Emergency intubation in trauma in KwaZulu-Natal Province, South Africa.

BACKGROUND: Advanced airway management is a research priority in prehospital care. There is a high burden of major trauma in KwaZulu-Natal (KZN) Province, South Africa (SA), and transfer times to trauma units are often prolonged. OBJECTIVES: To examine emergency intubation practice in trauma and burns patients in Pietermaritzburg, KZN, and its environs. METHODS: This was a prospective consecutive case series, conducted from 11 May to 17 July 2016. Data were collected from urban emergency department (ED), rural hospital and roadside procedures in Pietermaritzburg and its drainage area. Patients with emergency intubation following trauma were eligible for inclusion. The primary outcome was successful airway management. Secondary outcomes included first-pass success and adverse events. RESULTS: Forty-one cases were recorded in patients aged 1 - 60 years. No instances of unsuccessful airway management were reported. Recorded first-pass intubation success rates were higher in receiving EDs than rural hospitals (19/22 v. 2/7; p=0.003). Use of a formal preintubation checklist was associated with a higher first-pass success rate (21/23 v. 6/15; p=0.001) and fewer adverse events (0/23 v. 7/16; p<0.001). Identified adverse event rates were 1/22 (EDs), 5/8 (rural hospitals) and 2/9 (roadside). Unmedicated intubation was more common in rural hospitals than EDs (3/8 v. 1/22; p=0.019), despite absence of cardiac arrest in these cases. Minimum standards of anaesthetic monitoring were not consistently met in any setting. CONCLUSIONS: The use of a preprocedural checklist was associated with improved intubation outcomes and may improve practice in SA trauma care and the prehospital environment, including in rural hospitals. Standardised rapid sequence induction protocols, routine use of introducers and end-tidal carbon dioxide monitoring, and increased availability of intraosseous devices also merit consideration. Key performance indicators should be monitored routinely.

Vox Sanguinis International Forum on the use of prehospital blood products and pharmaceuticals in the treatment of patients with traumatic haemorrhage.

While specific practices and transported blood products vary around the world, most of the respondents in this International Forum transported at least one blood product for the transfusion to bleeding patients en route to the hospital. The most commonly carried product was RBCs, while the use of whole blood will likely increase given the recent reports of its successful use in the civilian setting, and because of the change in the AABB's Standards regulating its use. It will be interesting to see if plasma use in the prehospital setting becomes more widely used given today's enhanced appreciated of the coagulopathy of trauma and plasma's beneficial effect in reversing it, and if blood products are transported to the scene of injury by more vehicles, that is, not just predominantly in helicopters. It was not surprising that TXA is being widely administered as close to the time of injury as possible given its potential benefit in these patients. This International Forum highlights the importance of focusing attention on prehospital transfusion management with a need to further high­quality research in this area to guide optimal resuscitation strategies.

RePHILL: protocol for a randomised controlled trial of pre-hospital blood product resuscitation for trauma.

OBJECTIVES: To describe the 'Resuscitation with Pre-HospItaL bLood products' trial (RePHILL) - a multi-centre randomised controlled trial of pre-hospital blood product (PHBP) administration vs standard care for traumatic haemorrhage. BACKGROUND: PHBP are increasingly used for pre-hospital trauma resuscitation despite a lack of robust evidence demonstrating superiority over crystalloids. Provision of PHBP carries additional logistical and regulatory implications, and requires a sustainable supply of universal blood components. METHODS: RePHILL is a multi-centre, two-arm, parallel group, open-label, phase III randomised controlled trial currently underway in the UK. Patients attended by a pre-hospital emergency medical team, with traumatic injury and hypotension (systolic blood pressure <90 mmHg or absent radial pulse) believed to be due to traumatic haemorrhage are eligible. Exclusion criteria include age <16 years, blood product receipt on scene prior to randomisation, Advanced Medical Directive forbidding blood product administration, pregnancy, isolated head injury and prisoners. A total of 490 patients will be recruited in a 1 : 1 ratio to receive either the intervention (up to two units of red blood cells and two units of lyophilised plasma) or the control (up to four boluses of 250 mL 0.9% saline). The primary outcome measure is a composite of failure to achieve lactate clearance of ≥20%/h over the first 2 hours after randomisation and all-cause mortality between recruitment and discharge from the primary receiving facility to non-acute care. Secondary outcomes include pre-hospital time, coagulation indices, in-hospital transfusion requirements and morbidity. RESULTS: Pilot study recruitment began in December 2016. Approval to proceed to the main trial was received in June 2017. Recruitment is expected to continue until 2020. CONCLUSIONS: RePHILL will provide high-quality evidence regarding the efficacy and safety of PHBP resuscitation for trauma.

Extent of ductal carcinoma in situ within and surrounding invasive primary breast carcinoma.

BACKGROUND: The aim of this study was to evaluate the pathological and morphological features of ductal carcinoma in situ (DCIS) within and surrounding invasive ductal carcinoma, and to investigate its relationship with clinical outcome and established prognostic variables. METHODS: One hundred and seven patients with primary operable invasive breast carcinoma and associated DCIS treated by simple or subcutaneous mastectomy or wide local excision with radiotherapy were assessed. Those with pure DCIS and insufficient tumour available for examination were excluded. The most representative haematoxylin and eosin-stained sections from the remaining 91 samples were selected and examined at x 100 magnification using a 45-point, 2-mm grid graticule. The entire section was assessed and the cell under each point of the graticule was classed as either normal (a), DCIS surrounded by normal tissue (b), invasive tumour (c) or DCIS surrounded by invasive malignancy (d). The volume ratio of DCIS in the normal (b/(a + b)) and invasive (d/(c + d)) tissue was then calculated. RESULTS: The DCIS volume within invasive tumour was not associated with outcome. The DCIS volume within adjacent normal tissue, however, was associated with local recurrence (P = 0.025), disease-free interval (P = 0.048), the occurrence of distant metastases (P = 0.019), death (P = 0.049) and disease-free survival (P = 0.048). Volume ratios of DCIS in normal and invasive tissue were not related to known prognostic factors including lymph node stage, grade, tumour size, vascular invasion or patient age. CONCLUSION: There is a significant prognostic effect relating to the extent of DCIS associated with an invasive cancer, particularly with respect to local recurrence of tumour. This effect is restricted to the volume of DCIS in the tissue surrounding the invasive lesion rather than the intratumoral component.

Obesity management.

Recent national initiatives to reduce the numbers of people classified as obese appear to have failed. Norma Crombie summarises some current thinking on the subject and outlines the role of the nurse in helping obese people to set and meet realistic targets for their weight management.

Evidence that eating frequency is inversely related to body weight status in male, but not female, non-obese adults reporting valid dietary intakes.

OBJECTIVE: To investigate the relationships between eating frequency (EF) and body weight status and to determine whether these relationships can be explained in terms of differences in physical activity levels, macronutrient intakes or energy compensation. DESIGN: Cross-sectional design; free-living subjects, 48 men and 47 women (aged 20-55 y, body mass index (BMI) 18-30), recruited in a workplace setting. MEASUREMENTS: Height and weight; skinfold thickness (four sites); EF, energy and macronutrient intakes (food diary, unweighed, recorded for seven consecutive days); physical activity (7 d activity diary and heart rate monitoring over 48 h period). RESULTS: In men there was a significant negative correlation between EF and body weight, and an inverse relationship with body mass index (BMI). EF was positively correlated with % energy from carbohydrate, although not with total energy intake. In women, there was no relationship between EF and body weight status; however, there were significant positive correlations between EF and total energy intake, and between EF and intakes of total carbohydrate and sugars. For both men and women, there were associations between EF and physical activity levels, approaching statistical significance. CONCLUSIONS: In men, the association between increased EF and lower body weight status may have been influenced by increased physical activity levels. As energy intake did not increase with EF, men appear to have compensated by reducing the mean energy consumed per eating episode. Energy compensation did not take place in women, with women who ate most frequently having the highest energy intakes, although this did not lead to higher BMIs. Physical activity, through participation in active leisure pursuits, may have been an important factor in weight control in women. The % contribution of carbohydrate to total energy was positively correlated with EF in both men and women, and further analysis showed that snack foods provided a higher proportion of carbohydrate than did foods eaten as meals. These results indicate that a high EF is likely to lead to a high carbohydrate diet, which may be favourable for weight control. Our findings suggest that in this population, a high EF was associated with leanness in men, and there was no link between EF and body weight status in women.

A critique of the effects of snacking on body weight status.

Increasingly Western populations appear to be moving away from the 'gorging' to the 'nibbling' pattern of eating, probably as a direct result of the increased availability of snack foods and snacks. There have been many individual suggestions for the definition of a 'snack', each one based on different parameters of measurement (Rotenburg, 1981; Bernstein et al, 1981; De Castro, 1993). However, no one definition has been universally accepted in the scientific literature due to the problems inherent in individual perception of what constitutes a 'snack' as opposed to a 'meal'. For the purposes of this review, however, a snack is defined as 'any food taken outwith a regular mealtime (namely breakfast, lunch and dinner) or snack item taken in place of such meal.' Snacking is commonly regarded by the general public as predisposing to overweight and obesity, believing that it is more beneficial to adhere to an eating pattern of three meals a day. Thus, in this context, many weight reduction programmes include avoidance of snacks, reducing the frequency of eating occasions to two to three times a day. Indeed one hypothesis, the Booth hypothesis (Booth, 1988), suggests that this growing trend for snacking is a major factor in the aetiology of obesity. However, there is evidence to suggest that snacking, per se, may not necessarily predispose to overweight and that those individuals who snack throughout the day may have positive advantages, in terms of body weight control, over those conforming to a rigid pattern of three meals a day. This paper reviews the literature in the area of eating frequency with respect to energy balance and body weight control and suggests some directions for further research.