Adolescents with prior patellar dislocation report affected quality of life and function, as measured using the Banff Patella Instability Instrument, Kujala and EQ-5D-5L index scores.

PURPOSE: We aimed to establish patient-reported outcome measure (PROM) reference data for a cohort of patients with prior patellar dislocation without previous knee surgery. METHODS: All inhabitants of the Faroe Islands aged 15-19 years were sent an online survey via secure email to establish a national cohort. They were asked to answer questions regarding demographics, whether they had prior patellar dislocation and to complete the PROMs: the Banff Patella Instability Instrument (BPII), Kujala, Marx activity and EQ-5D-5L questionnaires. Participants who had undergone knee surgery were excluded. Participants who had prior patellar dislocation underwent radiographic examinations to diagnose trochlear dysplasia. The study included three cohorts: the general population, prior patellar dislocation and prior patellar dislocation and trochlear dysplasia cohorts. RESULTS: Of the 3749 individuals contacted, 1119 completed the survey and responded to at least one PROM. Of these, 102 reported a history of patellar dislocation and 57 of them had trochlear dysplasia. All PROMs, except the Marx score, reflected a worse quality of life and function after patellar dislocation than in the general population cohort; this was most pronounced in the BPII. The percentage of people experiencing problems in EQ-5D-5L dimensions was higher in the patellar dislocation and trochlear dysplasia cohorts than in the general population cohort in all EQ-5D-5L domains, except anxiety/depression. CONCLUSION: Adolescents who had patellar dislocation reported reduced quality of life and function according to the BPII, Kujala and EQ-5D-5L index values, as well as all EQ-5D-5L domains, except for anxiety/depression. However, their activity levels remained high. LEVEL OF EVIDENCE: Level III.

Team-based digital communication reduced patient-initiated phone calls to the hospital and improved patient satisfaction after orthopedic surgery: a randomized controlled trial in 70 patients.

BACKGROUND AND PURPOSE: Post-discharge inquiries to the hospital are predominantly conducted through phone calls. The rigid timing of these calls is inconvenient for patients and disrupts the workflows of healthcare professionals. The aim of this study was to investigate the effect of a team-based digital communication intervention (eDialogue) facilitated through a messenger-like commercial solution on patient-initiated phone calls to the hospital after discharge. Secondarily, we investigated other patient-initiated contacts, patients' perception of continuity of care, and their perception of feeling safe and satisfied after hospital discharge. METHODS: On the day of discharge, 70 surgically treated orthopedic patients were randomized to the intervention group with access to eDialogue (n = 35) or the control group with standard communication pathways by phone call (n = 35) for the following 8 weeks. Through eDialogue, the intervention group had access to team-based asynchronous digital communication in text and photos with healthcare professionals across disciplines and sectors. Inclusion criteria were discharge to own home and receipt of rehabilitation services from both hospital and primary care after discharge. RESULTS: We found a significant reduction in the mean number of patient-initiated phone calls to the hospital from 2.3 (95% confidence interval [CI] 1.4-4.1) in the control group to 0.5 (CI 0.3-1.0) in the intervention group (P = 0.004). Across groups, patients reported similar perceptions of continuity of care; however, the participants in the intervention group expressed significantly improved perceptions of, and satisfaction with, access to healthcare after discharge. CONCLUSION: Access to eDialogue reduced patient-initiated phone calls to the hospital, enhanced patient satisfaction with healthcare accessibility, and did not compromise patients' perception of continuity of care after discharge compared with standard communication pathways.

High prevalence of patellar dislocation and trochlear dysplasia in a geographically and genetically isolated society: an observational national cohort study from the Faroese Knee Cohort.

BACKGROUND AND PURPOSE: We aimed to calculate the prevalence of patellar dislocation (PD) and trochlear dysplasia (TD) in a national cohort aged 15-19 years in the Faroe Island. PATIENTS AND METHODS: All inhabitants in the Faroe Islands aged 15-19 years were invited to answer an online survey, including demographics and questions regarding prior PD. Participants with prior PD were invited for radiographs and MRI of both knees to be taken. Trochlear dysplasia was defined as one of the following: Dejour type A-D on radiographs, lateral trochlear inclination angle (LTI) < 11°, or trochlear depth < 3 mm on MRI. RESULTS: 3,749 individuals were contacted, 41 were excluded, and 1,638 (44%) completed the survey. 146 reported a prior PD (the PD cohort) and 100 accepted to participate and have radiographs and MRI taken of both knees (the clinical PD cohort), 76 of whom were diagnosed with TD. The national prevalence of PD was 8.9%. The national prevalence of symptomatic TD was 6.8%. The prevalence of TD in the clinical PD cohort was 76%. TD was bilateral in 78% of TD patients, but only 27% of patients with bilateral TD had PD in both knees. CONCLUSION: The prevalence of PD in the Faroe Islands is found to be very high. The national prevalence of TD and the prevalence of TD in participants with prior PD is high, indicating a potential genetic influence.

Pubofemoral distances correlate to acetabular morphology and sonological instability in screening for hip dysplasia.

Aims: The present study seeks to investigate the correlation of pubofemoral distances (PFD) to α angles, and hip displaceability status, defined as femoral head coverage (FHC) or FHC during manual provocation of the newborn hip < 50%. Methods: We retrospectively included all newborns referred for ultrasound screening at our institution based on primary risk factor, clinical, and PFD screening. α angles, PFD, FHC, and FHC at follow-up ultrasound for referred newborns were measured and compared using scatter plots, linear regression, paired t-test, and box-plots. Results: We included 2,735 newborns, of whom 754 received a follow-up hip ultrasound within six weeks of age. After exclusion, 1,500 hips were included for analysis. Sex distribution was 372 male and 380 female, and the mean age at examination was 36.6 days (4 to 87). We found a negative linear correlation of PFD to α angles (p < 0.001), FHC (p < 0.001), and FHC during provocation (p < 0.001) with a 1 mm increase in PFD corresponding to a -2.1° (95% confidence interval (CI) -2.3 to -1.9) change in α angle and a -3.4% (95% CI -3.7 to -3.0) change in FHC and a -6.0% (-6.6 to -5.5) change in FHC during provocation. The PFD was significantly higher with increasing Graf types and in displaceable hips (p < 0.001). Conclusion: PFD is strongly correlated to both α angles and hip displaceability, as measured by FHC and FHC during provocation, in ultrasound of newborn hips. The PFD increases as the hips become more dysplastic and/or displaceable.

Birthweight correlates to pubo-femoral distances and α angles in hip ultrasound of newborns at 6 weeks of age: a retrospective cohort study.

BACKGROUND AND PURPOSE: There is inconsistency in the literature regarding the relationship between increased birthweight and risk of developmental dysplasia of the hip (DDH). We aimed to investigate the correlation between birthweight and pubo-femoral distance (PFD), as well as Graf's α angle in newborns undergoing hip ultrasound examination at 6 weeks of age. PATIENTS AND METHODS: Basic newborn characteristics and ultrasound measurements were retrospectively collected during a 1-year study period. We excluded multiple births, newborns born at less than 37 gestational weeks, and incomplete information. Simple and multiple linear regression analyses were performed to evaluate the correlation of birthweight and PFD, and, second, birthweight and α angles including a stratified regression analysis investigating the potential effect modification of sex. RESULTS: 707 newborns (1,414 hips) were included. Mean birthweight was significantly higher for male newborns (P < 0.001). Increased birthweight was positively correlated to PFD values (crude coefficient 0.21, 95% confidence interval [CI] 0.10-0.32) and the correlation was still present after adjusting for sex, family history, and breech presentation (adjusted coefficient 0.18, CI 0.07-0.29). The stratified α angle model for the males was significant for both the crude coefficient (-0.73, CI -1.28 to -0.19) and the adjusted (-0.59, CI -1.15 to -0.03), and also for the females (crude coefficient -1.14, CI -1.98 to -0.31 and adjusted coefficient -1.15, CI -1.99 to -0.31). CONCLUSION: We found that increased birthweight positively correlated to PFD, and negatively correlated to α angle, but this was not of clinical significance.

MRI May Be More Valuable than Pelvic Radiographs in the Assessment of Paediatric Borderline Acetabular Dysplasia.

The osseous acetabular index (OAI) and cartilaginous acetabular index (CAI) is often used in diagnosing acetabular dysplasia (AD) in children. We examined the reliability of OAI and CAI in AD diagnostics and compared OAI measurements obtained from radiographs versus MRI. Four raters performed retrospective repeated measurements of the OAI and CAI on pelvic radiographs and MRI scans of 16 consecutive patients (mean age 5 years (2-8)) examined for borderline AD during a period of 2½ years. In MRI, the image selected for analysis by the raters was also registered. Spearman's correlation, scatter plots, and Bland-Altman (BA) plots were analysed for correlation between OAI on pelvic radiographs (OAIR) and MRI scans (OAIMRI), while intra- and interrater reliability was assessed for OAIR, OAIMRI, CAI, and MRI image selection using intraclass correlation coefficients (ICC). ICC values for inter- and intrarater reliability of OAIR, OAIMRI, and CAI were all above 0.65, with no significant differences observed. ICC values (CI) for individual raters' MRI image selection was 0.99 (0.998-0.999). The mean difference (95% CI) between OAIR and OAIMRI was -0.99 degrees (-1.84; -0.16), while the mean absolute difference (95% CI) between OAIR and OAIMRI was 3.68 degrees (3.17; 4.20). Absolute differences between OAIR and OAIMRI was independent of pelvic positioning or time interval between radiographs and MRI scans. OAI and CAI had high Intrarater reliability but mediocre interrater reliability. There was an absolute difference of 3.7 degrees in OAI between pelvic radiographs and MRI scans.

Pubo-Femoral Distances Measured Reliably by Midwives in Hip Dysplasia Ultrasound.

The pubo-femoral distance (PFD) has been suggested as an ultrasound screening tool for developmental dysplasia of the hip (DDH). The aim of this study was to examine if midwives undergoing minimal training could reliably perform pediatric hip ultrasound and PFD measurements. Eight recruited midwives performed two rounds of independent blinded PFD measurements on 15 static ultrasound images and participated in four supervised live-scanning sessions. The midwives were compared to a group of three experienced musculoskeletal radiologists. Reliability was evaluated using inter-rater correlation coefficients (ICC). Linear regression was used to quantify the learning curve of the midwives as a group. There was near complete intra- and inter-rater agreement (ICC > 0.89) on static ultrasound images across both rounds of rating for midwives and radiologists. The midwives performed a mean of 29 live hip scans (range 24−35). The mean difference between midwives and supervising radiologists was 0.36 mm, 95% CI (0.12−0.61) for the first session, which decreased to 0.20 mm, 95% CI (0.04−0.37) in the fourth session. ICC for PFD measurements increased from 0.59 mm, 95% CI (0.37−0.75) to 0.78 mm, 95% CI (0.66−0.86) with progression in sessions. We conclude that midwives reliably perform PFD measurements of pediatric hips with minimal training.

Emergency Craniotomy and Burr-Hole Trephination in a Low-Resource Setting: Capacity Building at a Regional Hospital in Cambodia.

To evaluate the teaching effect of a trauma training program in emergency cranial neurosurgery in Cambodia on surgical outcomes for patients with traumatic brain injury (TBI). We analyzed the data of TBI patients who received emergency burr-hole trephination or craniotomy from a prospective, descriptive cohort study at the Military Region 5 Hospital between January 2015 and December 2016. TBI patients who underwent emergency cranial neurosurgery were primarily young men, with acute epidural hematoma (EDH) and acute subdural hematoma (SDH) as the most common diagnoses and with long transfer delay. The incidence of favorable outcomes three months after chronic intracranial hematoma, acute SDH, acute EDH, and acute intracerebral hematoma were 96.28%, 89.2%, 93%, and 97.1%, respectively. Severe traumatic brain injury was associated with long-term unfavorable outcomes (Glasgow Outcome Scale of 1-3) (OR = 23.9, 95% CI: 3.1-184.4). Surgical outcomes at 3 months appeared acceptable. This program in emergency cranial neurosurgery was successful in the study hospital, as evidenced by the fact that the relevant surgical capacity of the regional hospital increased from zero to an acceptable level.

Referral criteria recognition of screeners in the Danish screening programme for hip dysplasia.

INTRODUCTION: The aim of this study was to review risk factors used in the current Danish screening programme for developmental dysplasia of the hip (DDH) and the self-reported recognition of these risk factors among midwives, general practitioners (GP) and GPs in training. METHODS: A survey of regional DDH referral guidelines was conducted through online regional guideline databases. Furthermore, risk factors used as referral criteria for DDH were compared across regions. Using an online survey, we asked midwives, GPs and GPs in training to identify which of six risk factors for DDH were currently featured as referral criteria for specialised DDH examination in the referral guidelines of their employment region. Answers were compared with the DDH referral guidelines of the responders' employment region. RESULTS: We collected 178 survey responses and 11 local and regional DDH referral guidelines. Six risk factors were identified from referral guidelines (breech presentation, oligohydramnios, family history of DDH, clubfeet, twins and premature birth). Overall, correct answer percentages for currently used risk factors for DDH as specified in the corresponding regional guidelines were: 96% (breech presentation), 90% (family history of DDH), 66% (twins), 63% (premature birth), 34% (clubfeet) and 29% (oligohydramnios). CONCLUSIONS: This study found variation in the referral criteria among Danish regional DDH referral guidelines and an overall high level of recognition for two out of six referral criteria but a low level of recognition for the remaining four. FUNDING: The authors received no financial support for the research conducted in preparation of this article. TRIAL REGISTRATION: not relevant.

Intrarater Reliability of Digital Thermography in Detecting Pin Site Infection: A Proof of Concept Study.

AIM AND OBJECTIVE: The purpose of this study was to explore the capability and Intrarater reliability of thermography in detecting pin site infection. MATERIALS AND METHODS: This is an explorative proof of concept study. Clinical assessment of pin sites was performed by one examiner with the Modified Gordon Pin Infection Classification from grade 0 to 6. Thermography of the pin sites was performed with a FLIR C3 camera. The analysis of the thermographic images was done in the software FLIR Tools. The maximum skin temperature around the pin site and the maximum temperature for the whole thermographic picture were measured. An Intrarater agreement was established and test-retests were performed with different camera angles. RESULTS: Thirteen (four females, nine males) patients (age 9-72 years) were included. Indications for frames: Fracture (n=4), two deformity correction, one lengthening and six bone transport. Days from surgery to thermography ranged from 27 to 385 days. Overall, 231 pin sites were included. Eleven pin sites were diagnosed with early signs of infection: five grade 1, five grade 2 and one grade 3. Mean pin site temperature for each patient was calculated, varied between patients from 29.0°C to 35.4°C (mean 33.9°C). With 34°C as cut-off value for infection, sensitivity was 73%; specificity, 67%; positive predictive value, 10%; and negative predictive value, 98%. Intrarater agreement for thermography was ICC 0.85 (0.77-0.92). The temperature measured was influenced by the camera positioning in relation to the pin site with a variance of 0.2. CONCLUSIONS: Measurements of pin site temperature using the hand-held FLIR C3 infrared camera was a reliable method and the temperature was related to infection grading. CLINICAL SIGNIFICANCE: This study demonstrated that digital thermography with a hand-held camera might be used for monitoring the pin sites after operations to detect early infection. HOW TO CITE THIS ARTICLE: Rahbek O, Husum HC, Fridberg M, et al. Intrarater Reliability of Digital Thermography in Detecting Pin Site Infection: A Proof of Concept Study. Strategies Trauma Limb Reconstr 2021;16(1):1-7.

Self-reported knowledge of national guidelines for clinical screening for hip dysplasia: a web-based survey of midwives and GPs in Denmark.

BACKGROUND: The positive predictive value of clinical hip examinations performed by generalist health professionals in screening for developmental dysplasia of the hip (DDH) is low and declining. AIM: To assess the self-reported recognition of nationally recommended clinical hip examinations in the screening programme for DDH in Denmark among midwives, GPs, and GPs in training. DESIGN & SETTING: A cross-sectional, web-based open survey study among Danish midwives, GPs, and GPs in training. METHOD: Responders were asked to identify which of six written statements of clinical hip examinations were featured in the national Danish guidelines on DDH screening. Three statements were the official statements of the Ortolani, Galeazzi, and hip abduction examinations from the national guidelines, and three statements were false and constructed by the author group. Participants were asked to select up to six statements. RESULTS: A total of 178 (58 GPs, 97 midwives, and 23 GPs in training) responses were included. Overall, 89% of responders correctly identified the Ortolani manoeuvre and 92% correctly identified one of the constructed descriptions as being false. The remaining four descriptions had significantly lower correct answer percentages ranging from 41%-58%, with significantly lower correct answer percentages of midwives for three out of all six descriptions when compared with GPs. CONCLUSION: The recognition of two out of three recommended clinical hip examinations in the Danish screening programme for DDH is low overall among current screeners. Efforts should be made to heighten the knowledge level by further education of screeners.

[Screening of dysplasia of the hip in Denmark].

The screening programme for developmental dysplasia of the hip (DDH) in Denmark is based on clinical examination and selective ultrasound examination of children with established risk factors for DDH. This method of screening may not reduce the proportion of lately diagnosed cases. Universal screening for DDH is cost-efficient and may eliminate late diagnosis of DDH and minimise the need for corrective surgery. In this review, we propose developing a new universal screening programme for DDH in Denmark.

Positive predictive values in clinical screening for developmental dysplasia of the hip.

AIM: To establish the positive predictive value (PPV) of clinical hip examinations performed by referrers in the Danish screening programme for Developmental Dysplasia of the Hip (DDH) utilising three definitions of true positive DDH diagnosis. METHODS: We retrospectively identified 290 children (169 female) referred during a 4-year period to the orthopaedic outpatient clinic at our institution with a positive clinical hip examination. Positive predictive value was calculated for clinical hip examinations across three definitions of a true positive clinical hip examination for all referrers and subgroups consisting of general practitioners, midwives and paediatricians. The PPV for clinical hip examinations was calculated for paediatric orthopaedic surgeons using one of the three definitions. RESULTS: Positive predictive value of clinical hip examinations for all referrers were 5.4%, 3.6% and 1.8% with the definition of a true positive DDH diagnosis defined as clinical instability found by orthopaedic surgeon, ultrasound classification ≥Graf IIc or both definitions combined, respectively. Positive predictive value of clinical hip examinations performed by orthopaedic surgeons was 33.3% with a true positive clinical examination defined as an ultrasound classification ≥Graf IIc. CONCLUSION: We conclude that the positive predictive value of clinical hip examinations made by referrers in the Danish screening programme for DDH is low.

What is the association between MRI and conventional radiography in measuring femoral head migration?

Background and purpose - Pelvic radiographs are traditionally used for assessing femoral head migration in residual acetabular dysplasia (RAD). Knowledge of the heightened importance of cartilaginous structures in this condition has led to increased use of MRI in assessing both osseous and cartilaginous structures of the pediatric hip. Therefore, we assessed the relationship between migration percentages (MP) found on MRI and conventional radiographs. Second, we analyzed the reliability of MP in MRI and radiographs.Patients and methods - We retrospectively identified 16 patients (mean age 5 years [2-8], 14 girls), examined for RAD during a period of 2½ years. 4 raters performed blinded repeated measurements of osseous migration percentage (MP) and cartilaginous migration percentage (CMP) in MRI and radiographs. Pelvic rotation and tilt indices were measured in radiographs. Bland-Altman (B-A) plots and intraclass correlation coefficients (ICC) were calculated for agreement and reliability.Results - B-A plots for MPR and MPMRI produced a mean difference of 6.4 with limits of agreement -11 to 24, with higher disagreements at low average MP values. Mean MPR differed from mean MPMRI (17% versus 23%, p < 0.001). MPR had the best interrater reliability with an ICC of 0.92 (0.86-0.96), compared with MPMRI and CMP with ICC values of 0.61 (0.45-0.70) and 0.52 (0.26-0.69), respectively. Intrarater reliability for MPR, MPMRI and CMP all had ICC values above 0.75 and did not differ statistically significantly. Differences inMPMRI and MPR showed no correlation to pelvic rotation index, pelvic tilt index, or interval between radiograph and MRI exams.Interpretation - Pelvic radiographs underestimated MP when compared with pelvic MRI. We propose CMP as a new imaging measurement, and conclude that it has good intrarater reliability but moderate interrater reliability. Measurement of MP in radiographs and MRI had mediocre to excellent reliability.

Suggestion for new 4.4 mm pubo-femoral distance cut-off value for hip instability in lateral position during DDH screening.

Background and purpose - Current selective screening algorithms for developmental dysplasia of the hip (DDH) are insufficient. Universal screening programs have been proposed but so far have been deemed too expensive and time consuming. The pubo-femoral distance may solve this problem as a quick, low-cost, highly sensitive, and specific sonographic measurement for DDH, but this has only been validated in the supine position. Therefore we validated pubo-femoral distance (PFD) in the lateral position as an indicator for instability of the hip. Methods - All participants had undergone ultrasonographic diagnostics using the modified Graf technique. In addition, PFD measurements in lateral position were performed. Results were compared between 25 infants who had been treated for DDH because of dysplastic appearance on ultrasound combined with clinical instability and a control group consisting of 100 untreated infants screened for DDH. Sensitivity, specificity, and cut-off points were determined using Receiver operating characteristics (ROC) analysis. Results - We found a mean PFD of 6.8 mm (6.2-7.4) in the treated group with a control group PFD of 3.4 mm (3.3-3.6) (p < 0.005). A PFD value above a threshold of 4.4 mm yielded a sensitivity of 100% and a specificity of 93% for detecting unstable DDH. Interpretation - PFD measured in lateral position was statistically significantly increased in hips of children treated for DDH with Denis Browne hip brace compared with healthy children with unaffected stable hips. Furthermore, the PFD measurement had a high level of sensitivity and specificity at a cut-off value of 4.4 mm. A cut-off value of 6.00 mm has previously been reported as the gold standard in supine position. We suggest that 4.4 mm is used in lateral position.

Mirror therapy for phantom limb and stump pain: a randomized controlled clinical trial in landmine amputees in Cambodia.

Background and aims The aim of the study was to examine the effect of mirror and tactile therapy on phantom and stump pain in patients with traumatic amputations, with particular reference to amputees in low-income communities. Methods The study was conducted with an open, randomized, semi-crossover case-control design in rural Cambodia. A study sample of 45 landmine victims with trans-tibial amputations was allocated to three treatment arms; mirror therapy, tactile therapy, and combined mirror-and-tactile therapy. Non-responders from the mono-therapy interventions were crossed over to the alternative intervention. The intervention consisted of 5 min of treatment every morning and evening for 4 weeks. Endpoint estimates of phantom limb pain (PLP), stump pain, and physical function were registered 3 months after the treatment. Results All three interventions were associated with more that 50% reduction in visual analogue scale (VAS)-rated PLP and stump pain. Combined mirror-tactile treatment had a significantly better effect on PLP and stump pain than mirror or tactile therapy alone. The difference between the three treatment arms were however slight, and hardly of clinical relevance. After treatment, the reduction of pain remained unchanged for an observation period of 3 months. Conclusions The study documents that a 4-week treatment period with mirror and/or tactile therapy significantly reduces PLP and stump pain after trans-tibial amputations. Implications The article reports for the first time a randomized controlled trial of mirror therapy in a homogenous sample of persons with traumatic amputations. The findings are of special relevance to amputees in low-resource communities.

Open Fracture Management in Low-Resource Settings: A Medical Training Experience in Cambodian Hospitals.

INTRODUCTION: A prospective interventional study has been carried out on the teaching effect and sustainability of low-cost trauma training program in open tibia fracture management for health workers. MATERIALS AND METHODS: In 2007, an external fixator and a patella-bearing orthosis were developed at a rural workshop in Cambodia. From 2010 to 2016, a core group of nine Cambodian health workers was trained in open fracture management by Norwegian senior surgeons, using the locally made fixator and brace. The training outcome was also assessed by a questionnaire comprising of assertions regarding theoretical understanding, technical skills and self-confidence in understanding the biomechanical properties of locally made external fixator and its application; the use of handmade orthosis and principle in covering of soft-tissue defects. RESULTS: The students managed 23 cases with the new technique with a primary healing rate of 70% (95% CI 48.1-85.5). A significant increase in self-reported technical skills, understanding, and self-confidence was reported. CONCLUSION: This study demonstrates that the capacity building of reconstructive surgery in low-resource settings by local doctors and paramedics is clearly a reasonable option that may substantially reduce amputation of the limbs.

Delivery as Trauma: A Prospective Time-Cohort Study of Maternal and Perinatal Mortality in Rural Cambodia.

OBJECTIVE: The majority of maternal and perinatal deaths are preventable, but still women and newborns die due to insufficient Basic Life Support in low-resource communities. Drawing on experiences from successful wartime trauma systems, a three-tier chain-of-survival model was introduced as a means to reduce rural maternal and perinatal mortality. METHODS: A study area of 266 villages in landmine-infested Northwestern Cambodia were selected based on remoteness and poverty. The five-year intervention from 2005 through 2009 was carried out as a prospective study. The years of formation in 2005 and 2006 were used as a baseline cohort for comparisons with later annual cohorts. Non-professional and professional birth attendants at village level, rural health centers (HCs), and three hospitals were merged with an operational prehospital trauma system. Staff at all levels were trained in life support and emergency obstetrics. Findings The maternal mortality rate was reduced from a baseline level of 0.73% to 0.12% in the year 2009 (95% CI Diff, 0.27-0.98; P<.01). The main reduction was observed in deliveries at village level assisted by traditional birth attendants (TBAs). There was a significant reduction in perinatal mortality rate by year from a baseline level at 3.5% to 1.0% in the year 2009 (95% CI Diff, 0.02-0.03; P<.01). Adjusting maternal and perinatal mortality rates for risk factors, the changes by time cohort remained a significant explanatory variable in the regression model. CONCLUSION: The results correspond to experiences from modern prehospital trauma systems: Basic Life Support reduces maternal and perinatal death if provided early. Trained TBAs are effective if well-integrated in maternal health programs. Houy C , Ha SO , Steinholt M , Skjerve E , Husum H . Delivery as trauma: a prospective time-cohort study of maternal and perinatal mortality in rural Cambodia. Prehosp Disaster Med. 2017;32(2):180-186.

Ketamine for prehospital trauma analgesia in a low-resource rural trauma system: a retrospective comparative study of ketamine and opioid analgesia in a ten-year cohort in Iraq.

BACKGROUND: Opioid analgesics are used in most trauma systems, and only a few studies report on the use of ketamine for prehospital analgesia. In a low-cost rural trauma system in Iraq paramedics have been using prehospital ketamine analgesia for ten years. This study aims to evaluate the effects of prehospital analgesia on physiologic trauma severity indicators and compare the effect of ketamine and pentazocine on those indicators. METHODS: The investigation was conducted as a retrospective cohort study with parallel group design. Three subsamples of trauma patients were compared: no analgesia (n = 275), pentazocine analgesia (n = 888), and ketamine analgesia (n = 713). Physiologic severity scores were calculated based on rated values for respiratory rate, blood pressure, and consciousness. The associations between outcomes and explanatory variables were assessed using a generalized linear model. RESULTS: Paramedic administration of analgesia was associated with a better physiologic severity score (PSS) outcome (p = 0.01). In the two subsamples receiving analgesia significantly better outcomes were observed for respiration (p < 0.0001) and systolic blood pressure (p < 0.0001). In patients with Injury Severity Score >8 ketamine was associated with a significantly better effect on the systolic blood pressure compared to opioid analgesia (p = 0.03). CONCLUSION: Prehospital analgesia for trauma victims improves physiologic severity indicators in a low-resource trauma system. Compared to pentazocine, ketamine was associated with improved blood pressure for patients with serious injuries. In a low-resource setting, ketamine seems to be a good choice for prehospital analgesia in trauma patients.