Administration of tranexamic acid for victims of severe trauma within pre-hospital care ambulance services (PHCAS) in Malaysia

@#Introduction: Trauma is a Global threat and the 5th highest cause of all-cause mortality in Malaysia caused predominantly due to road traffic accidents. Majority of trauma victims are young adults aged between 21-40 years old. In Malaysia, 24 out of 100,000 population die annually due to trauma, rating us amongst the highest in South East Asia. These alarming figures justify aggressive preventive and mitigation strategies. The aim of this paper is to promote the implementation of evidence-based interventions that will reduce the rate of preventable death because of trauma. Tranexamic acid is one of the few interventions in the early management of severe trauma with level-one evidence. Tranexamic acid has been proven to reduce all causes of mortality and mortality due to bleeding. Evidence proves that it is most effective when administered early, particularly within the 1st hour of trauma. This proposed guideline is formulated based upon quality evidence from multicentre studies, clinical practices in other countries and consideration of the local demographic factors with the intent of enabling an easy and simple pathway to administer tranexamic acid early in the care of the severely injured. Conclusion: The guideline highlights select pre-hospital criteria’s and the methods for drug administration. The authors recognise that some variants may be present amongst certain institutions necessitating minor adaptations, nevertheless the core principles of advocating tranexamic acid early in the course of pre-hospital trauma should be adhered to.

Enhanced recovery program [erp] versus traditional care after elective left side colorectal cancer surgery

Aims: We aimed to study the effect of ERAS protocol after left side colorectal cancer surgery in comparison with patients were subjected to traditional care

Methods: Retrospective study comparing 2 groups of patients who underwent elective left side colorectal cancer surgery. Group A: 25 patients admitted between November 2014 and April 2015 subjected to ERAS, and Group B: 25 patients admitted between January 2008 and August 2008 received traditional care. Both groups were consecutive cases. The notes were examined to determine the following outcome measures: Short-term morbidity, Length of stay, 30 days Readmission rate and Mortality

Results: 25 patients with ERAS matched with 25 traditional recovery cases for baseline demographics. 96% started oral fluids on D1 in group A compared to 8% in group B, 96% in group . A tolerated full diet on D6 compared to 72% in group B. Bowel movements by D5 was group A 92% compared to only 36% in group B. Total LOS mean for group A was 7 days vs 12.48 in group B [p=0.005]. Complications occurred less frequently in group A compared to group B [anastomotic leak with 8% [n=2] in group A versus 16% [n=4] in group B, prolonged ileus with 8% [n=2] in group A versus 16% [n=4] in group B [p = 0.663]. Mobility on D1 40% [n=10] in group A was an independent factor which decreased LOS, as all stayed< 5 days [p=0.002] and developed less complications [4% [p=0.027]]

Conclusion: ERAS didn‘t affect complications rate significantly following left side colorectal surgery, however reduced LOS as it improved tolerating oral intake and bowel movement. Mobility D1 can be independent pridector of reduced both complications and LOS and should be encouraged for all patients

Trends in hematopoietic stem cell transplant activity in Lebanon

Hematopoietic stem cell transplantation [HSCT] has been accessible to the population residing in Lebanon and surrounding countries since 1997. HSCT programs were developed in two major hospitals in Beirut: American University of Beirut Medical Center [AUBMC] and Makassed General Hospital. Mount Lebanon Hospital initiated an autologous HSCT activity later. Between 2012 and 2016, the HSCT activity in Lebanon reached a total of 897 transplants, among which 303 [33.8%] were allogeneic HSCT and 594 [66.2%] were autologous HSCT. Overall, autologous HSCT activity has remained stable over the past 5 years, whereas allogeneic HSCT activity has seen a steep increase between 2012 and 2013 followed by a modest increase later. Haploidentical transplantation has mushroomed and represented almost half of allogeneic HSCT activity in 2016. AUBMC and Makassed General Hospital are members of the European Blood and Marrow Transplantation [EBMT] and East Mediterranean Blood and Marrow Transplantation groups, and AUBMC has been accredited by JACIE [Joint Accreditation Committee - ISCT and EBMT] since 2016. The past 5 years have seen an increase in HSCT-related research and publications, mainly from AUBMC. These research activities were predominantly focused on personalized conditioning for allogeneic HSCT and post-transplant maintenance therapy

Hematopoietic stem cell transplantation in the eastern mediterranean region [EMRO] 2008-2009: report on behalf of the eastern mediterranean bone marrow transplantation [EMBMT] group

The Eastern Mediterranean Bone Marrow Transplantation [EMBMT] Group has accumulated over 25 years of data and experience in hematopoietic stem cell transplantation [HSCT], most particularly in he-moglobinopathies, severe aplastic anemia [SAA], and inherited metabolic and immune disorders, in addition to hematologic malignancies peculiar to the region and where recent updates in trends in activities are warranted. To study trends in HSCT activities in the World Health Organization-Eastern Mediterranean [EM] region surveyed by EMBMT between 2008 and 2009. STUDY DESIGN: Retrospective analysis of the survey data, mainly of the cumulative number of transplants, types of transplants [autologous vs. allogeneic], types of conditioning as myeloablative [MAC] vs. reduced intensity conditioning [RIC] and trends in leukemias, hemo-globinopathies, SAA, inherited bone marrow failure syndromes amongst others. Fourteen teams from ten Eastern Mediterranean Region Organization [EMRO] countries reported their data [100% return rate] to the EMBMT for the years 2008-2009 with a total of 2608 first HSCT [1286 in 2008; 1322 in 2009]. Allogeneic HSCT represented the majority [63%] in both years. The main indications for allogeneic HSCT were acute leukemias [732; 44%], bone marrow failure syndromes [331, 20%], hemoglobinopathies [255; 15%] and immune deficiencies [90; 5%]. There was a progressive increase in the proportions of chronic myeloid leukemia [CML] cases transplanted beyond the first chronic phase [3; 7% of all CML cases in 2008 vs 13; 29% in 2009]. The main indications for autologous transplants were plasma cell disorders [345; 36%] Hodgkin disease [256; 27%], non-Hodgkin lymphoma [207; 22%] and solid tumors [83; 9%]. RIC continued to show a progressive increase over the years [7% in 2007, 11% in 2008 and 13% in 2009], yet remained relatively low compared to contemporary practices in Europe published by EBMT. The vast majority [95%] of allo-HSCT sources were from sibling donors with a continued dominance of peripheral blood [PB] [1076; 63%], while cord blood transplant [CBT] increased to 83 [5% of allo-HSCT], matched unrelated donor [MUD] remained underutilized [1; 0%] and there were no haploidentical transplants reported. Large centers with >50 HSCT/year showed a plateau of the total number of allo-HSCT over the last 5 years that may be related to capacity issues and needs further study. There is an overall increased rate of HSCT in the EMRO region with a significant increase in utilization of CBT and allogeneic PB-HSCT as a valuable source. However, further research on outcome data and development of regional donor banks [CB and MUD] may help facilitate future planning to satisfy the regional needs and increase collaboration within the group and globally

Rate of conversion and complications of laparoscopic cholecystectomy in a tertiary care center in Saudi Arabia

Problems during laparoscopic cholecystectomy include bile duct injury, conversion to open operation, and other postoperative complications. We retrospectively evaluated the causes for conversion and the rate of conversion from laparoscopic to open cholecystectomy and assessed the postoperative complications. Of 340 patients who presented with symptomatic gall bladder disease over a 2-year period, 290 [85%] patients were evaluated on an elective basis and scheduled for surgery, while the remaining 50 [14.7%] patients were admitted emergently with a diagnosis of acute cholecystitis. The mean age of the patients was 41.9 [12.6] years. Conversion to laparotomy occurred in 17 patients [5%]. The incidence of complications was 3.2%. The most common complication was postoperative transient pyrexia, which was seen in four patients [1.2%] followed by postoperative wound infection in three patients [0.9%], postoperative fluid collection and bile duct injury in two patients each [0.6%].Laparoscopic cholecystectomy remains the 'gold standard' by which all other treatment modalities are judged. Conversion from laparoscopic to open cholecystectomy should be based on the sound clinical judgment of the surgeon and not be due to a lack of individual expertise

Radiofrequency ablation of unresectable liver malignancies: evaluation of the laparoscopic approach

In this study, 12 consecutive patients with unresectable hepatic malignancies were treated with laparoscopic RFA. A total of 28 tumors with median tumor volume of 35 mm [8-58] were detected in the 12 patients. The group included seven patients with hepatoma arising on a background of cirrhosis and five patients with multiple deposits from primary colorectal cancer. Total ablation was performed in seven patients with hepatoma and five patients with secondary deposits. Total ablation with a minimum of 0.5 cm margin was achieved in 26 lesions [92%]. No complications were encountered postoperatively and all patients were discharged within two days of the intervention. After a median follow-up of 11.8 months, local recurrence occurred in one patient [8%] and new hepatic tumors developed in two patients [16%]. This study confirmed the safety and therapeutic potential of laparoscopic ultrasound-guided RFA in patients with inoperable hepatic tumors

Temporary defunctioning stomas: a randomized clinical trial comparing loop ileostomy with loop transverse colostomy following low anterior resection with total mesorectal excision

Patients undergoing low anterior resection with total mesorectal excision who required a defunctioning stoma were randomly allocated to receive either a loop ileostomy [n=13] [group A] or a loop transverse colostomy [n=14] [group B]. Postoperative morbidity following closure were compared. From May 1999 to May 2002, 13 patients had a loop ileostomy and 14 had a loop colostomy following low anterior resection. There were no significant differences in the difficulty of formation or closure, or in the postoperative recovery between the groups. However, the ileostomy was associated with significantly less appliance changes. Wound infection was also significantly more common after closure of colostomy compared with the ileostomy. Furthermore, four complications directly related to the stoma in the loop transverse colostomy group have been seen [prolapse [two] and incisional hernia during follow-up [two]]. None of these complications occurred in the loop ileostomy group