Hepatic microvascular changes in rat abdominal compartment syndrome.

BACKGROUND: Abdominal compartment syndrome (ACS) is associated with an increased rate of multiple organ dysfunction and is an independent marker for mortality. Our objective was to develop an animal model to study the mechanisms of tissue and microvascular injury associated with ACS at the microscopic level. MATERIALS AND METHODS: ACS was established in rats with CO2 insufflation at 20 mm Hg for 2 h, with an abdominal cast. Sinusoidal perfusion, inflammatory response, and cell death were quantified in exteriorized livers. Respiratory and renal dysfunction were assessed biochemically and morphologically. Myeloperoxidase levels, a marker of neutrophil activation, were measured in the liver, lung, and small intestine. RESULTS: Continuously perfused sinusoids were significantly lower in the ACS group (81.4 ± 2.2% versus 99.6% ± 0.50), with an increase in nonperfused and intermittently perfused sinusoids (P < 0.05). Hepatocellular death and the number of activated leukocytes in postsinusoidal venules showed 7- and 18-fold increases, respectively, in the ACS group (P < 0.05). A significant increase in blood urea nitrogen levels in experimental rats was also observed. Myeloperoxidase levels were found to be 8-fold higher in lungs of ACS rats relative to control (P < 0.05), as well as statistically significant increase in the pCO2 and decrease in pH of ACS rats. CONCLUSIONS: We have successfully developed a model of ACS with documented evidence of renal and respiratory dysfunction. In addition, we have microscopy-confirmed evidence of early inflammatory changes and perfusion deficits in the liver with a concomitant increase in cell death in the ACS group.

Factors affecting transfusion requirement after hip fracture: can we reduce the need for blood?

BACKGROUND: Hip fractures are common injuries that result in blood loss and frequently require the transfusion of blood products. We sought to identify risk factors leading to increased blood transfusion in patients presenting with hip fractures, especially those factors that are modifiable. METHODS: We retrospectively reviewed the cases of all patients who had fixation of their hip fractures between October 2005 and February 2010. The need for transfusion was correlated with potential risk factors, including age, sex, preoperative hemoglobin, fracture type, fixation method and more. RESULTS: A total of 835 patients had fixation of their hip fractures during the study period; 631 met the inclusion criteria and 249 of them (39.5%) were transfused. We found an association between need for blood transfusion and female sex (p = 0.018), lower preoperative hemoglobin (p < 0.001), fracture type (p < 0.001) and fixation method (p < 0.001). Compared with femoral neck fractures, there was a 2.37 times greater risk of blood transfusion in patients with intertrochanteric fractures (p < 0.001) and a 4.03 times greater risk in those with subtrochanteric fractures (p < 0.001). Dynamic hip screw (DHS) fixation decreased the risk of transfusion by about half compared with intramedullary nail or hemiarthroplasty. We found no association with age, delay to operation (p = 0.17) or duration of surgery (p = 0.30). CONCLUSION: The only modifiable risk factor identified was fixation method. When considering blood transfusion requirements in isolation, we suggest a potential benefit in using a DHS for intertrochanteric and femoral neck fractures amenable to DHS fixation.

CONTEXTE: La fracture de la hanche est un traumatisme fréquent, qui cause une perte sanguine et nécessite souvent la transfusion de produits sanguins. Nous avons tenté d'identifier les facteurs de risque associés à une hausse du nombre des transfusions sanguines chez des patients ayant subi une fracture de la hanche, en particulier les facteurs modifiables. MÉTHODES: Au cours d'une étude rétrospective, on a revu les cas de tous les patients chez qui on avait pratiqué une ostéosynthèse pour une fracture de la hanche survenue entre octobre 2005 et février 2010. La nécessité d'une transfusion sanguine a été associée à d'éventuels facteurs de risque, dont l'âge, le sexe, le taux d'hémoglobine préopératoire, le type de fracture, la technique d'ostéosynthèse, et d'autres facteurs encore. RÉSULTATS: Au total, 835 patients avaient subi une ostéosynthèse pour fracture de la hanche au cours de la période à l'étude; 631 satisfaisaient les critères d'inclusion à l'étude et parmi eux, 249 (39,5 %) ont reçu une transfusion sanguine. On a observé l'existence d'un lien entre la nécessité d'une transfusion sanguine et le sexe féminin (p = 0,018), une plus faible concentration d'hémoglobine préopératoire (p < 0,001), le type de fracture (p <0,001) et la technique d'ostéosynthèse (p < 0,001). Par rapport aux fractures du col fémoral, le risque de transfusion sanguine était 2,37 fois plus élevé chez les patients présentant une fracture intertrochantérienne (p < 0,001) et 4,03 fois plus élevé chez ceux présentant une fracture sous-trochantérienne (p <0,001). En utilisant une vis dynamique de hanche, le risque de transfusion sanguine a diminué d'environ 50 % par rapport à l'enclouage centromédullaire ou à l'hémiarthroplastie. Aucun lien n'a été observé avec l'âge, le délai de l'intervention chirurgicale (p = 0,17), ni avec sa durée (p = 0,30). CONCLUSION: La technique d'ostéosynthèse est l'unique facteur de risque modifiable ayant été identifié. Mais lorsqu'on évalue la nécessité d'une transfusion sanguine sans tenir compte des facteurs de risque, nos résultats semblent indiquer qu'on aurait avantage à utiliser une vis dynamique de hanche pour consolider les fractures intertrochantériennes et les fractures du col fémoral.

A comparison of surgical delays in directly admitted versus transferred patients with hip fractures: opportunities for improvement?

BACKGROUND: The increasing incidence of hip fractures in our aging population challenges orthopedic surgeons and hospital administrators to effectively care for these patients. Many patients present to regional hospitals and are transferred to tertiary care centres for surgical management, resulting in long delays to surgery. Providing timely care may improve outcomes, as delay carries an increased risk of morbidity and mortality. METHODS: We retrospectively reviewed the cases of all patients with hip fractures treated in a single Level 1 trauma centre in Canada between 2005 and 2012. We compared quality indicators and outcomes between patients transferred from a peripheral hospital and those directly admitted to the trauma centre. RESULTS: Of the 1191 patients retrospectively reviewed, 890 met our inclusion criteria: 175 who were transferred and 715 admitted directly to the trauma centre. Transfer patients' median delay from admission to operation was 93 hours, whereas nontransfer patients waited 44 hours (p < 0.001). The delay predominantly occurred before transfer, as the patients had to wait for a bed to become available at the trauma centre. The median length of stay in hospital was 20 days for transfer patients compared with 13 days for nontransfer patients (p < 0.001). Regional policy changes enacted in 2011 decreased the median transfer delay from regional hospital to tertiary care centre from 47 to 27 hours (p = 0.005). CONCLUSION: Policy changes can have a significant impact on patient care. Prioritizing patients and expediting transfer will decrease overall mortality, reduce hospital stay and reduce the cost of hip fracture care.

CONTEXTE: L'incidence croissante des fractures de la hanche dans notre population vieillissante pose un défi aux chirurgiens orthopédistes et aux administrateurs hospitaliers qui souhaitent offrir des soins efficaces à ces patients. De nombreux patients se présentent dans des hôpitaux régionaux avant d'être transférés dans des centres de soins tertiaires pour y être opérés, ce qui retarde la chirurgie. Fournir les soins requis en temps voulu pourrait améliorer les résultats étant donné que tout retard s'accompagne d'un risque accru de morbidité et de mortalité. MÉTHODES: Nous avons effectué une revue rétrospective de tous les cas de fracture de la hanche traités dans un centre canadien de traumatologie de niveau 1 entre 2005 et 2012. Nous avons comparé les indicateurs de qualité et les résultats entre les patients transférés d'un hôpital régional et les patients admis directement au centre de traumatologie. RÉSULTATS: Parmi les 1191 cas analysés rétrospectivement, 890 répondaient à nos critères d'inclusion : 175 avaient été transférés et 715 avaient été admis directement au centre de traumatologie. Le délai médian entre l'admission et la chirurgie chez les patients transférés a été de 93 heures, alors que les patients non transférés ont attendu 44 heures (p < 0,001). Le délai est principalement survenu avant le transfert, car les patients devaient attendre qu'un lit se libère au centre de traumatologie. La durée médiane du séjour hospitalier a été de 20 jours pour les patients transférés, contre 13 jours pour les patients non transférés (p < 0,001). Les changements apportés à la politique régionale en 2011 ont abrégé de 47 à 27 heures (p = 0,005) le délai médian avant le transfert des hôpitaux régionaux vers le centre de soins tertiaires. CONCLUSION: Les changements de politiques peuvent avoir un impact significatif sur les soins aux patients. Prioriser les cas et accélérer les transferts réduiront la mortalité globale, abrégeront les séjours hospitaliers et réduiront les coûts associés au traitement des fractures de la hanche.

The underlying aetiologies of coma in febrile Sudanese children.

BACKGROUND: Cerebral malaria, acute bacterial meningitis and viral encephalitis are the main causes of fever and altered consciousness in the tropics. In areas where reliable laboratory testing is unavailable, over diagnosis and misdiagnosis of these conditions is likely. In malaria endemic countries non-malarial contributors to coma may be overlooked, overburdening available resources. The aim of this study is to evaluate the underlying causes of altered mental state in children presenting with fever and coma to tertiary medical facilities in Sudan. METHODS: Children over one month of age admitted to the emergency departments of three main hospitals in Khartoum with fever and coma were investigated for cerebral malaria, acute bacterial meningitis and Herpes simplex encephalitis during April to November 2011. RESULTS: One hundred and four children presenting with fever and coma were evaluated. Cerebral malaria was clinically suspected in 38 patients and 5 were confirmed. Acute bacterial meningitis was suspected in 63 patients and confirmed in 15. Herpes encephalitis was confirmed in only one case. There were five cases of mixed infection and the remainder were unknown. CONCLUSION: The clinical diagnoses of cerebral malaria, acute bacterial meningitis and viral encephalitis are unreliable. Further studies to evaluate the underlying causes of coma in febrile Sudanese children are warranted.

Prevalence of smoking among school adolescents in Khartoum State.

Tobacco is the single most important cause of chronic morbidity in the Developed World. Tobacco use primarily begins in early adolescence, reportedly before the time of high school graduation. By 2015 tobacco use is projected to cause 50% more deaths than AIDS. A cross sectional school based survey was conducted in primary and secondary school in Khartoum State. The study aimed to estimate the prevalence of smoking in school adolescents and associated personal and social factors. A total of 910 students with complete questionnaires were included in the analysis, of whom 13.6% were found to be current cigarette smokers. Factors that played role in initiation of smoking included smoking among parents, other family members and close friends. School adolescents who have friends or parents who smoke should be the main target for tobacco control. Smoking should become public health priority in Sudan to educate adolescents and parents regarding its hazards.