% had GOSE available and about 60% other 6-month outcomes. We used natural effects models to decompose the total effect of sex/gender on the outcomes into indirect effects that passed through the specified mediators and the remaining direct effects. In our study population, women had worse outcomes and these were only partly explained by psychiatric history, and not considerably explained by sociodemographic variables nor by care pathways. Factors other than differences in specified variables seem to underlie observed differences between men and women in outcomes after mild TBI. Future studies should explore more aspects of gender roles and identity and biological factors underpinning sex and gender differences in TBI outcomes.
Publisher: BMJ
Date: 22-08-2011
DOI: 10.1136/BMJQS-2011-000109
Abstract: In the wake of adverse events, injured patients and their families have a complex range of needs and wants. The tort system, even when operating at its best, will inevitably fall far short of addressing them. In Australia and New Zealand, government-run health complaints commissions take a more flexible and expansive approach to providing remedies for patients injured by or disgruntled with care. Unfortunately, survey research has shown that many patients in these systems are dissatisfied with their experience. We hypothesised that an important explanation for this dissatisfaction is an 'expectations gap' discordance between what complainants want and what they eventually get out of the process. Analysing a s le of complaints relating to informed consent from the Commission in Victoria (Australia's second largest state, with 5.2 million residents), we found evidence of such a gap. One-third (59/189) of complainants who sought restoration received it 1 in 5 complainants (17/101) who sought correction received assurances that changes had been or would be made to reduce the risk of others suffering a similar harm and fewer than 1 in 10 (3/37) who sought sanctions saw steps taken to achieve this outcome initiated. We argue that bridging the expectations gap would go far toward improving patient satisfaction with complaints systems, and suggest several ways this might be done.
Publisher: BMJ
Date: 06-2020
DOI: 10.1136/BMJOPEN-2019-033236
Abstract: To assess the effect of a mobile phone application for prehospital notification on resuscitation and patient outcomes. Longitudinal prospective cohort study with preintervention and postintervention cohorts. Major trauma centre in India. Injured patients being transported by ambulance and allocated to red (highest) and yellow (medium) triage categories. A prehospital notification application for use by ambulance and emergency clinicians to notify emergency departments (EDs) of an impending arrival of a patient requiring advanced lifesaving care. The primary outcome was the proportion of eligible patients arriving at the hospital for which prehospital notification occurred. Secondary outcomes were the availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray, and ED and in-hospital mortality. Data from January 2017 to January 2018 were collected with 208 patients in the preintervention and 263 patients in the postintervention period. The proportion of patients arriving after prehospital notification improved from 0% to 11% (p .001). After the intervention, more patients were managed with a trauma call-out (relative risk (RR) 1.30 95% CI: 1.10 to 1.52) a trauma bay was ready for more patients (RR 1.47 95% CI: 1.05 to 2.05) and a trauma team leader present for more patients (RR 1.50 95% CI: 1.07 to 2.10). There was no difference in time to the initial chest X-ray (p=0.45). There was no association with mortality at hospital discharge (RR 0.94 95% CI: 0.72 to 1.23), but the intervention was associated with significantly less risk of patients dying in the ED (RR 0.11 95% CI: 0.03 to 0.39). The prehospital notification application for severely injured patients had limited uptake but implementation was associated with improved trauma reception and reduction in early deaths. Quality improvement efforts with ongoing data collection using the trauma registry are indicated to drive improvements in trauma outcomes in India. NCT02877342 .
Publisher: Wiley
Date: 07-02-2012
DOI: 10.1111/J.1463-1318.2010.02477.X
Abstract: The aim of this study was to identify and synthesize the hospital discharge criteria that have been used in the colorectal surgery literature. A systematic literature search was conducted using eight bibliographic databases. Searches were limited to English language journal articles published between January 1996 and October 2009. Primary research applying hospital discharge criteria following colorectal surgery was included. Study selection was made independently by two reviewers. Discharge criteria were extracted from each included study. The 156 studies identified by the search strategy described 70 different sets of criteria to indicate readiness for discharge. The majority of studies applied a combination of three or four criteria those most frequently cited were tolerance of oral intake (80%), return of bowel function (70%), adequate pain control (44%) and adequate mobility (35%). End-points employed to determine the achievement of criteria were generally poorly defined. A variety of hospital discharge criteria were applied in the colorectal surgery literature. Development of standardized criteria will allow more accurate comparison of results between studies assessing hospital length of stay or other discharge-related outcome measures.
Publisher: Elsevier BV
Date: 11-2008
Publisher: Wiley
Date: 24-11-2003
Publisher: BMJ
Date: 13-02-2013
DOI: 10.1136/BMJ.F846
Publisher: Wiley
Date: 09-1998
DOI: 10.1111/J.1445-2197.1998.TB04841.X
Abstract: The usual methods of closure of major chest and abdominal wall defects have significant disadvantages. Skin grafts provide no structural support and result in incisional hernias. Synthetic mesh requires skin cover and is prone to infection and wound breakdown. The tensor fasciae latae (TFL) myocutaneous flap offers skin cover and a semi-rigid fascial layer. We document our unit's experience in pedicled and free TFL flaps. The TFL flap closure of trunk defects was undertaken in 10 patients between August 1989 and April 1997. All cases were not amenable to primary closure and repair with synthetic mesh or skin grafts. The defect was satisfactorily repaired in all cases without subsequent herniation. The closure techniques using a pedicled TFL flap and a TFL flap for a free-tissue transfer are described. We conclude that the TFL flap is the method of choice for repairs of major truncal defects.
Publisher: Elsevier BV
Date: 12-2014
DOI: 10.1016/J.INJURY.2014.06.004
Abstract: Patients who have sustained traumatic brain injury (TBI) have increased nutritional requirements yet are often unable to eat normally, and adequate nutritional therapy is needed to optimise recovery. The aim of the current scoping review was to describe the existing evidence for improved outcomes with optimal nutrition therapy in adult patients with moderate to severe TBI, and to identify gaps in the literature to inform future research. Using an exploratory scoping study approach, Medline, Cinahl, Embase, CENTRAL, the Neurotrauma reviews in the Global Evidence Mapping (GEM) Initiative, and Evidence Reviews in Acquired Brain Injury (ERABI) were searched from 2003 to 14 November 2013 using variations of the search terms 'traumatic brain injury' and 'nutrition'. Articles were included if they reported mortality, morbidity, or length of stay outcomes, and were classified according to the nature of nutrition intervention and study design. Twenty relevant articles were identified of which: 12 were original research articles two were systematic reviews one a meta-analysis and five were narrative reviews. Of these, eleven explored timing of feed provision, eight explored route of administration of feeding, nine examined the provision of specific nutrients, and none examined feeding environment. Some explored more than one intervention. Three sets of guidelines which contain feeding recommendations were also identified. Inconsistency within nutrition intervention methods and outcome measures means that the present evidence base is inadequate for the construction of best practice guidelines for nutrition and TBI. Further research is necessary to elucidate the optimal nutrition therapy for adults with TBI with respect to the timing, route of administration, nutrient provision and feeding environment. A consensus on the ideal outcome measure and the most appropriate method and timing of its measurement is required as a foundation for this evidence base.
Publisher: Elsevier BV
Date: 05-2018
DOI: 10.1016/J.BJA.2018.02.007
Abstract: There is a need for robust, clearly defined, patient-relevant outcome measures for use in randomised trials in perioperative medicine. Our objective was to establish standard outcome measures for postoperative pulmonary complications research. A systematic literature search was conducted using MEDLINE, Web of Science, SciELO, and the Korean Journal Database. Definitions were extracted from included manuscripts. We then conducted a three-stage Delphi consensus process to select the optimal outcome measures in terms of methodological quality and overall suitability for perioperative trials. From 2358 records, the full texts of 81 manuscripts were retrieved, of which 45 met the inclusion criteria. We identified three main categories of outcome measure specific to perioperative pulmonary outcomes: (i) composite outcome measures of multiple pulmonary outcomes (27 definitions) (ii) pneumonia (12 definitions) and (iii) respiratory failure (six definitions). These were rated by the group according to suitability for routine use. The majority of definitions were given a low score, and many were imprecise, difficult to apply consistently, or both, in large patient populations. A small number of highly rated definitions were identified as appropriate for widespread use. The group then recommended four outcome measures for future use, including one new definition. A large number of postoperative pulmonary outcome measures have been used, but most are poorly defined. Our four recommended outcome measures include a new definition of postoperative pulmonary complications, incorporating an assessment of severity. These definitions will meet the needs of most clinical effectiveness trials of treatments to improve postoperative pulmonary outcomes.
Publisher: Oxford University Press (OUP)
Date: 03-10-2021
Abstract: Estimates of seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies have been h ered by inadequate assay sensitivity and specificity. Using an enzyme-linked immunosorbent assay–based approach that combines data about immunoglobulin G responses to both the nucleocapsid and spike receptor binding domain antigens, we show that excellent sensitivity and specificity can be achieved. We used this assay to assess the frequency of virus-specific antibodies in a cohort of elective surgery patients in Australia and estimated seroprevalence in Australia to be 0.28% (95% Confidence Interval, 0–1.15%). These data confirm the low level of transmission of SARS-CoV-2 in Australia before July 2020 and validate the specificity of our assay.
Publisher: Elsevier BV
Date: 12-2016
Publisher: Wiley
Date: 2020
DOI: 10.1111/ANAE.14869
Abstract: An ageing population and rising healthcare costs are challenging cost-efficient hospital systems wanting to adapt, employing novel organisational structures designed to merge erse skill sets. This needs not only physician and nursing leadership but also new models of care. Anaesthetists have expanded their role into the broader multidisciplinary field of peri-operative medicine, emphasising collaboration and safety in health teams. A greater focus on patient-centred care and shared decision making, along with validated metrics to quantify quality improvement activities, have emphasised the importance of comfort, patient satisfaction and quality of life after surgery. Shared decision-making is more likely to be manifest in a flat hierarchy in which each member of the team brings their own experience and skills to optimise patient care. Successful surgery is best achieved by a coordinated, multidisciplinary team, embedded in a culture of collaboration and safety.
Publisher: Mary Ann Liebert Inc
Date: 07-2021
Abstract: In medical research, missing data is common. In acute diseases, such as traumatic brain injury (TBI), even well-conducted prospective studies may suffer from missing data in baseline characteristics and outcomes. Statistical models may simply drop patients with any missing values, potentially leaving a selected subset of the original cohort. Imputation is widely accepted by methodologists as an appropriate way to deal with missing data. We aim to provide practical guidance on handling missing data for prediction modeling. We hereto propose a five-step approach, centered around single and multiple imputation: 1) explore the missing data patterns 2) choose a method of imputation 3) perform imputation 4) assess diagnostics of the imputation and 5) analyze the imputed data sets. We illustrate these five steps with the estimation and validation of the IMPACT (International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury) prognostic model in 1375 patients from the CENTER-TBI database, included in 53 centers across 17 countries, with moderate or severe TBI in the prospective European CENTER-TBI study. Future prediction modeling studies in acute diseases may benefit from following the suggested five steps for optimal statistical analysis and interpretation, after maximal effort has been made to minimize missing data.
Publisher: Elsevier BV
Date: 09-2012
Publisher: Medical Journals Sweden AB
Date: 2019
Abstract: Debate regarding factors associated with persistent symptoms following mild traumatic brain injury continues. Nested within a trial aiming to change practice in emergency department management of mild traumatic brain injury, this study investigated the nature of persistent symptoms, work/study outcomes, anxiety and quality of life and factors associated with persistent symptoms following injury, including the impact of receiving information about mild traumatic brain injuries in the emergency department. A total of 343 in iduals with mild traumatic brain injury completed the Rivermead Post-Concussion Symptom Questionnaire, Hospital Anxiety Depression Scale - Anxiety Scale, and Quality of Life - Short Form in average 7 months post-injury. Overall, 18.7% of participants reported 3 or more post-concussional symptoms, most commonly fatigue (17.2%) and forgetfulness (14.6%). Clinically significant anxiety was reported by 12.8%, and was significantly associated with symptom reporting, as were mental and physical quality of life scores. Significant predictors of post-concussional symptoms at follow-up were pre-injury psychological issues, experiencing loss of consciousness, and having no recall of receiving information about brain injury in the emergency department. This study confirms that loss of consciousness and pre-injury psychological issues are associated with persistent symptom reporting. Not receiving injury information in the emergency department may also negatively influence symptom reporting.
Publisher: AMPCo
Date: 07-2002
DOI: 10.5694/J.1326-5377.2002.TB04687.X
Abstract: To determine the effect of proximity of surgical specialists on general practitioners' (GPs') rates of referral of surgical problems to specialist care (ie, are surgical referral rates of GPs in rural or remote areas similar to those of GPs in urban centres?). A cross-sectional survey of GP-patient encounters. The Bettering the Evaluation and Care of Health (BEACH) program, which involves all active registered GPs in Australia. A random s le of 3030 GPs, each providing details of 100 consecutive patient encounters. Proportion of surgical problems (including ophthalmological and obstetric and gynaecological) referred to surgical specialists (surgeons' rooms, hospital outpatient departments or hospital emergency departments). Absence of a local specialist did not significantly influence the proportion of surgical problems referred by GPs overall, but the proportion referred was significantly lower for obstetric (odds ratio [OR], 0.56 95% CI, 0.44-0.70) and ophthalmological (OR, 0.60 95% CI, 0.49-0.73) problems. Other factors independently associated with referral of a lower proportion of problems included male GPs, female and younger patients, holders of a Health Care Card, injury-related and non-cancer-related problems, follow-up presentations, and more than one problem managed at an encounter. Our findings confirm that rural and remote GPs undertake much of their patients' antenatal care, and are less likely to use specialists when managing ophthalmological problems. Absence of local specialists in other surgical specialties is not a barrier to referral of patients with surgical disorders.
Publisher: Springer Science and Business Media LLC
Date: 24-02-2016
DOI: 10.1007/S00268-016-3452-Y
Abstract: In India, half of the annual 200,000 road traffic deaths occur in hospitals, but the exact in-hospital trauma mortality rate remains unknown. A research consortium of universities, with a mandate to reduce trauma mortality, measured the baseline 30-day in-hospital mortality rate. Between September 2013 and February 2015, trained data collectors collected on-admission demographic, physiological vital signs, and health service performance indicators (time of injury to admission, investigation, or intervention) on all patients with traumatic injuries admitted to four public university hospitals in three Indian megacities. Of the 11,202 hospitalized trauma patients, 21.4 % died within 30 days of hospitalization. The median age was 30 years for survivors and 37 years for non-survivors. The on-admission systolic blood pressure and Glasgow Coma Score was near-normal in survivors, but was significantly lower in non-survivors and associated with both early and late mortality (p = 0.001). In the absence of a trauma system, there were process-of-care delays from injury to reaching and being examined, investigated, or operated in the hospital. Using a multi-institutional Indian registry, this study is the first to systematically document that the 30-day in-hospital trauma mortality was twice that found in similar registries from high-income countries. Physiological scoring of on-admission vitals was clinically useful to predict mortality. More research is needed to understand the causes of high mortality and time delays in the process of delivering trauma care in India, which has no prehospital or trauma system.
Publisher: Research Square Platform LLC
Date: 19-03-2021
DOI: 10.21203/RS.3.RS-308964/V1
Abstract: Plasma fibrinogen is an important coagulation factor that is susceptible to post-translational modification by oxidants. We have reported altered fibrin polymerization and increased methionine oxidation in fibrinogen after exposure to hypochlorous acid (HOCl), and similarly in the fibrinogen of severely injured trauma patients. Molecular dynamics suggests that methionine oxidation offers a mechanistic link between oxidative stress and coagulation through fibrin protofibril lateral aggregation by disruption of AαC domain structures. However, experimental evidence explaining how HOCl oxidation impairs fibrinogen structure and function has not been demonstrated. We used polymerization studies and two dimensional-nuclear magnetic resonance spectrometry (2D-NMR) to test the hypothesis that HOCl oxidation alters fibrinogen conformation in the prefibrillar state and T 2 water surface relaxation of fibrin fiber assemblies. We found that both HOCl oxidation of purified fibrinogen and addition of HOCl-oxidized fibrinogen to plasma disrupted fibrin polymerization similarly to competitive inhibition of polymerization using a recombinant AαC fragment (AαC 419–502). DOSY NMR measurement of 1 H fibrinogen at 25 o C demonstrated that fibrinogen oxidation increased translational diffusion coefficient by 17.4%, suggesting a more compact and rapidly translational motion of the protein with oxidation. 2D-NMR analysis of control plasma fibrin gels indicated that water existed in two states, namely intermediate (T 2i ) in the hydration shell of fibrin fibers, and bulk (T 2 ) within the gel. T 2 relaxation of bulk water protons was decreased 2-fold in oxidized fibrin gels and was inversely proportional to gel fiber density (T 2 ). The fast exchange of water protons between hydration shell (T 2i ) and bulk water, indicating oxidation increased fiber hydration and formed densely packed fibrin gels. We have confirmed experimentally that HOCl oxidation affected native fibrinogen and fibrin gel structures and have demonstrated that NMR can serve as a valuable tool to probe the oxidative rearrangement of fibrin clot structure.
Publisher: Wiley
Date: 05-2008
Publisher: BMJ
Date: 03-2021
DOI: 10.1136/BMJOPEN-2020-046522
Abstract: Haemorrhage causes most preventable prehospital trauma deaths and about a third of in-hospital trauma deaths. Tranexamic acid (TXA), administered soon after hospital arrival in certain trauma systems, is an effective therapy in preventing or managing acute traumatic coagulopathy. However, delayed administration of TXA appears to be ineffective or harmful. The effectiveness of prehospital TXA, incidence of thrombotic complications, benefit versus risk in advanced trauma systems and the mechanism of benefit remain uncertain. The Pre-hospital Anti-fibrinolytics for Traumatic Coagulopathy and Haemorrhage (The PATCH-Trauma study) is comparing TXA, initiated prehospital and continued in hospital over 8 hours, with placebo in patients with severe trauma at risk of acute traumatic coagulopathy. We present the trial protocol and an overview of the statistical analysis plan. There will be 1316 patients recruited by prehospital clinicians in Australia, New Zealand and Germany. The primary outcome will be the eight-level Glasgow Outcome Scale Extended (GOSE) at 6 months after injury, dichotomised to favourable (GOSE 5–8) and unfavourable (GOSE 1–4) outcomes, analysed using an intention-to-treat (ITT) approach. Secondary outcomes will include mortality at hospital discharge and at 6 months, blood product usage, quality of life and the incidence of predefined adverse events. The study was approved by The Alfred Hospital Research and Ethics Committee in Victoria and also approved in New South Wales, Queensland, South Australia, Tasmania and the Northern Territory. In New Zealand, Northern A Health and Disability Ethics Committee provided approval. In Germany, Witten/Herdecke University has provided ethics approval. The PATCH-Trauma study aims to provide definitive evidence of the effectiveness of prehospital TXA, when used in conjunction with current advanced trauma care, in improving outcomes after severe injury. NCT02187120 .
Publisher: Royal Society of Chemistry (RSC)
Date: 2020
DOI: 10.1039/D0NR02787A
Abstract: Nanoparticle dimers composed of different metals or metal oxides, as well as different shapes and sizes, are of wide interest for applications ranging from nanoplasmonic sensing to nanooptics to biomedical engineering.
Publisher: Wiley
Date: 09-04-2012
DOI: 10.1111/J.1365-2753.2012.01835.X
Abstract: Defining 'best practice' is one of the first and crucial steps in any Knowledge Translation (KT) research project. Without a sound understanding of what exactly should happen in practice, it is impossible to measure the extent of existing gaps between 'desired' and 'actual' care, set implementation goals, and monitor performance. The aim of this paper is to present a practical, stepped and interactive process to develop best practice recommendations that are actionable, locally applicable and in line with the best available research-based evidence, with a view to adapt these into process measures (quality indicators) for KT research purposes. Our process encompasses the following steps: (1) identify current, high-quality clinical practice guidelines (CPGs) and extract recommendations (2) select strong recommendations in key clinical management areas (3) update evidence and create evidence overviews (4) discuss evidence and produce agreed 'evidence statements' (5) discuss the relevance of the evidence with local stakeholders and (6) develop locally applicable actionable best practice recommendations, suitable for use as the basis of quality indicators. Actionable definitions of local best practice are a prerequisite for doing KT research. As substantial resources go into rigorously synthesizing evidence and developing CPGs, it is important to make best use of such available resources. We developed a process for efficiently developing locally applicable actionable best practice recommendations from existing high-quality CPGs that are in line with current research evidence.
Publisher: MDPI AG
Date: 22-06-2022
DOI: 10.3390/PH15070772
Abstract: Breast cancers are most frequently oestrogen receptor (ER) and progesterone receptor (PR) positive and [18F]Fluorodeoxyglucose PET-CT (FDG) has lower sensitivity for these subtypes. The gastrin-releasing peptide receptor (GRPR) is overexpressed in ER+/PR+ breast cancers. This study assessed the safety and potential of [64Cu]Cu-Sarcophagine (SAR)-Bombesin PET/CT (BBN) in re-staging metastatic ER+/PR+/human epidermal growth-factor-2-negative (HER2-) breast cancer. Seven patients with metastatic ER+/PR+/HER2- breast cancer undergoing staging underwent [64Cu]Cu-SAR-BBN PET-CT. Bloods, vital signs and electrocardiogram, blood tracer-clearance and dosimetry were undertaken. GRPR status was assessed in available metastatic biopsy s les. Staging with conventional imaging ([18F]FDG, bone scan and diagnostic CT) was within 3 weeks of [64Cu]Cu-SAR-BBN PET/CT. PET scans were assessed visually and quantitatively. Seven patients underwent imaging. One of the seven had de-novo metastatic breast cancer and six of the seven recurrent metastatic disease. Two of the seven had lobular subtype. No adverse events were reported. All seven patients were positive on conventional imaging (six of seven on FDG). [64Cu]Cu-SAR-BBN imaging was positive in five of the seven. Both [64Cu]Cu-SAR-BBN-negative patients had disease identified on [18F]FDG. One patient was [64Cu]Cu-SAR-BBN positive/[18F]FDG negative. Four of seven patients were [64Cu]Cu-SAR-BBN positive/[18F]FDG positive. In these four, mean SUVmax was higher for [64Cu]Cu-SAR-BBN than [18F]FDG (SUVmax 15 vs. 12). In the classical lobular subtype (two of seven), [64Cu]Cu-SAR-BBN was more avid compared to [18F]FDG (SUVmax 20 vs. 11, and 20 vs. ). Dosimetry calculations estimated whole-body effective dose for 200 MBq of [64Cu]Cu-SAR-BBN to be 1.9 mSv. [64Cu]Cu-SAR-BBN PET/CT appears safe and may have diagnostic value in metastatic ER+/PR+/HER2- breast cancer, particularly the lobular subtype. Further evaluation is warranted.
Publisher: Springer Science and Business Media LLC
Date: 08-09-2023
Publisher: Cambridge University Press (CUP)
Date: 10-2010
DOI: 10.1017/S026646231000108X
Abstract: Objectives: The objective of this study is to profile the health technology assessments (HTAs) produced in Canada and other selected countries and assess their potential to inform policy making about health systems in jurisdictions other than the ones for which they were produced, and to develop and pilot test prototypes for packaging and assessing the relevance of HTAs for health system managers and policy makers. Methods: We compiled an inventory of all HTAs that were produced by nine HTA agencies between September 2003 and August 2006 coded the title and abstract of each HTA according to the technologies assessed, methods used, and whether or not context-specific actionable messages were provided developed a prototype for a structured, decision-relevant HTA summary and for a relevance-assessment form and pilot-tested the prototypes using semistructured telephone interviews with a purposive s le of Canadian healthcare managers and policy makers. Results: Our review of the 223 HTAs identified that: (i) 44 HTAs addressed health system arrangements (20 percent) (ii) 205 incorporated a systematic review (92 percent), whereas only 12 incorporated a sociopolitical assessment using explicit methods (5 percent) and (iii) 50 contained context-specific actionable messages (22 percent). Our interviews identified significant support for both the general idea of an HTA summary and the prototype's specific elements, but mixed views about using peer assessments of relevance. Conclusions: Those involved in supporting the use of HTAs in policy making about health systems may wish to produce structured decision-relevant summaries for their systematic review-containing HTAs to increase the prospects for their HTAs being used outside the jurisdiction for which they were produced.
Publisher: AMPCo
Date: 03-2001
Publisher: Springer Science and Business Media LLC
Date: 16-11-2018
Publisher: Elsevier BV
Date: 09-2010
Publisher: Wiley
Date: 27-07-2011
DOI: 10.1111/J.1365-2753.2010.01526.X
Abstract: This qualitative study identifies cultural factors that influence the effective implementation of evidence-based medicine (EBM) in surgical practice among Australian surgeons. In-depth interviews (n = 22) were conducted with surgeons from a variety of specialties within a large hospital system in Victoria, Australia. The interviews explored the surgeons' understanding of EBM and challenges to the adoption of EBM. The canons and procedures of the Miles and Huberman's Matrix Analyses approach to qualitative research guided the coding and organization of the data derived from the semi-structured interviews. Surgeons had a good understanding of EBM, but viewed it as little more than a system of evidence, which was often orced from actual clinical practice. The data also suggested that surgical culture(s) and typologies of surgical style were important variables in the implementation of EBM. The results suggest that the ideal method of EBM implementation is workplace instruction led by surgeons, who exhibit scientist and/or clinician styles of surgical practice EBM training should occur early in the surgeons' careers and EBM practice should be role modelled in the presence of trainees by surgeons who exhibit either a scientist and/or clinician style of surgical practice. The study findings suggest that using pre-existing surgical culture(s) and styles is an important component in the implementation of EBM in surgery. The effective use of the scientist and/or clinician surgeon within the apprenticeship model and the context-specific collegial networks of the surgical profession appear to be key elements in ensuring the successful implementation of EBM in surgery.
Publisher: Mary Ann Liebert Inc
Date: 19-10-2020
Publisher: Wiley
Date: 2021
DOI: 10.1111/ANS.16564
Publisher: Springer Science and Business Media LLC
Date: 06-09-2017
Publisher: CSIRO Publishing
Date: 2021
DOI: 10.1071/AH21016
Abstract: The global focus on nation states’ responses to the COVID-19 pandemic has rightly highlighted the importance of science and evidence as the basis for policy action. Those with a lifelong passion for evidence-based policy (EBP) have lauded Australia’s and other nations’ policy responses to COVID-19 as a breakthrough moment for the cause. This article reflects on the complexity of the public policy process, the perspectives of its various actors, and draws on Alford’s work on the Blue, Red and Purple zones to propose a more nuanced approach to advocacy for EBP in health. We contend that the pathway for translation of research evidence into routine clinical practice is relatively linear, in contrast to the more complex course for translation of evidence to public policy – much to the frustration of health researchers and EBP advocates. Cairney’s description of the characteristics of successful policy entrepreneurs offers useful guidance to advance EBP and we conclude with proposing some practical mechanisms to support it. Finally, we recommend that researchers and policy makers spend more time in the Purple zone to enable a deeper understanding of, and mutual respect for, the unique contributions made by research, policy and political actors to sound public policy.
Publisher: Elsevier BV
Date: 07-2015
Publisher: Elsevier BV
Date: 03-2015
DOI: 10.1016/J.INJURY.2015.10.011
Abstract: Providing current, reliable and evidence based information for clinicians and researchers in a synthesised and summarised way can be challenging particularly in the area of traumatic brain injury where a vast number of reviews exists. These reviews vary in their methodological quality and are scattered across varying sources. In this paper, we present an overview of systematic reviews that evaluate the pharmacological interventions in traumatic brain injury (TBI). By doing this, we aim to evaluate the existing evidence for improved outcomes in TBI with pharmacological interventions, and to identify gaps in the literature to inform future research. We searched the Neurotrauma Evidence Map on systematic reviews relating to pharmacological interventions for managing TBI in acute phase. Two reviewers independently screened search results and appraised each systematic review using the validated AMSTAR tool and extracted data from the review. A total of 288 systematic reviews relating to TBI were available on the Neurotrauma Evidence Map at the time of this study. We identified 19 systematic reviews on pharmacological management for acute TBI with publications dates ranging from 1998 to 2014. The studies were of varying methodological quality, with a mean AMSTAR score of 7.78 (range 2-11]. The evidence from high quality systematic reviews show that there is currently insufficient evidence for the use of magnesium, monoaminergic and dopamine agonists, progesterone, aminosteroids, excitatory amino acid inhibitors, haemostatic and antifibrinolytic drugs in TBI. Anti-convulsants are only effective in reducing early seizures with no significant difference between phenytoin and leviteracetam. There is no difference between propofol and midazolam for sedation in TBI patients and ketamine may not cause increased ICP. Overviews of systematic review provide informative and powerful summaries of evidence based research.
Publisher: Wiley
Date: 21-10-2013
DOI: 10.1111/ANS.12417
Abstract: The effectiveness of massive transfusion protocols (MTPs) has been assumed from low quality studies with multiple biases. This review aimed to (i) evaluate the association between the institution of an MTP and mortality and (ii) determine the effect of MTPs on transfusion practice post trauma. A systematic review of studies that examined patient outcomes before and after the institution of an MTP in the same centre was conducted. The design and results of each study were described. Heterogeneity was assessed using the Q test and the I(2) statistic. Odds ratios (ORs) for dichotomous outcomes from each study were pooled. There were eight studies that satisfied inclusion criteria with marked heterogeneity in study populations (I(2) = 72.1%, P = 0.001). Two studies showed significantly improved mortality following implementation of an MTP, and six studies showed no significant change. Pooled OR for the effect of an MTP on short-term mortality was 0.73 (95% confidence interval: 0.48-1.11). The effect of MTPs on transfusion practice was varied. Despite the popularity of MTPs and directives mandating their use in trauma centres, in before-after studies, MTPs have not always been associated with improved mortality. Evidence-based standardization of MTPs, improved compliance and analysis of broader endpoints were identified as areas for further research.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2006
Publisher: MDPI AG
Date: 08-09-2021
Abstract: Immunotherapy has transformed the treatment landscape of melanoma however, despite improvements in patient outcomes, monotherapy can often lead to resistance and tumour escape. Therefore, there is a need for new therapies, combination strategies and biomarker-guided decision making to increase the subset of patients most likely to benefit from treatment. Poly (ADP-ribose) polymerase (PARP) inhibitors act by synthetic lethality to target tumour cells with homologous recombination deficiencies such as BRCA mutations. However, the application of PARP inhibitors could be extended to a broad range of BRCA-negative cancers with high rates of DNA damage repair pathway mutations, such as melanoma. Additionally, PARP inhibition has the potential to augment the therapeutic effect of immunotherapy through multi-faceted immune-priming capabilities. In this review, we detail the immunological role of PARP and rationale for combining PARP and immune checkpoint inhibitors, with a particular focus on a subset of melanoma with homologous recombination defects that may benefit most from this targeted approach. We summarise the biology supporting this combined regimen and discuss preclinical results as well as ongoing clinical trials in melanoma which may impact future treatment.
Publisher: Elsevier BV
Date: 10-2020
Publisher: Elsevier BV
Date: 12-2008
Publisher: SAGE Publications
Date: 12-2013
Abstract: Systematic review. We assessed the current state of spine registries by collecting spine trauma data and assessing their compliance to defined registry standards of being clinical quality. We ascertained if these registries collected spinal cord injury data alone or with spine column trauma data. A systematic review was performed using MEDLINE and Embase databases for articles describing dedicated spinal cord and spine column databases published between January 1990 and April 2011. Correspondence with these registries was performed via e-mail or post. When no correspondence was possible, the registries were analyzed with best information available. Three hundred eight full-text articles were reviewed. Of 41 registries identified, 20 registries fulfilled the criteria of being clinical quality. The main reason for failure to attain clinical quality designation was due to the unavailability of patient outcomes. Eight registries collected both spine column and spinal cord injury data with 33 collecting only traumatic spinal cord injury data. There is currently a paucity of clinical quality spine trauma registries. Clinical quality registries are important tools for demonstrating trends and outcomes, monitoring care quality, and resolving controversies in the management of spine trauma. An international spine trauma data set (containing both spinal cord and spine column injury data) and standardized approach to recording and analysis are needed to allow international multicenter collaboration and benchmarking.
Publisher: Elsevier BV
Date: 07-2015
DOI: 10.1016/J.SURG.2015.04.005
Abstract: Surgery is a crucial component of health systems, yet its contribution has been difficult to define. We linked national hospital service utilization with national epidemiologic data to describe the use of surgical procedures in the management of a broad spectrum of conditions. We compiled International Classification of Diseases-10-Australian Modification codes from the New Zealand National Minimum Dataset, 2008-2011. Using primary cause of admission, we aggregated hospitalizations into 119 disease states and 22 disease subcategories of the World Health Organization Global Health Estimate (GHE). We queried each hospitalization for any surgical procedure in a binary manner to determine the volume of surgery for each disease state. Surgical procedures were defined as requiring general or neuroaxial anesthesia. We then ided the volume of surgical cases by counts of disease prevalence from the Global Burden of Disease Study 2010 to determine annual surgical incidence. Between 2008 and 2011, there were 1,108,653 hospital admissions with 275,570 associated surgical procedures per year. Surgical procedures were associated with admissions for all 22 GHE disease subcategories and 116 of 119 GHE disease states. The sub-categories with the largest surgical case volumes were Unintentional Injuries (48,073), Musculoskeletal Diseases (38,030), and Digestive Diseases (27,640). Surgical incidence ranged widely by in idual disease states with the highest in: Other Neurological Conditions, Abortion, Appendicitis, Obstructed Labor, and Maternal Sepsis. This study confirms that surgical care is required across the entire spectrum of GHE disease subcategories, illustrating a critical role in health systems. Surgical incidence might be useful as an index to estimate the need for surgical procedures in other populations.
Publisher: Springer Science and Business Media LLC
Date: 16-07-2020
DOI: 10.1007/S00415-020-10022-2
Abstract: Fatigue is one of the most commonly reported subjective symptoms following traumatic brain injury (TBI). The aims were to assess frequency of fatigue over the first 6 months after TBI, and examine whether fatigue changes could be predicted by demographic characteristics, injury severity and comorbidities. Patients with acute TBI admitted to 65 trauma centers were enrolled in the study Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI). Subjective fatigue was measured by single item on the Rivermead Post-Concussion Symptoms Questionnaire (RPQ), administered at baseline, three and 6 months postinjury. Patients were categorized by clinical care pathway: admitted to an emergency room (ER), a ward (ADM) or an intensive care unit (ICU). Injury severity, preinjury somatic- and psychiatric conditions, depressive and sleep problems were registered at baseline. For prediction of fatigue changes, descriptive statistics and mixed effect logistic regression analysis are reported. Fatigue was experienced by 47% of patients at baseline, 48% at 3 months and 46% at 6 months. Patients admitted to ICU had a higher probability of experiencing fatigue than those in ER and ADM strata. Females and in iduals with lower age, higher education, more severe intracranial injury, preinjury somatic and psychiatric conditions, sleep disturbance and feeling depressed postinjury had a higher probability of fatigue. A high and stable frequency of fatigue was found during the first 6 months after TBI. Specific socio-demographic factors, comorbidities and injury severity characteristics were predictors of fatigue in this study.
Publisher: Wiley
Date: 31-05-2023
DOI: 10.1111/ACEM.14745
Abstract: Transfusion of a high ratio of plasma to packed red blood cells (PRBCs), to treat or prevent acute traumatic coagulopathy, has been associated with survival after major trauma. However, the effect of prehospital plasma on patient outcomes has been inconsistent. The aim of this pilot trial was to assess the feasibility of transfusing freeze‐dried plasma with red blood cells (RBCs) using a randomized controlled design in an Australian aeromedical prehospital setting. Patients attended by helicopter emergency medical service (HEMS) paramedics with suspected critical bleeding after trauma managed with prehospital RBCs were randomized to receive 2 units of freeze‐dried plasma (Lyoplas N‐w) or standard care (no plasma). The primary outcome was the proportion of eligible patients enrolled and provided the intervention. Secondary outcomes included preliminary data on effectiveness, including mortality censored at 24 h and at hospital discharge, and adverse events. During the study period of June 1 to October 31, 2022, there were 25 eligible patients, of whom 20 (80%) were enrolled in the trial and 19 (76%) received the allocated intervention. Median time from randomization to hospital arrival was 92.5 min (IQR 68–101.5 min). Mortality may have been lower in the freeze‐dried plasma group at 24 h (RR 0.24, 95% CI 0.03–1.73) and at hospital discharge (RR 0.73, 95% CI 0.24–2.27). No serious adverse events related to the trial interventions were reported. This first reported experience of freeze‐dried plasma use in Australia suggests prehospital administration is feasible. Given longer prehospital times typically associated with HEMS attendance, there is potential clinical benefit from this intervention and rationale for a definitive trial.
Publisher: SAGE Publications
Date: 07-08-2020
Abstract: Although rehabilitation is beneficial for in iduals with traumatic brain injury (TBI), a significant proportion of them do not receive adequate rehabilitation after acute care. Therefore, the goal of this prospective and multicenter study was to investigate predictors of access to rehabilitation in the year following injury in patients with TBI. Data from a large European study (CENTER-TBI), including TBIs of all severities between December 2014 and December 2017 were used (N = 4498 patients). Participants were dichotomized into those who had and those who did not have access to rehabilitation in the year following TBI. Potential predictors included sociodemographic factors, psychoactive substance use, preinjury medical history, injury-related factors, and factors related to medical care, complications, and discharge. In the year following traumatic injury, 31.4% of patients received rehabilitation services. Access to rehabilitation was positively and significantly predicted by female sex (odds ratio [OR] = 1.50), increased number of years of education completed (OR = 1.05), living in Northern (OR = 1.62 reference: Western Europe) or Southern Europe (OR = 1.74), lower prehospital Glasgow Coma Scale score (OR = 1.03), higher Injury Severity Score (OR = 1.01), intracranial (OR = 1.33) and extracranial (OR = 1.99) surgery, and extracranial complication (OR = 1.75). On contrast, significant negative predictors were lack of preinjury employment (OR = 0.80), living in Central and Eastern Europe (OR = 0.42), and admission to hospital ward (OR = 0.47 reference: admission to intensive care unit) or direct discharge from emergency room (OR = 0.24). Based on these findings, there is an urgent need to implement national and international guidelines and strategies for access to rehabilitation after TBI.
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Russell Lindsay Gruen.