A checklist for trauma quality improvement meetings: A process improvement study.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.

Mortality following surgery for trauma in an Indian trauma cohort.

BACKGROUND: India accounts for 20 per cent of worldwide trauma mortality. Little is known about the quality of trauma surgery in an Indian setting. The aim of this study was to estimate the overall perioperative mortality rate, and to assess the association between type of acute surgical intervention and perioperative mortality among adult patients treated for trauma in an urban Indian setting. METHODS: Data were obtained from injured adult patients enrolled in four urban Indian hospitals during 2013-2015. Those who had surgery within 24 h of arrival at hospital were included in the analysis. Patients with missing data were excluded. The perioperative mortality rate was measured at 48 h and 30 days after arrival at hospital. Generalized linear mixed models were used for risk adjustment of procedure-specific mortality. RESULTS: Among 2986 patients who underwent trauma surgery, the overall 48-h mortality rate was 6·0 per cent, and the 30-day mortality rate was 23·1 per cent. The highest adjusted odds ratios (ORs) for 48-h mortality were found for patients who underwent surgery on the peripheral vasculature (OR 4·71, 95 per cent c.i. 1·18 to 16·59; P = 0·030) and the digestive system and spleen (OR 3·77, 1·33 to 9·01; P = 0·010) compared with those who had nervous system surgery. CONCLUSION: In this study of surgery in an Indian trauma cohort, there was an excess of late perioperative deaths. Mortality differed significantly according to the type of surgery being undertaken.

Does prehospital time affect survival of major trauma patients where there is no prehospital care?

BACKGROUND: Survival after major trauma is considered to be time dependent. Efficient prehospital care with rapid transport is the norm in developed countries, which is not available in many lower middle and low-income countries. The aim of this study was to assess the effect of prehospital time and primary treatment given on survival of major trauma patients in a setting without prehospital care. MATERIALS AND METHODS: This prospective observational study was carried out in a university hospital in Mumbai, from January to December 2014. The hospital has a trauma service but no organized prehospital care or defined interhospital transfer protocols. All patients with life- and/or limb-threatening injuries were included in the study. Injury time and arrival time were noted and the interval was defined as "prehospital time" for the directly arriving patients and as "time to tertiary care" for those transferred. Primary outcome measure was in-hospital death (or discharge). RESULTS: Of 1181 patients, 352 were admitted directly from the trauma scene and 829 were transferred from other hospitals. In-hospital mortality was associated with age, mechanism and mode of injury, shock, Glasgow Coma Score <9, Injury Severity Score ≥16, need for intubation, and ventilatory support on arrival; but neither with prehospital time nor with time to tertiary care. Transferred patients had a significantly higher mortality (odds ratio = 1.869, 95% confidence interval = 1.233-2.561, P = 0.005) despite fewer patients with severe injury. Two hundred and ninety-four (35%) of these needed airway intervention while 108 (13%) needed chest tube insertion on arrival to the trauma unit suggesting inadequate care at primary facility. CONCLUSION: Mortality is not associated with prehospital time but with transfers from primary care; probably due to deficient care. To improve survival after major trauma, enhancement of resources for resuscitation and capacity building of on-duty doctors in primary centers should be a priority in countries with limited resources.

Tumor-specific targeting of an anticancer drug delivery system by LHRH peptide.

The central problem in cancer chemotherapy is the severe toxic side effects of anticancer drugs on healthy tissues. Invariably the side effects impose dose reduction, treatment delay, or discontinuance of therapy. To limit the adverse side effects of cancer chemotherapy on healthy organs, we proposed a drug delivery system (DDS) with specific targeting ligands for cancer cells. The proposed DDS minimizes the uptake of the drug by normal cells and enhances the influx and retention of the drug in cancer cells. This delivery system includes three main components: (i) an apoptosis-inducing agent (anticancer drug), (ii) a targeting moiety-penetration enhancer, and (iii) a carrier. We describe one of the variants of such a system, which utilizes camptothecin as an apoptosis-inducing agent and poly(ethylene glycol) as a carrier. Luteinizing hormone-releasing hormone (LHRH) was used as a targeting moiety (ligand) to LHRH receptors that are overexpressed in the plasma membrane of several types of cancer cells and are not expressed detectably in normal visceral organs. The results showed that the use of LHRH peptide as a targeting moiety in the anticancer DDS substantially enhanced the efficacy of chemotherapy, led to amplified apoptosis induction in the tumor, and minimized the side effects of the anticancer drug on healthy organs. The LHRH receptor targeting DDS did not show in vivo pituitary toxicity and did not significantly influence the time course or the plasma concentration of luteinizing hormone and its physiological effects on the reproductive functions of mice.

Repeat CT scan in closed head injury.

BACKGROUND: Cranial CT scans are often repeated to observe the progress of an intracranial injury. This prospective observational study analyses the effect of repeat CT scans with the aim of formulating a guideline for their use. METHODS: One hundred and seventy-five patients with blunt head injury presenting to the trauma unit and undergoing CT scan were included. Unstable patients with polytrauma were excluded. There was no standard protocol for ordering the repeat cranial CT scans. This decision was purely based on the discretion of neurosurgeons. RESULTS: CT scan was repeated in 53 (30%) patients. The clinical indications for the repeat CT scan could be grouped into three: (i) clinical deterioration, (ii) failure of improvement, and (iii) as a follow-up scan. Nine underwent surgical intervention based on the repeat CT scan findings. They were associated with clinical deterioration and had a better survival after surgery. In others the repeat CT scan findings did not alter the management. CONCLUSION: When a head injured patient shows clinical deterioration, it is necessary to repeat the CT scan to pick up a surgically treatable lesion; which is likely in a significant number of patients. Repeat CT scan as a matter of "routine" follow-up when the patient is clinically status-quo or improving, is unlikely to yield any further information necessitating change in treatment. This guideline may be useful in settings where CT scan facility is not easily available or expenditure is an issue.

Molecular targeting of drug delivery systems to cancer.

This review presents molecular targeting approaches in anticancer drug delivery systems (DDS) and identifies new developments in these systems. Targeting approaches include passive targeting (enhanced permeability and retention effect), targeting specific tumor conditions, topical delivery and active targeting, namely, targeting organs, cells, intracellular organelles and molecules, sandwich targeting, promoter targeting, indirect targeting and targeting by external stimuli. A novel advanced proapoptotic anticancer DDS that utilizes several molecular targets will be considered. Experimental data suggest that this DDS can simultaneously: (1) induce cell death, (2) prevent adverse effects on healthy tissues; (3) suppress and prevent multidrug resistance; and (4) inhibit cellular antiapoptotic defense.

Molecular targeting of drug delivery systems to ovarian cancer by BH3 and LHRH peptides.

Novel targeted proapoptotic anticancer drug delivery systems were developed and evaluated. Poly(ethyleneglycol) (PEG) conjugates were used as carriers. Camptothecin (CPT) was used as an anticancer agent-apoptosis inductor. Two types of molecular targets were investigated: (1) an extracellular membrane receptor specific to ovarian cancer and (2) intracellular controlling mechanisms of apoptosis. Synthetic peptides similar to luteinizing hormone-releasing hormone (LHRH) and BCL-2 homology 3 (BH3) peptide were used as a targeting moiety and a suppressor of cellular antiapoptotic defense, respectively. Three different conjugates (CPT-PEG, CPT-PEG-BH3 and CPT-PEG-LHRH) were synthesized and examined in A2780 human ovarian cancer cells. Cytotoxicity, expression of genes encoding BCL-2, BCL-XL, SMAC, APAF-1 proteins and caspases 3 and 9, the activity of caspases 3 and 9 and apoptosis induction were studied. Taken together the results indicate much higher cytotoxicity and apoptosis-inducing activity of PEG-CPT conjugates when compared to free CPT. Moreover, the effects of targeted CPT-PEG-BH3 and CPT-PEG-LHRH conjugates were more pronounced than the non-targeted PEG-CPT conjugate. The results confirmed the feasibility of this new two-tier molecular targeting strategy for enhancing the efficacy of cancer chemotherapy.

Enhancing the efficacy of chemotherapeutic drugs by the suppression of antiapoptotic cellular defense.

The study was aimed at evaluating the combination of a traditional anticancer drug doxorubicin (DOX) with a suppressor of antiapoptotic cellular defense--synthetic peptide corresponding to the minimal sequence of BCL-2 homology 3 (BH3) domain. BH3 peptide was delivered into cells by fusion with a peptide corresponding to the Antennapedia (Ant) internalization sequence. The cytotoxicity of DOX, Ant-BH3 and Ant-BH3 mixed in with DOX, mitochondrial transmembrane potential, expression of genes encoding pro- and antiapoptotic members of BCL-2 protein family and caspases, caspases activity, apoptosis induction were assessed in human ovarian carcinoma cells. It was found that the combination in one drug formulation of DOX and Ant-BH3 produced two main effects: (1) enhancing the apoptosis induction by an anticancer drug, and (2) preventing the development of antiapoptotic cellular drug resistance. The results confirmed that anticancer drug-BH3 combination might form the basis for a new advanced anticancer proapoptotic drug delivery systems.

Identification of tumor markers in models of human colorectal cancer using a 19,200-element complementary DNA microarray.

Metastasis represents a crucial transition in disease development and progression and has a profound impact on survival for a wide variety of cancers. Cell line models of metastasis have played an important role in developing our understanding of the metastatic process. We used a 19,200-element human cDNA microarray to profile transcription in three paired cell-line models of colorectal tumor metastasis. By correlating expression patterns across these cell lines, we have identified 176 genes that appear to be differentially expressed (greater than 2-fold) in all highly metastatic cell lines relative to their reference. An analysis of these genes reiterates much of our understanding of the metastatic process and suggests additional genes, many of previously uncharacterized function, that may be causatively involved in, or at least prognostic of, metastasis. Northern analysis of a limited number of these genes validates the observed pattern of expression and suggests that further investigation and functional characterization of the identified genes is warranted.

A concise guide to cDNA microarray analysis.

Microarray expression analysis has become one of the most widely used functional genomics tools. Efficient application of this technique requires the development of robust and reproducible protocols. We have optimized all aspects of the process, including PCR amplification of target cDNA clones, microarray printing, probe labeling and hybridization, and have developed strategies for data normalization and analysis.