Duration and predictors of emergency surgical operations - basis for medical management of mass casualty incidents

Background

Hospitals have a critically important role in the management of mass causality incidents (MCI), yet there is little information to assist emergency planners. A significantly limiting factor of a hospital''s capability to treat those affected is its surgical capacity. We therefore intended to provide data about the duration and predictors of life saving operations.

Methods

The data of 20,815 predominantly blunt trauma patients recorded in the Trauma Registry of the German-Trauma-Society was retrospectively analyzed to calculate the duration of life-saving operations as well as their predictors. Inclusion criteria were an ISS ≥ 16 and the performance of relevant ICPM-coded procedures within 6 h of admission.

Results

From 1,228 patients fulfilling the inclusion criteria 1,793 operations could be identified as life-saving operations. Acute injuries to the abdomen accounted for 54.1% followed by head injuries (26.3%), pelvic injuries (11.5%), thoracic injuries (5.0%) and major amputations (3.1%). The mean cut to suture time was 130 min (IQR 65-165 min). Logistic regression revealed 8 variables associated with an emergency operation: AIS of abdomen ≥ 3 (OR 4,00), ISS ≥ 35 (OR 2,94), hemoglobin level ≤ 8 mg/dL (OR 1,40), pulse rate on hospital admission < 40 or > 120/min (OR 1,39), blood pressure on hospital admission < 90 mmHg (OR 1,35), prehospital infusion volume ≥ 2000 ml (OR 1,34), GCS ≤ 8 (OR 1,32) and anisocoria (OR 1,28) on-scene.

Conclusions

The mean operation time of 130 min calculated for emergency life-saving surgical operations provides a realistic guideline for the prospective treatment capacity which can be estimated and projected into an actual incident admission capacity. Knowledge of predictive factors for life-saving emergency operations helps to identify those patients that need most urgent operative treatment in case of blunt MCI.     

Effect of antibodies on the expression of Plasmodium falciparum circumsporozoite protein gene

Antibodies are known to play an important role in the control of malaria infection. However, they can modulate parasite development enhancing infection. The effect of anti-Plasmodium antibodies on the expression of circumsporozoite protein gene (csp) was investigated. Plasmodium falciparum 3D7 in vitro cultures were submitted to: i) anti- circumsporozoite protein monoclonal antibody (anti-CSP-mAb) [1microg/ml, 0.1microg/ml, 0.01microg/ml and 0.001microg/ml] and ii) purified IgG Fab fragment from a pool of malaria patients [1mg/ml and 1microg/ml]; and compared to control cultures. After 24h the number of ring infected erythrocytes was determined in order to calculate invasion efficacy. At 48h culture supernatant was collected, and the amount of circumsporozoite protein determined by ELISA, parasitaemia was calculated and cells were processed for RNA preparation. Expression of csp gene was quantified using Real time RT-PCR. There was an increase in parasite growth when treated with lower anti-CSP-mAb concentration, which was associated with lower csp expression, while 1mug/ml anti-CSP-mAb treatment presented a growth inhibitory effect accompanied by high csp expression.     

Nasogastric tubes: a lot of bother

The insertion of the nasogastric tube is one of the procedure that produces the most discomfort for the patients and practitioners. The AA, with the make use of their clinical experience and the data of the literature, report some personal reflections about the management of the nasogastric tube. The AA also analyse some variables (choice of the tube, approach to the patient, insertion of the tube, examination of the position, fixation and removal) that can influence on discomfort of the patient. The choice of the most right SNG is an important moment for the correct insertion; an effect we need to adjust the material and diameter of the tube to the prearranged use. The common practice demonstrates that the collaboration with the patient, obtained by "direct" and "indirect" strategies, gives more possibilities to immediately success of this procedure. The literature explains that it is possible to decrease the discomfort with topical anesthesia; still there are some points of view to clarify. From analyse of the different methods to check the position of SNG, the pH test of the aspirating fluid is the best solution. Once examination of right placement, we need to fix in different points (at least two). From personal experience the removal of SNG is better tolerate that the insertion because the patient is more conscious to be on the mend. The principal recommendation is to abstain from insertion of SNG if it is not closely necessary!     

Es necesario el control de la psoriasis a largo plazo

Psoriasis is an immune mediated, inflammatory skin condition affecting approximately 1.43% of Spanish population. In clinical practice, physicians use PASI index to assess the severity. Psoriasis causes physical and mental disability comparable to other chronic diseases and affects seriously the patients quality of life. For treatment we have different options. Conventional systemic treatment such as methotrexate, cyclosporine and acitretin may be associated with relevant side effects, and organ toxicity that avoid long term therapy. Several psoriasis patients have other comorbid disorders like obesity, diabetes, dyslipemia, hypertension and an increased rate of cardiovascular disease and metabolic syndrome and these patients need safer treatments. The accumulating clinical experience with new therapies consistent on biological agents like efalizumab indicates that are effective therapies, with safety profile and no evidence of cumulative toxicity that allows a long term use. A better control of psoriasis improves patients quality of life.     

Different effects of ascorbate deprivation and classical vascular nitrate tolerance on aldehyde dehydrogenase-catalysed bioactivation of nitroglycerin

Background and purpose:

Vascular tolerance to nitroglycerin (GTN) may be caused by impaired GTN bioactivation due to inactivation of mitochondrial aldehyde dehydrogenase (ALDH2). As relaxation to GTN is reduced but still sensitive to ALDH2 inhibitors in ascorbate deficiency, we compared the contribution of ALDH2 inactivation to GTN hyposensitivity in ascorbate deficiency and classical in vivo nitrate tolerance.

Experimental approach:

Guinea pigs were fed standard or ascorbate-free diet for 2 weeks. Reversibility was tested by feeding ascorbate-deficient animals standard diet for 1 week. Nitrate tolerance was induced by subcutaneous injection of 50 mg·kg⁻¹ GTN 4 times daily for 3 days. Ascorbate levels were determined in plasma, blood vessels, heart and liver. GTN-induced relaxation was measured as isometric tension of aortic rings; vascular GTN biotransformation was assayed as formation of 1,2-and 1,3-glyceryl dinitrate (GDN).

Key results:

Two weeks of ascorbate deprivation had no effect on relaxation to nitric oxide but reduced the potency of GTN ∼10-fold in a fully reversible manner. GTN-induced relaxation was similarly reduced in nitrate tolerance but not further attenuated by ALDH inhibitors. Nitrate tolerance reduced ascorbate plasma levels without affecting ascorbate in blood vessels, liver and heart. GTN denitration was significantly diminished in nitrate-tolerant and ascorbate-deficient rings. However, while the ∼10-fold preferential 1,2-GDN formation, indicative for active ALDH2, had been retained in ascorbate deficiency, selectivity was largely lost in nitrate tolerance.

Conclusions and implications:

These results indicate that nitrate tolerance is associated with ALDH2 inactivation, whereas ascorbate deficiency possibly results in down-regulation of ALDH2 expression.     

Thermochromism of Highly Luminescent Photopolymer Flexible Films Based On Eu (III) Salts Confined in Polysulfone

Here we discuss the influence of two different cations on the emissive properties of the highly emissive [Eu(fod)₄]⁻ anion. The studied Eu(III) salts were [C₁₆Pyr][Eu(fod)₄] (1), and the previously reported [Chol][Eu(fod)₄]. C₁₆Pyr stands for N-cetylpyridinium, Chol for cholinium and fod for 1,1,1,2,2,3,3-heptafluoro-7,7-dimethyloctane-4,6-dionate. 1 is classified as ionic liquid, with melting point close to 60 °C, and presented a luminescence quantum yield of (ϕ) 100%. Ultrabright emissive photopolymers were obtained for the first time using polysulfone as the host matrix. The films were prepared with incorporation of 10% (w/w) of 1 and [Chol][Eu(fod)₄] in the polymeric matrix, which improved its thermal stability. Additionally, the luminescence of CholEu(fod)₄/PSU presented a strong temperature dependence with a ratiometric thermal behavior.     

The impact of changing dental needs on cost savings from fluoridation

Background:  Although community water fluoridation has been one of the cornerstone strategies for the prevention and control of dental caries, questions are still raised regarding its cost-effectiveness. This study assessed the impact of changing dental needs on the cost savings from community water fluoridation in Australia.
Methods:  Net costs were estimated as Costs_(programme) minus Costs_{(averted caries).} Averted costs were estimated as the product of caries increment in non-fluoridated community, effectiveness of fluoridation and the cost of a carious surface. Modelling considered four age-cohorts: 6–20, 21–45, 46–65 and 66+ years and three time points 1970s, 1980s, and 1990s. Cost of a carious surface was estimated by conventional and complex methods. Real discount rates (4, 7 (base) and 10%) were utilized.
Results:  With base-case assumptions, the average annual cost savings/person, using Australian dollars at the 2005 level, ranged from $56.41 (1970s) to $17.75 (1990s) (conventional method) and from $249.45 (1970s) to $69.86 (1990s) (complex method). Under worst-case assumptions fluoridation remained cost-effective with cost savings ranging from $24.15 (1970s) to $3.87 (1990s) (conventional method) and $107.85 (1970s) and $24.53 (1990s) (complex method). For 66+ years cohort (1990s) fluoridation did not show a cost saving, but costs/person were marginal.
Conclusions:  Community water fluoridation remains a cost-effective preventive measure in Australia.