Progressive loss of bone mass in children with Fontan circulation.

OBJECTIVE: We investigated bone mineral density (BMD) at different ages after the Fontan completion, and we evaluated the relationship between BMD, vitamin D levels, and pertinent patient variables. METHODS: A cross-sectional sample of 64 patients was examined with dual-energy X-ray absorptiometry (DXA) scans to determine BMD. Of these patients, 24 were also examined with BoneXpert software to determine bone mass density (BMX), expressed as the bone health index (BHI). Blood samples from all patients were analyzed. Patients were divided into three different age groups; A: 4-9 years old (n = 22), B: 10-15 years old (n = 21), and C: 16-18 years old (n = 21). RESULTS: Overall, BMD z scores were (mean ± SD): -1.0 ± 1.3 for the lumbar spine and -0.2 ± 1.2 for the total body. Groups B and C had significantly lower z score values compared to group A. Of patients in group C, 35% had z score values ≤-2 SD of the mean of the healthy population. There was no difference related to systemic ventricular anatomy (left or right); however, patients with lateral tunnels had lower BMD than patients with extra cardiac conduits. Overall, the BHI z score was (mean ± SD): -1.2 ± 0.9, but low BMX did not correlate with low BMD. The 25-hydroxy vitamin D level was 58 ± 30 nmol/L. Vitamin D levels decreased with age: in group C, 33.3% of patients exhibited vitamin D deficiencies. Vitamin D levels were not correlated with bone mineral densities. CONCLUSION: BMD levels decreased with age in patients with Fontan circulation. Different bone components were involved. Vitamin D levels also decreased with age, but they were not consistently associated with bone mineral densities. The single factor most predictive of low BMD was a lateral tunnel Fontan, compared to an extra cardiac Fontan.

Evaluation of training program for surgical trauma teams in Botswana.

BACKGROUND: Trauma represents a challenge to healthcare systems worldwide, particularly in low-and middle-income countries. Positive effects can be achieved by improving trauma care at the scene of the accident and throughout hospitalization and rehabilitation. Therefore, we assessed the long-term effects of national implementation of a training program for multidisciplinary trauma teams in a southern African country. METHODS: From 2007 to 2009, an educational program for trauma, "Better and Systematic Team Training," (BEST) was implemented at all government hospitals in Botswana. The effects were assessed through interviews, a structured questionnaire, and physical inspections using the World Health Organization's "Guidelines for Essential Trauma Care." Data on human and physical resources, infrastructure, trauma administrative functions, and quality-improvement activities before and at 2-year follow-up were compared for all 27 government hospitals. RESULTS: A majority of hospitals had formed local trauma organizations; half were performing multidisciplinary trauma simulations and some had organized multidisciplinary trauma teams with alarm criteria. A number of hospitals had developed local trauma guidelines and local trauma registries. More equipment for advanced airway management and stiff cervical collars were available after 2 years. There were also improvements in the skills necessary for airway and breathing management. The most changes were seen in the northern region of Botswana. CONCLUSIONS: Implementation of BEST in Botswana hospitals was associated with several positive changes at 2-year follow-up, particularly for trauma administrative functions and quality-improvement activities. The effects on obtaining technical equipment and skills were moderate and related mostly to airway and breathing management.

Trauma care in Africa: a status report from Botswana, guided by the World Health Organization's "Guidelines for Essential Trauma Care".

BACKGROUND: Trauma represents a significant and increasing challenge to health care systems all over the world. This study aimed to evaluate the trauma care capabilities of Botswana, a middle-income African country, by applying the World Health Organization's Guidelines for Essential Trauma Care. METHODS: All 27 government (16 primary, 9 district, 2 referral) hospitals were surveyed. A questionnaire and checklist, based on "Guidelines for Essential Trauma Care" and locally adapted, were developed as situation analysis tools. The questionnaire assessed local trauma organization, capacity, and the presence of quality improvement activity. The checklist assessed physical availability of equipment and timely availability of trauma-related skills. Information was collected by interviews with hospital administrators, key personnel within trauma care, and through on-site physical inspection. RESULTS: Hospitals in Botswana are reasonably well supplied with human and physical resources for trauma care, although deficiencies were noted. At the primary and district levels, both capacity and equipment for airway/breathing management and vascular access was limited. Trauma administrative functions were largely absent at all levels. No hospital in Botswana had any plans for trauma education, separate from or incorporated into other improvement activities. Team organization was nonexistent, and training activities in the emergency room were limited. CONCLUSIONS: This study draws a picture of trauma care capabilities of an entire African country. Despite good organizational structures, Botswana has room for substantial improvement. Administrative functions, training, and human and physical resources could be improved. By applying the guidelines, this study creates an objective foundation for improved trauma care in Botswana.

Mannequin or standardized patient: participants' assessment of two training modalities in trauma team simulation.

BACKGROUND: Trauma team training using simulation has become an educational compensation for a low number of severe trauma patients in 49 of Norway's 50 trauma hospitals for the last 12 years. The hospitals' own simple mannequins have been employed, to enable training without being dependent on expensive and advanced simulators. We wanted to assess the participants' assessment of using a standardized patient instead of a mannequin. METHODS: Trauma teams in five hospitals were randomly exposed to a mannequin or a standardized patient in two consecutive simulations for each team. In each hospital two teams were trained, with opposite order of simulation modality. Anonymous, written questionnaires were answered by the participants immediately after each simulation. The teams were interviewed as a focus group after the last simulation, reflecting on the difference between the two simulation modalities. Outcome measures were the participants' assessment of their own perceived educational outcome and comparison of the models, in addition to analysis of the interviews. RESULTS: Participants' assessed their educational outcome to be high, and unrelated to the order of appearance of patient model. There were no differences in assessment of realism and feeling of embarrassment. Focus groups revealed that the participants felt that the choice between educational modalities should be determined by the simulated case, with high interaction between team and patient being enhanced by a standardized patient. CONCLUSION: Participants' assessment of the outcome of team training seems independent of the simulation modality when the educational goal is training communication, co-operation and leadership within the team.

Effects of nationwide training of multiprofessional trauma teams in norwegian hospitals.

BACKGROUND: Norway has 50 trauma hospitals serving a geographically disperse population (4.6 million) and many have low trauma case loads. We showed that personnel find functioning as a team especially challenging, and developed a 1-day training course, arranged locally at each hospital, focused on team training in communication, leadership, and cooperation during simulated patient treatment. This study evaluates the effects of training on participants' knowledge, confidence, and perceived trauma team performance, controlling for hospital size and the participants' previous experience. METHODS: Anonymous, written questionnaires were answered by 4,203 participants (28% physicians, 55% nurses) in 44 hospitals before and immediately after training courses, and by 1,368 trauma team members in 26 of the hospitals 6 months after their last training course. Outcome measures were knowledge and confidence concerning the respondent's own role, and evaluation of trauma team performance in live trauma resuscitations. RESULTS: There was a significant increase in self-reported knowledge and confidence among all participants. Community hospitals and participants without recent trauma experience had the lowest preintervention scores, but reached levels comparable to participants at the other hospitals after training. The effects increased after 6 months, with trauma team performance evaluated as having improved, even by team members who had not participated in the training. CONCLUSIONS: Practical team training in hospitals improved the participants' perceived knowledge and confidence, which continued to increase for 6 months after training independent of participants' experience level, suggesting that small hospitals may reach levels comparable to major hospitals.

Team-oriented training for damage control surgery in rural trauma: a new paradigm.

BACKGROUND: The geography of Norway has led to an initiative to train teams from rural hospitals in damage control surgery using a team-oriented approach based on Crew Resource Management. Our aim was to evaluate this approach and its impact on trauma care in rural hospitals across Norway. METHODS: Thirty-eight teams from 21 hospitals participated in 10 courses (during the years 2003-2006) where providers from the same hospital trained as a team. Each course consisted of interactive lecture modules and operative sessions on live porcine models that emphasize communication, collaboration and team-based problem solving. The data collection tools were a postcourse questionnaire and a phone survey of participating hospitals. RESULTS: Teams consisted of surgeons (34%), operating room nurses (35%), and anesthesiology staff (31%). Almost all course participants (N = 228, 99%) reported a dramatic increase in their proficiency with damage control techniques. There was a mean increase of 2.3 points in proficiency with extraperitoneal pelvic packing and 1.5 points with emergency thoracotomy on a 5-step Likert scale. The team approach was perceived as crucial by 218 (94%) of participants. The phone survey revealed 12 cases of lifesaving rural damage control operations by course participants in the past 3 years (estimated cost: $15,075 per life saved). Of the 18 hospitals surveyed, 17 modified their trauma protocols as a result of the course. CONCLUSION: Teaching damage control surgery using a team-oriented approach is an innovative educational method for rural hospitals.

Training operating room teams in damage control surgery for trauma: a followup study of the Norwegian model.

BACKGROUND: Because the hospitals in Norway are mostly rural community hospitals that see life-threatening trauma only infrequently, we developed a course in damage control surgery based on a live porcine model in 1999. The course also focuses on teamwork and leadership training based on crew resource management principles. The aim of this study was to evaluate the direct educational benefit from the course and whether participants had used the damage control techniques in their subsequent daily practice. STUDY DESIGN: A total of 103 participants completed 2 questionnaires about the self-efficacy for damage control surgery, the first at completion of the course and the second at least 6 months after the course. RESULTS: There was a significant increase in the number of trauma team members who felt comfortable performing damage control surgery (from 17% before the course to 62% at followup; p < 0.001). Almost half the surgeons and operating room nurses reported using damage control techniques in their subsequent practice. Participants considered the focus on team-oriented training important. Four of every five participants thought this course had improved their ability to handle severely injured patients. CONCLUSIONS: This study shows that a team-oriented operative trauma course is not only beneficial in the short term, but the principles and techniques learned are subsequently applied by the graduates in their daily practice. Course content and structure, particularly the emphasis on integral operating room teams working together, is especially suitable for the rural setting.

[Can ear temperature measurement be used in a hospital?]. / Kan øretemperaturmåling brukes i sykehus?

BACKGROUND: There are two principle means of infrared thermometry: tympanic thermometry and ear canal thermometry. The purpose of this study was to examine the reliability of these ear thermometers compared with the digital rectal thermometer. MATERIAL AND METHODS: We used two different infrared ear thermometers in this study; one type measured the tympanic temperature, the other the temperature in the ear canal. The rectal temperature was defined as the gold standard. The temperatures measured with the ear thermometers were compared to rectal temperature on 213 patients older than 18 years at Haukeland University Hospital. RESULTS: The tympanic and ear canal measurements showed an average of 0.5 and 0.2 degrees Celsius respectively lower than the rectal temperature. The difference between the two types of ear thermometers was 0.4 degrees (p < 0.001, 95% CI 0.18 to 0.42). By using the tympanic thermometer, the sensitivity of detecting fever was 14% and the negative predictive value was 89%. Ear canal thermometry had 55% sensitivity for finding fever and a negative predictive value of 95%. INTERPRETATION: There are many advantages by using ear thermometers, but the accuracy and ability to detect fever is not good enough for it to be recommended in a clinical practice. We recommend using rectal thermometers.

Bicycle-related injuries among young children related to age at debut of cycling.

This study focuses on bicycle-related injuries among young children and the effect of being an inexperienced beginner related to age at debut of cycling. The study was based on a random stratified population sample of 1200 children aged 4-15 years in Bergen, Norway. Data about age at debut of cycling, cycling habits and any previous bicycle-related injuries were collected. A child was defined as a beginner within the first 12 months of active cycling. Relation between the first bicycle-related injury and age at debut was analysed by the Kaplan-Meier method. The risk of getting injured during the first 12 months of active cycling were significant lower for children aged 7 or 8 years at the debut of cycling compared to younger children (hazard ratio = 0.78, P < 0.001). Children cycling more than 1h per week were at greater risk of getting injured during the first 12 months than those who cycled less (hazard ratio = 1.95, P = 0.014). This study shows that the risk of getting injured during the first 12 months of active cycling is reduced if bicycling debut is delayed until 7 or 8 years instead of at 4 or 5 years.

Protective effect of different types of bicycle helmets.

The effectiveness of bicycle helmets in preventing head injuries is well documented. There are different opinions about the effectiveness of helmets in preventing face injuries, and few studies have analyzed the effect of different types of helmets. This study was performed to examine the effect of different helmet types to head and face injuries. The use of helmets was analyzed in cyclists with head or face injuries and compared with two control groups. The main control group was cyclists that had injuries not including the head or neck, and another control group was cyclists that had been involved in an accident, regardless of whether they had sustained any injury. Cross-table and logistic regression analyses were applied to analyze the protective effect of helmets. A total of 991 injured patients served as a basis for this study. Most of the accidents, (82%) were single accidents with no other persons involved. Of patients with injuries to the head, excluding face, 11.4% had been using hard shell helmets, and 9.6% had been using foam helmets at the time of the accident. Among the emergency room controls, the proportion of hard shell helmet users and foam helmet users was 26.4% and 11.4%, respectively. Compared to non-helmet users, this gave an odds ratio of 0.36 (CI = 0.21-0.60) for getting head injuries if the cyclists had been using hard shell helmets at the time of the injury, and 0.83 (CI = 0.41-1.67) for users of foam helmets. The odds ratio for getting face injuries was 0.90 (CI = 0.58-1.41) among users of hard shell helmets, and 1.87 (CI = 1.03-3.40) for users of foam helmets. The use of hard shell helmets reduced the risk of getting injuries to the head. Children less than nine years old that used foam helmets had an increased risk of getting face injuries. All bicyclists should be recommended to use hard shell bicycle helmets while cycling.

[Clinical examination of the pelvis in patients with multiple traumas is unreliable]. / Klinisk undersøkelse av bekkenet hos multitraumatiserte er upålitelig.

BACKGROUND: The primary examination of a seriously injured patient is often done according to the Advanced Trauma Life Support concept. This concept calls for routine x-rays of the chest, pelvis and cervical spine. We have seen a tendency in Norway towards selective use of the pelvic film according to trauma mechanism and physical findings, even in patients with multiple traumas. MATERIAL AND METHODS: Four cases illustrate the risk of missing serious injuries in patients with multiple injuries if routine pelvic x-ray is omitted. A review of the literature confirms that routine pelvic x-ray may be omitted only if the patient is alert, has a negative physical pelvic examination, and no other distracting painful injuries. INTERPRETATION: Early x-ray of the pelvis should still be a routine in patients with multiple injuries, but may be omitted in patients with normal consciousness, no distracting painful injuries and no pain on examination of the pelvis.