Prevention of postoperative pancreatic fistula after pancreatectomy: results of a Canadian RAND/UCLA appropriateness expert panel.

BACKGROUND: We aimed to define the appropriateness of interventions for the prevention of postoperative pancreatic fistulas (POPF) after pancreatectomy, given the lack of consistent data on this topic. METHODS: Using the RAND/UCLA appropriateness method, we assembled an expert panel to rate clinical scenarios for interventions to prevent POPF after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP). RESULTS: The following interventions were rated appropriate: individualized risk prediction for all patients; perioperative pasireotide administration for patients undergoing PD who have a soft pancreatic gland and a pancreatic duct size of less 3 mm and for patients undergoing DP; pancreaticogastrostomy for patients undergoing PD who have a soft pancreatic gland and pancreaticojejunostomy for PD for patients with a pancreatic duct size of 6 mm or greater regardless of pancreatic gland texture; duct-to-mucosa anastomosis for all patients undergoing PD and dunking anastomosis for patients undergoing PD who have a pancreatic duct size of less than 3 mm with a firm pancreatic gland; simple stapled and reinforced stapled transection for all DP; surgical drains for PD and DP in patients with a soft pancreatic gland; and open and minimally invasive surgery for DP and open surgery for PD. The following were rated inappropriate: gastrointestinal anastomosis for stump closure in all DP and omission of surgical drain in PD for patients with a pancreatic duct diameter less than 3 mm and a soft pancreatic gland. CONCLUSION: The expert panel identified appropriate and inappropriate scenarios for POPF prevention following pancreatectomy, to provide guidance to clinicians. However, the appropriateness of the interventions in the majority of the clinical scenarios was rated as uncertain, demonstrating equipoise.

Liver-First Approach for Synchronous Colorectal Metastases: Analysis of 7360 Patients from the LiverMetSurvey Registry.

BACKGROUND: The liver-first approach in patients with synchronous colorectal liver metastases (CRLM) has gained wide consensus but its role is still to be clarified. We aimed to elucidate the outcome of the liver-first approach and to identify patients who benefit at most from this approach. METHODS: Patients with synchronous CRLM included in the LiverMetSurvey registry between 2000 and 2017 were considered. Three strategies were analyzed, i.e. liver-first approach, colorectal resection followed by liver resection (primary-first), and simultaneous resection, and three groups of patients were analyzed, i.e. solitary metastasis, multiple unilobar CRLM, and multiple bilobar CRLM. In each group, patients from the three strategy groups were matched by propensity score analysis. RESULTS: Overall, 7360 patients were analyzed: 4415 primary-first, 552 liver-first, and 2393 simultaneous resections. Compared with the other groups, the liver-first group had more rectal tumors (58.0% vs. 31.2%) and higher hepatic tumor burden (more than three CRLMs: 34.8% vs. 24.0%; size > 50 mm: 35.6% vs. 22.8%; p < 0.001). In patients with solitary and multiple unilobar CRLM, survival was similar regardless of treatment strategy, whereas in patients with multiple bilobar metastases, the liver-first approach was an independent positive prognostic factor, both in unmatched patients (3-year survival 65.9% vs. primary-first 60.4%: hazard ratio [HR] 1.321, p = 0.031; vs. simultaneous resections 54.4%: HR 1.624, p < 0.001) and after propensity score matching (vs. primary-first: HR 1.667, p = 0.017; vs. simultaneous resections: HR 2.278, p = 0.003). CONCLUSION: In patients with synchronous CRLM, the surgical strategy should be decided according to the hepatic tumor burden. In the presence of multiple bilobar CRLM, the liver-first approach is associated with longer survival than the alternative approaches and should be evaluated as standard.

Additional value of gadoxetic acid-enhanced MRI to conventional extracellular gadolinium-enhanced MRI for the surgical management of colorectal and neuroendocrine liver metastases.

BACKGROUND: Liver resection being the only potentially curative treatment for patients with liver metastasis, it is critical to select the appropriate preoperative imaging modality. The aim of this study was to assess the impact of preoperative gadoxetic acid-enhanced MRI compared to a conventional extracellular gadolinium-enhanced MRI on the surgical management of colorectal and neuroendocrine liver metastasis. METHODS: We included 110 patients who underwent both a gadoxetic acid-enhanced MRI (hepatospecific contrast) and conventional extracellular gadolinium for the evaluation of colorectal or neuroendocrine liver metastases, from January 2012 to December 2015 at the CHU de Québec - Université Laval. When the number of lesions differed, a hepatobiliary surgeon evaluated if the gadoxetic acid-enhanced MRI modified the surgical management. RESULTS: Gadoxetic acid-enhanced MRI found new lesions in 25 patients (22.7%), excluded lesions in 18 patients (16.4%) and identified the same number in 67 patients (60.9%). The addition of the gadoxetic acid-enhanced MRI directly altered the surgical management in 19 patients overall (17.3% (95% CI [10.73-25.65])). CONCLUSION: Despite the additional cost associated with gadoxetic acid-enhanced MRI compared to conventional extracellular gadolinium-enhanced MRI, the use of this contrast agent has a significant impact on the surgical management of patients with liver metastases.

Patient blood management for liver resection: consensus statements using Delphi methodology.

BACKGROUND: Blood loss and transfusion remain a significant concern in liver resection (LR). Patient blood management (PBM) programs reduce use of transfusions and improve outcomes and costs, but are not standardized for LR. This study sought to create an expert consensus statement on PBM for LR using modified Delphi methodology. METHODS: An expert panel representing hepato-biliary surgery, anesthesiology, and transfusion medicine was invited to participate. 28 statements addressing the 3 pillars of PBM were created. Panelists were asked to rate statements on a 7-point Likert scale. Three-rounds of iterative rating and feedback were completed anonymously, followed by an in-person meeting. Consensus was reached with at least 70% agreement. RESULTS: The 35 experts panel recommended routine pre-operative transfusion risk assessment, and investigation and management of anemia with iron supplementation. Intra-operatively, restrictive fluid administration without routine central line insertion was recommended, along with intermittent hepatic pedicle occlusion and surgical techniques considerations. Specific criteria for restrictive intra-operative and post-operative transfusion strategy were recommended. CONCLUSIONS: PBM for LR included medical and technical interventions throughout the perioperative continuum, addressing specificities of LR. Diffusion and adoption of these recommendations can standardize PBM for LR to improve patient outcomes and resource utilization.

Assessing tools for management of noncolorectal nonneuroendocrine liver metastases: External validation of a prognostic model.

INTRODUCTION: Selection criteria and benefits for resection of noncolorectal, nonneuroendocrine liver metastases (NCNNELM) remain debated. A prognostic score was developed by the Association Française de Chirurgie (AFC) for patient selection, but not validated. We performed a geographic external validation of this score. METHODS: Patients with resected NCNNELM from six institutions (2000-2014) were assigned risk groups based on the AFC score. Discrimination was evaluated by visually inspecting separation of overall survival (OS) curves among risk categories. The slope of the continuous score on OS and hazard ratios for risk categories were examined. RESULTS: Of 165 patients, 53 (32.1%) were low-risk, 85 (51.5%) intermediate-risk, and 27 (16.4%) high-risk. The OS curves did not separate among risk groups: 5-year OS were 60.1% (low), 57.1% (intermediate), and 55.6% (high). The parameter estimate (0.02) indicated lower discrimination than in the AFC cohort. Hazard ratios of 1.05 (0.63 to 1.70) for low vs intermediate, 0.87 (0.46 to 1.64) for low vs high, and 0.83 (0.46 to 1.49) for intermediate vs. high, demonstrated lack of discrimination in OS among risk groups. CONCLUSION: While long-term survival is achievable, discrimination of the AFC score is not maintained in a geographic external cohort of resected NCNNELM. It is not generalizable to this external population.

Temporal trends in the use of diagnostic imaging for inpatients with pancreatic conditions: How much ionizing radiation are we using?

BACKGROUND: Low-dose ionizing radiation from medical imaging has been indirectly linked with subsequent cancer and increased costs. Computed tomography (CT) is the gold standard for defining pancreatic anatomy and complications. Our primary goal was to identify the temporal trends associated with diagnostic imaging for inpatients with pancreatic diseases. METHODS: Data were extracted from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (NIS) database from 2000 to 2008. Pancreas-related ICD-9 diagnostic codes were matched to all relevant imaging modalities. RESULTS: Between 2000 and 2008, a significant increase in admissions (p < 0.001), but decrease in overall imaging procedures (p = 0.032), for all pancreatic disorders was observed. This was primarily a result of a reduction in the number of CT and endoscopic retrograde cholangiopancreatography examinations (i.e., reduced radiation exposure, p = 0.008). A concurrent increase in the number of inpatient magnetic resonance cholangiopancreatography/magnetic resonance imaging performed was observed (p = 0.040). Intraoperative cholangiography and CT remained the dominant imaging modality of choice overall (p = 0.027). CONCLUSION: Inpatients with pancreatic diseases often require diagnostic imaging during their stay. This results in substantial exposure to ionizing radiation. The observed decrease in the use of CT may reflect an improved awareness of potential stochastic risks.

CONTEXTE: Les faibles doses de rayonnement ionisant associées à l'imagerie médicale ont été indirectement associées à des cas subséquents de cancer et à une augmentation des coûts. Considérée comme la norme dans le domaine, la tomographie par ordinateur est utilisée pour étudier l'anatomie et les complications pancréatiques. Notre principal objectif consistait à dégager les tendances temporelles associées à l'utilisation de l'imagerie diagnostique chez des patients hospitalisés atteints de maladies pancréatiques. MÉTHODES: Des données ont été extraites de la base de données du Nationwide Inpatient Sample [échantillon national sur les malades hospitalisés] associé au Healthcare Cost and Utilization Project [Projet sur les coûts et l'utilisation des soins de santé] pour les années 2000 à 2008. Les codes de la CIM-9 attribués aux maladies pancréatiques ont été associés aux techniques d'imagerie pertinentes. RÉSULTATS: De 2000 à 2008, une hausse importante du nombre d'admissions (p < 0,001) a été observée pour l'ensemble des maladies pancréatiques, parallèlement à une baisse du nombre total d'examens d'imagerie (p = 0,032). Ces changements sont principalement attribuables à une diminution du nombre de tomographies par ordinateur et de cholangiopancréatographies rétrogrades endoscopiques effectuées (donc à une diminution de l'exposition au rayonnement, p = 0,008). Par ailleurs, une augmentation du nombre de tomographies et de cholangio-pancréatographies par résonance magnétique effectuées sur des patients hospitalisés (p = 0,040) a également été observée. Dans l'ensemble, les cholangio-pancréatographies et les tomographies peropératoires demeurent les techniques d'imagerie les plus utilisées (p = 0,027). CONCLUSION: Les patients atteints de maladies pancréatiques ont généralement besoin de subir un examen d'imagerie médicale pendant leur séjour à l'hôpital, et peuvent donc être exposés à une dose substantielle de rayonnement ionisant. La baisse observée du nombre de tomographies par ordinateur pourrait témoigner d'une sensibilisation améliorée aux risques stochastiques potentiels.

Predictive factors for sentinel lymph nodes and non-sentinel lymph nodes metastatic involvement: a database study of 1,041 melanoma patients.

BACKGROUND: Sentinel lymph node (SLN) biopsy may identify patients who may need completion lymphadenectomy and adjuvant therapy. METHODS: Univariate and multivariate analysis were conducted for SLN status in a prospective cohort of 1,041 patients. A biopsy was recommended for melanoma greater than or equal to 1 mm thick or greater than or equal to .75 mm with poor prognostic features. RESULTS: For sentinel node status, mitotic rate is very significant in univariate analysis. In multivariate analysis, Breslow, lymphovascular invasion, and primary site were significant. Breslow thickness greater than or equal to 2 mm and SLN with macroscopic burden greater than or equal to 2 mm are the only statistically significant variables predicting the non-SLN status in multivariate analysis. CONCLUSIONS: The data confirm the importance of Breslow, lymphovascular invasion, and body site for SLN status. The cutoff of 2 mm for tumor load in SLN appears to be a simple technique to find the high-risk patients with further lymph node disease.

In search of the best reconstructive technique after pancreaticoduodenectomy: pancreaticojejunostomy versus pancreaticogastrostomy.

BACKGROUND: It has been suggested that pancreaticogastrostomy (PG) is a safer reconstruction than pancreaticojejunostomy (PJ), resulting in lower morbidity, including lower pancreatic leak rates and decreased postoperative mortality. We compared PJ and PG after pancreaticoduodenectomy (PD). METHODS: A randomized clinical trial was designed. It was stopped with 50% accrual. Patients underwent either PG or PJ reconstruction. The primary outcome was the pancreatic fistula rate, and the secondary outcomes were overall morbidity and mortality. We used the Student t, Mann-Whitney U and χ(2) tests for intention to treat analysis. The effect of randomization, American Society of Anesthesiologists score, soft pancreatic texture and use of pancreatic stent on overall complications and fistula rates was calculated using logistic regression. RESULTS: Our trial included 98 patients. The rate of pancreatic fistula formation was 18% in the PJ and 25% in the PG groups (p = 0.40). Postoperative complications occurred in 48% of patients in the PJ and 58% in the PG groups (p = 0.31). There were no significant predictors of overall complications in the multivariate analysis. Only soft pancreatic gland predicted the occurrence of pancreatic fistula (odds ratio 5.89, p = 0.003). CONCLUSION: There was no difference in the rates of pancreatic leak/fistula, overall complications or mortality between patients undergoing PG and and those undergoing PJ after PD.

CONTEXTE: Selon certains, la pancréatogastrostomie (PG) est une technique de reconstruction plus sécuritaire que la pancréatojéjunostomie (PJ) et entraîne une morbidité moindre, y compris un taux moins élevé de fuites pancréatiques et une mortalité postopératoire diminuée. Nous avons comparé la PJ et la PG post-pancréatoduodénectomie. MÉTHODES: Un essai clinique randomisé a été conçu et cessé à l'atteinte d'un taux de participation de 50 %. Les patients ont subi une reconstruction par PG ou par PJ. Le paramètre principal était le taux de fistules pancréatiques et les paramètres secondaires étaient la morbidité et la mortalité globales. Nous avons utilisé les tests t de Student, U de Mann­Whitney et du χ2 carré pour l'analyse en intention de traiter. Nous avons calculé l'effet de la randomisation, du score de l'American Society of Anesthesiologists, de la consistance molle du pancréas et du recours à l'endoprothèse pancréatique sur les complications globales et les taux de fistules à l'aide d'une analyse de régression logistique. RÉSULTANTS: Notre essai a regroupé 98 patients. Le taux de fistules pancréatiques a été de 18 % dans le groupe soumis à la PJ et de 25 % dans le groupe soumis à la PG (p = 0,40). Des complications postopératoires sont survenues chez 48 % des patients du groupe soumis à la PJ et chez 58 % du groupe soumis à la PG (p = 0,31). Aucun prédicteur significatif des complications globales n'est ressorti à l'analyse multivariée. Seule la consistance molle du pancréas a permis de prédire la survenue d'une fistule pancréatique (rapport des cotes 5,89, p = 0,003). CONCLUSION: Nous n'avons noté aucune différence quant aux taux de fuites ou de fistules pancréatiques, de complications globales ou de mortalité entre les patients soumis à la PG et à la PJ post-pancréatoduodénectomie.

Transarterial embolization therapies for the treatment of hepatocellular carcinoma: CEPO review and clinical recommendations.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most deadly cancers in the world and its incidence rate has consistently increased over the past 15 years in Canada. Although transarterial embolization therapies are palliative options commonly used for the treatment of HCC, their efficacy is still controversial. The objective of this guideline is to review the efficacy and safety of transarterial embolization therapies for the treatment of HCC and to develop evidence-based recommendations. METHOD: A review of the scientific literature published up to October 2013 was performed. A total of 38 studies were included. RECOMMENDATIONS: Considering the evidence available to date, the CEPO recommends the following: (i) transarterial chemoembolization therapy (TACE) be considered a standard of practice for the palliative treatment of HCC in eligible patients; (ii) drug-eluting beads (DEB)-TACE be considered an alternative and equivalent treatment to conventional TACE in terms of oncological efficacy (overall survival) and incidence of severe toxicities; (iii) the decision to treat with TACE or DEB-TACE be discussed in tumour boards; (iv) bland embolization (TAE) not be considered for the treatment of HCC; (v) radioembolization (TARE) not be considered outside of a clinical trial setting; and (vi) sorafenib combined with TACE not be considered outside of a clinical trial setting.

The "weekend warrior": fact or fiction for major trauma?

BACKGROUND: The "weekend warrior" engages in demanding recreational sporting activities on weekends despite minimal physical activity during the week. We sought to identify the incidence and injury patterns of major trauma from recreational sporting activities on weekends versus weekdays. METHODS: We performed a retrospective cohort study using the Alberta Trauma Registry comparing all adults who were severely injured (injury severity score [ISS] ≥ 12) while engaging in physical activity on weekends versus weekdays between 1995 and 2009. RESULTS: Among the 351 identified patients (median ISS 18; median hospital stay 6 d; mortality 6.6%), significantly more were injured on the weekend than during the week (54.8% v. 45.2%, p = 0.016). Common mechanisms were motocross (23.6%), hiking or mountain/rock climbing (15.4%), skateboarding or rollerblading (12.3%), hockey/ice-skating (10.3%) and aircraft- (9.9%) and water-related (7.7%) activities. This distribution was similar regardless of the day of the week. Most patients were injured as a result of a ground-level (21.9%) or higher fall while hiking, mountain climbing or rock climbing (25.9%); motocross-related incidents (24.2%); or collision with a tree, person, man-made object or moving vehicle (14.0%). Injury patterns were similar across both groups (all p > 0.05): head (55.8%), spine (35.1%), chest (35.0%), extremities (31.1%), face (17.4%), abdomen (13.1%). Surgical intervention was required in 41% of patients: 15.1% required open reduction and internal fixation, 8.3% spinal fixation, 7.4% craniotomy, 5.1% facial repair and 4.3% laparotomy. CONCLUSION: The weekend warrior concept may be a validated entity for major trauma.

CONTEXTE: Le « guerrier du dimanche ¼ s'adonne à des activités sportives récréatives la fin de semaine, malgré un degré minime d'activité physique durant la semaine. Nous avons voulu mesurer l'incidence des blessures et les types de traumatismes majeurs consécutifs à des activités sportives pratiquées la fin de semaine plutôt que les jours de semaine. MÉTHODES: Nous avons procédé à une étude de cohorte rétrospective à partir du registre de traumatologie de l'Alberta pour comparer tous les adultes victimes d'une blessure grave (score de gravité des traumatismes ≥ 12) lors de la pratique d'activités physiques la fin de semaine plutôt que les jours de semaine, entre 1995 et 2009. RÉSULTATS: Parmi les 351 patients recensés (score médian 18, séjour hospitalier médian 6 j, mortalité 6,6 %), un nombre significativement plus grand se sont blessés la fin de semaine plutôt qu'un jour de semaine (54,8 % c. 45,2 %, p = 0,016). Les activités les plus souvent en cause étaient : motocross (23,6 %), randonnée/ alpinisme/ escalade (15,4 %), planche à roulettes ou patins à roues alignées (12,3 %), hockey/patin sur glace (10,3 %) et activités pratiqués dans les airs (9,9 %) et sur l'eau (7,7 %). Cette distribution est demeurée similaire, indépendamment du jour de la semaine. La plupart des patients ont subi leurs blessures par suite d'une chute au niveau du sol (21,9 %) ou de plus haut lors de randonnées, d'alpinisme ou d'escalade (25,9 %), d'un accident de motocross (24,2 %) ou d'une collision avec un arbre, une personne, un obstacle artificiel ou un véhicule en mouvement (14,0 %). Les types de traumatismes étaient similaires dans tous les groupes (tous, p > 0,05) : tête (55,8 %), colonne vertébrale (35,1 %), thorax (35,0 %), membres (31,1 %), visage (17,4 %), abdomen (13,1 %). Chez 41 % des patients, il a fallu intervenir chirurgicalement : 15,1 % réduction ouverte avec fixation interne, 8,3 % fixation vertébrale, 7,4 % craniotomie, 5,1 % intervention au visage et 4,3 % laparotomie. CONCLUSION: Le concept de « guerrier du dimanche ¼ pourrait être une entité valide associée à des traumatismes majeurs.

Does regional variation impact decision-making in the management and palliation of pancreatic head adenocarcinoma? Results from an international survey.

BACKGROUND: Management and palliation of pancreatic head adenocarcinoma is challenging. End-of-life decision-making is a variable process involving multiple factors. METHODS: We conducted a qualitative, physician-based, 40-question international survey characterizing the impact of medical, religious, social, training and system factors on care. RESULTS: A total of 258 international clinicians completed the survey. Respondents were typically fellowship-trained (78%), with a mean of 16 years' experience in a university-affiliated (93%) hepato-pancreato-biliary group (96%) practice. Most (91%) believed resection is potentially curative. Most patients were discussed preoperatively by multidisciplinary teams (94%) and medical assessment clinics (68%), but rarely critical care (21%). Intraoperative surgical palliation included double bypass or no intervention for locally advanced nonresectable tumours (41% and 49% v. 14% and 85%, respectively, for patients with hepatic metastases). Postoperative admission to the intensive care unit was frequent (58%). Severe postoperative complications were often treated with aggressive cardiopulmonary resuscitation, intubation and critical care (96%), with no defined time points for futility (74%). Admitting surgeons guided most end-of-life decisions (97%). Formal medical futility laws were rarely available (26%). Insurance status did not alter treatment (97%) or palliation (95%) in non-universal care regions. Clinician experience, regional culture and training background impacted treatment (all p < 0.05). CONCLUSION: Despite remarkable overall agreement, geographic and training differences are evident in the treatment and palliation of pancreatic head adenocarcinoma.

CONTEXTE: Le traitement et les soins palliatifs pour l'adénocarcinome de la tête du pancréas sont complexes. Les décisions de fin de vie reposent sur un processus hautement variable qui dépend de multiples facteurs. MÉTHODES: Nous avons administré à des médecins un sondage international qualitatif à 40 questions afin de caractériser l'impact sur les soins exercé par différents facteurs, notamment médicaux, religieux, sociaux, relatifs à la formation et systémiques. RÉSULTATS: En tout, 258 cliniciens ont participé à ce sondage international. Les participants étaient en général des spécialistes (78%), cumulaient en moyenne 16 ans d'expérience dans le domaine hépatopancréatobiliaire (96%) au sein d'un groupe affilié à une université (93%). La plupart (91%) ont dit croire que la résection est potentiellement curative. La majorité des cas faisaient l'objet de discussions préopératoires par des équipes multidisciplinaires (94%) et en clinique d'évaluation médicale (68%), mais rarement par une équipe de soins intensifs (21%). Les soins palliatifs chirurgicaux peropératoires incluaient la double dérivation ou la non intervention en présence de tumeurs non résécables localement avancées (41% et 49% c. 14% et 85%, respectivement, chez les patients porteurs de métastases hépatiques). L'admission postopératoire aux soins intensifs a eacute;té fréquente (58%). Les complications postopératoires graves étaient souvent traitées par réanimation cardiorespiratoire énergique, intubation et soins intensifs (96 %), sans critères chronologiques de futilité définis (74 %). C'est aux chirurgiens traitants que revenait la plupart des décisions de fin de vie (97 %). Peu avaient accès à des consignes formelles au sujet de la futilité des interventions médicales (26 %). La couverture d'assurance n'a modifié ni le traitement (97%) ni les soins palliatifs (95%) dans les régions où les soins n'étaient pas universels. L'expérience des médecins, la culture régionale et la formation de base ont eu un impact sur le traitement (toutes, p < 0,05). CONCLUSION: Malgré une concordance remarquable, des différences géographiques et des différences liées à la formation ont eu un impact sur le traitement et les soins palliatifs pour l'adénocarcinome de la tête du pancréas.

Prevention of delirium in trauma patients: are we giving thiamine prophylaxis a fair chance?

BACKGROUND: Delirium is associated with increased morbidity and mortality in injured patients. Wernicke encephalopathy (WE) is delirium linked to malnutrition and chronic alcoholism. It is prevented with administration of thiamine. Our primary goal was to evaluate current blood alcohol level (BAL) testing and thiamine prophylaxis in severely injured patients. METHODS: We retrospectively reviewed the cases of 1000 consecutive severely injured patients admitted to hospital between Mar. 1, 2009, and Dec. 31, 2009. We used the patients' medical records and the Alberta Trauma Registry. RESULTS: Among 1000 patients (mean age 48 yr, male sex 70%, mean injury severity score 23, mortality 10%), 627 underwent BAL testing at admission; 221 (35%) had a BAL greater than 0 mmol/L, and 189 (30%) had a BAL above the legal limit of 17.4 mmol/L. The mean positive BAL was 41.9 mmol/L. More than 4% had a known history of alcohol abuse. More patients were assaulted (20% v. 9%) or hit by motor vehicles (10% v. 6%) when intoxicated (both p < 0.05). Most injuries occurred after falls (37%) and motor vehicle collisions (33%). Overall, 17% of patients received thiamine prophylaxis. Of the 221 patients with elevated BAL, 44% received thiamine prophylaxis. Of those with a history of alcohol abuse, 77% received thiamine prophylaxis. CONCLUSION: Despite the strong link between alcohol abuse, trauma and WE, more than one-third of patients were not screened for alcohol use. Furthermore, a minority of intoxicated patients received adequate prophylaxis against WE. Given the low risk and cost of BAL testing and thiamine prophylaxis and the high cost of delirium, standard protocols for prophylaxis are essential.

CONTEXTE: Le délire est associé à une morbidité et une mortalité accrues chez les traumatisés. L'encéphalopathie de Wernicke (EW) est un délire associé à la malnutrition et à l'alcoolisme chronique que l'on peut prévenir en administrant de la thiamine. Notre objectif principal était d'évaluer le recours actuel aux tests d'alcoolémie et au traitement prophylactique à la thiamine chez les grands traumatisés. MÉTHODES: Nous avons passé en revue de manière rétrospective 1000 cas consécutifs d'hospitalisation pour traumatismes graves entre le 1er mars 2009 et le 31 décembre 2009. Nous avons utilisé les dossiers médicaux des patients et le Registre des traumatismes de l'Alberta. RÉSULTATS: Sur 1000 patients (âge moyen 48 ans, sexe masculin 70 %, indice moyen de gravité des traumatismes 23, mortalité 10 %), 627 ont subi un test d'alcoolémie à leur admission; 221 (35 %) présentaient un taux d'alcoolémie supérieur à 0 mmol/L et 189 (30 %) avaient un taux d'alcoolémie au-dessus de la limite permise de 17,4 mmol/L. Le taux moyen des tests d'alcoolémie positifs était de 41,9 mmol/L. Plus de 4 % de ces cas avaient des antécédents d'alcoolisme. Les patients qui étaient sous l'effet de l'alcool ont davantage été victimes d'agressions (20 % c. 9 %) ou d'accidents impliquant un véhicule (10 % c. 6 %; tous deux p < 0,05). La majorité des traumatismes ont été causés par des chutes (37 %) ou des accidents de la route (33 %). Dans l'ensemble, 17 % des patients ont reçu un traitement prophylactique à la thiamine. Parmi les 221 patients qui présentaient un taux d'alcoolémie élevé, 44 % ont reçu de la thiamine en prophylaxie. Parmi ceux qui présentaient des antécédents d'abus d'alcool, 77 % ont reçu un traitement prophylactique à la thiamine. CONCLUSION: Malgré le lien étroit entre abus d'alcool, traumatismes et EW, plus du tiers des patients n'ont subi aucun test d'alcoolémie. En outre, seule une minorité de patients intoxiqués ont reçu une prophylaxie adéquate contre l'EW. Compte tenu des risques faibles et des coûts peu élevés du test d'alcoolémie et de la prophylaxie par thiamine et des coûts élevés occasionnés par les épisodes de délire, il est essentiel d'instaurer des protocoles standard de prophylaxie.

Timeliness in obtaining emergent percutaneous procedures in severely injured patients: how long is too long and should we create quality assurance guidelines?

BACKGROUND: Modern trauma care relies heavily on nonoperative, emergent percutaneous procedures, particularly in patients with splenic, pelvic and hepatic injuries. Unfortunately, specific quality measures (e.g., arrival to angiography times) have not been widely discussed. Our objective was to evaluate the time interval from arrival to initiation of emergent percutaneous procedures in severely injured patients. METHODS: All severely injured trauma patients (injury severity score [ISS] > 12) presenting to a level 1 trauma centre (2007-2010) were analyzed with standard statistical methodology. RESULTS: Among 60 severely injured patients (mean ISS 31, hypotension 18%, mortality 12%), the median time interval to the initiation of an angiographic procedure was 270 minutes. Of the procedures performed, 85% were therapeutic embolizations and 15% were diagnostic procedures. Splenic (median time 243 min, range 32-801 min) and pelvic (median time 278 min, range 153-466 min) embolizations accounted for 43% and 25% of procedures, respectively. The median embolization procedure duration for the spleen was 28 (range 15-153) minutes compared with 59 (range 34-171) minutes for the pelvis. Nearly 22% of patients required both an emergent percutaneous and subsequent operative procedure. Percutaneous therapy typically preceded open operative explorations. CONCLUSION: The time interval from arrival at the trauma centre to emergent percutaneous procedures varied widely. Improved processes emphasizing patient transition from the trauma bay to the angiography suite are essential. Discussion regarding the appropriate time to angiography is needed so this marker can be used as a quality outcome measure for all level 1 trauma centres.

CONTEXTE: De nos jours, en traumatologie, les soins reposent largement sur des interventions non chirurgicales percutanées d'extrême urgence, particulièrement chez les patients blessés à la rate, au bassin et au foie. Malheureusement, les indices de qualité spécifiques (p. ex., temps écoulé entre l'arrivée et l'angiographie) n'ont pas fait l'objet de discussions approfondies. Notre objectif était de mesurer le temps écoulé entre l'arrivée et l'instauration des interventions percutanées d'extrême urgence chez les grands blessés. MÉTHODES: Tous les grands polytraumatisés (indice de gravité des blessures [IGB] > 12) amenés dans un centre de traumatologie de niveau 1 (2007­2010) ont fait l'objet d'une analyse au moyen d'une méthodologie statistique standard. RÉSULTATS: Pour 60 patients gravement blessés (IGB moyen 31, hypotension 18 %, mortalité 12%), le temps écoulé avant l'instauration d'une intervention angio gra phique a été de 270 minutes. Parmi les interventions effectuées, 85% ont été des embolisations thérapeutiques et 15% des interventions diagnostiques. Les embolisations spléniques (temps écoulé médian 243 minutes, intervalle 32­801 minutes) et pelviennes (temps écoulé médian 278 minutes, intervalle 153­466 minutes) ont représenté 43% et 25% des interventions, respectivement. La durée médiane de l'intervention d'embolisation dans le cas de la rate a été de 28 (intervalle 15­153) minutes, contre 59 (intervalle 34­171) minutes pour les blessures touchant le bassin. Près de 22 % des patients ont eu besoin d'une intervention percutanée d'extrême urgence et d'une intervention chirurgicale par la suite. Les explorations chirurgicales ouvertes ont généralement été précédées d'un traitement percutané. CONCLUSION: Le temps écoulé entre l'arrivée au centre de traumatologie et les interventions percutanées d'extrême urgence varie beaucoup. Il faut, sans contredit, améliorer les processus en soulignant l'importance du transfert des patients de la salle de traumatologie à la salle d'angiographie et poursuivre la discussion sur le temps écoulé avant l'angiographie pour que ce marqueur puisse servir comme paramètre de mesure de la qualité dans tous les centres de traumatologie de niveau 1.

Pericardiocentesis in trauma: a systematic review.

BACKGROUND: Pericardiocentesis (PCC) had been taught as a mandatory skill in the Advanced Trauma Life Support (ATLS®) course as a bridge to definitive surgical therapy for traumatic pericardial tamponade since its inception in 1978. Immediate thoracotomy for penetrating trauma to the heart and chest has resulted in the decreased use of PCC in trauma. PCC is now offered as an optional skill in the ninth edition of the ATLS®. A review of the literature regarding the use and effectiveness of PCC in traumatic pericardial tamponade in the modern era is necessary to better define its current role in trauma care. METHODS: Scientific publications from 1970 to 2010 involving PCC after trauma were identified. The Preferred Reporting Items for Systematic reviews and Meta-Analyses was used. Human studies describing acute traumatic tamponade were included. Publications involving nontraumatic or chronic pericardial tamponade from effusions caused by inflammatory, infectious, or neoplastic etiology were excluded. Publications were categorized by level of evidence. RESULTS: Of the 135 publications identified, 27 were included, composing of 2,094 trauma patients with suspected cardiac tamponade. The reported use of PCC decreased from 45.9% of patients in the period 1970 to 1979 down to 6.4% of patients in the period between 2000 and 2010 (p < 0.05). Reported rates describing the use of PCC as the sole intervention decreased from 13.7% in the period 1970 to 1979 to 2.1% in the period 2000 to 2010 (p < 0.05). Survival analysis after PCC was possible for 380 patients. Overall survival following PCC was 83.4% (n = 317) and 91.8% (n = 145) when used as the sole intervention. In patients who received PCC then thoracotomy, survival rate was 79.5% (n = 178). CONCLUSION: Studies on the use of PCC for trauma are limited and biased toward survivors. The reported survival rate is high. There remains a limited role for PCC in nontrauma centers where definitive surgical management is not immediately available and transport time to a higher level of care facility supports the use of temporary decompression by PCC. LEVEL OF EVIDENCE: Systematic review, level III.

Adjuvant treatment for endometrial cancer: literature review and recommendations by the Comité de l'évolution des pratiques en oncologie (CEPO).

OBJECTIVE: Despite the very good prognosis of endometrial cancer, a number of patients with localized disease relapse following surgery. Therefore, various adjuvant therapeutic approaches have been studied. The objective of this review is to evaluate the efficacy and safety of neoadjuvant and adjuvant therapies in patients with resectable endometrial cancer and to develop evidence-based recommendations. METHODS: A review of the scientific literature published between January 1990 and June 2012 was performed. The search was limited to published phase III clinical trials and meta-analyses evaluating the efficacy of neoadjuvant or adjuvant therapies in patients with endometrial carcinoma or carcinosarcoma. A total of 23 studies and five meta-analyses were identified. RESULTS: The selected literature showed that in patients with a low risk of recurrence, post-surgical observation is safe and recommended in most cases. There are several therapeutic modalities available for treatment of endometrial cancers with higher risk of recurrence, including vaginal brachytherapy, external beam radiotherapy, chemotherapy, or a combination of these. CONCLUSIONS: Considering the evidence available to date, the CEPO recommends the following: (1)post-surgical observation for most patients with a low recurrence risk; (2)adjuvant vaginal brachytherapy for patients with an intermediate recurrence risk; (3)adjuvant pelvic radiotherapy with or without vaginal brachytherapy for patients with a high recurrence risk; addition of adjuvant chemotherapy may be considered as an option for selected patients (excellent functional status, no significant co-morbidities, poor prognostic factors); (4)adjuvant chemotherapy and pelvic radiotherapy with or without brachytherapy and para-aortic irradiation for patients with advanced disease;

The body size-dependent diet composition of north american sea ducks in winter.

Daily food requirements scale with body mass and activity in animals. While small species of birds have higher mass-specific field metabolic rates than larger species, larger species have higher absolute energy costs. Under energy balance, we thus expect the small species to have a higher energy value diet. Also the weight and time constraints for flighted and diurnal foragers should set a maximum to the amount of prey items taken in one meal and to the daily number of meals, respectively. Further, avoidance of competition causes the species to reduce the amount of shared prey in their diet. Some diet segregation is therefore to be expected between species. We tested these hypotheses and investigated the role of body mass in the diet composition of 12 sea duck species (Somateria mollissima, Somateria spectabilis, Somateria fischeri, Polysticta stelleri, Bucephala clangula, Bucephala islandica, Bucephala albeola, Melanitta nigra, Melanitta perspicillata, Melanitta deglandi, Histrionicus histrionicus and Clangula hyemalis) wintering in North America. This study was based on a literature survey with special emphasis given to the diet data from the former US Bureau of Biological Survey. The data supported our hypothesis that the energy value of winter diet of sea ducks scales negatively with body mass. Diet diversity also scaled negatively with body mass. Our results suggest the existence of a minimum for the energy value of avian diets.

Severe street and mountain bicycling injuries in adults: a comparison of the incidence, risk factors and injury patterns over 14 years.

BACKGROUND: Street and mountain bicycling are popular recreational activities and prevalent modes of transportation with the potential for severe injury. The purpose of this investigation was to compare the incidence, risk factors and injury patterns among adults with severe street versus mountain bicycling injuries. METHODS: We conducted a retrospective cohort study using the Southern Alberta Trauma Database of all adults who were severely injured (injury severity score [ISS] ≥ 12) while street or mountain bicycling between Apr. 1, 1995, and Mar. 31, 2009. RESULTS: Among 11 772 severely injured patients, 258 (2.2%) were injured (mean ISS 17, hospital stay 6 d, mortality 7%) while street (n = 209) or mountain bicycling (n = 49). Street cyclists were often injured after being struck by a motor vehicle, whereas mountain bikers were frequently injured after faulty jump attempts, bike tricks and falls (cliffs, roadsides, embankments). Mountain cyclists were admitted more often on weekends than weekdays (61.2% v. 45.0%, p = 0.040). Injury patterns were similar for both cohorts (all p > 0.05), with trauma to the head (67.4%), extremities (38.4%), chest (34.1%), face (26.0%) and abdomen (10.1%) being common. Spinal injuries, however, were more frequent among mountain cyclists (65.3% v. 41.1%, p = 0.003). Surgical intervention was required in 33.3% of patients (9.7% open reduction internal fixation, 7.8% spinal fixation, 7.0% craniotomy, 5.8% facial repair and 2.7% laparotomy). CONCLUSION: With the exception of spine injuries, severely injured cyclists display similar patterns of injury and comparable outcomes, regardless of style (street v. mountain). Helmets and thoracic protection should be advocated for injury prevention.

CONTEXTE: Le vélo de ville et le vélo de montagne sont des activités récréatives et des modes de transport populaires très utilisés, qui comportent un risque de blessures graves. Le but de la présente étude était de comparer l'incidence des blessures, les facteurs de risque et les types de blessures les plus fréquents chez les adultes victimes d'accidents impliquant l'utilisation de la bicyclette en ville et hors-piste. MÉTHODES: Nous avons procédé à une étude de cohorte rétrospective à partir de la base de données de traumatologie du Sud de l'Alberta, en regroupant tous les adultes qui ont été victimes d'une blessure grave (indice de gravité de la blessure [IGB] ≥ 12), alors qu'ils circulaient à vélo en ville ou hors-piste entre le 1er avril 1995 et le 31 mars 2009. RÉSULTANTS: Parmi les 11 772 patients blessés gravement, 258 (2,2%) l'ont été (IGB moyen 17, séjour hospitalier 6 jours, mortalité 7%) alors qu'ils circulaient à bicyclette en ville (n = 209) ou hors-piste (n = 49). Les cyclistes qui roulent en ville sont souvent victimes de collision avec des automobiles, tandis que les adeptes du vélo de montagne se blessent souvent lors de tentatives de sauts ou d'acrobaties infructueuses et de chutes (escarpements, accotements, talus). Les adeptes du vélo de montagne ont été plus souvent admis les fins de semaine que les jours de semaine (61,2% c. 45,0%, p = 0,040). Les types de blessures étaient similaires dans les 2 groupes (tous p > 0,05), les traumatismes crâniens (67,4%), les blessures aux extrémités (38,4%), à la poitrine (34,1%), au visage (26,0%) et à l'abdomen (10,1%) ayant été les plus fréquents. Les lésions médullaires ont toutefois été plus fréquentes chez les adeptes du vélo de montagne (65,3% c. 41,1%, p = 0,003). Une intervention chirurgicale a été nécessaire chez 33,3% des patients (9,7% pour fixation interne par réduction chirurgicale, 7,8% pour une fixation du rachis, 7,0% pour une craniotomie, 5,8% pour réparation faciale et 2,7% pour laparotomie). CONCLUSIONS: À l'exception des blessures à la colonne vertébrale, les cyclistes gravement blessés présentent des types de blessures similaires et des résultats comparables, indépendamment du type de vélo qu'ils pratiquent (ville c. montagne). Il faut promouvoir le port de casques et de plastrons de protection pour prévenir les blessures.

Occult pneumothoraces in critical care: a prospective multicenter randomized controlled trial of pleural drainage for mechanically ventilated trauma patients with occult pneumothoraces.

BACKGROUND: Patients with an occult pneumothoraces (OPTXs) may be at risk of tension pneumothoraces (TPTXs) without drainage or pleural drainage complications if treated. METHODS: Adults with traumatic OPTXs and requiring positive-pressure ventilation (PPV) were randomized to pleural drainage or observation (one side only enrolled if bilateral). All subsequent care and method of pleural drainage was per attending physician discretion. The primary outcome was a composite of respiratory distress (RD) (need for urgent pleural drainage, acute/sustained increases in O2 requirements, ventilator dysynchrony, and/or charted respiratory events). RESULTS: Ninety severely injured patients (mean [SD], Injury Severity Score [ISS], 33 [11]) were studied at four centers: Calgary (55), Toronto (27), Quebec (6), and Sherbrooke (3). Forty were randomized to tube thoracostomy, and 50 were randomized to observation. The risk of RD was similar between the observation and tube thoracostomy groups (relative risk, 0.71; 95% confidence interval, 0.40-1.27). There was no difference in mortality or intensive care unit (ICU), ventilator, or hospital days between groups. In those observed, 20% required subsequent pleural drainage (40% PTX progression, 60% pleural fluid, and 20% other). One observed patient (2%) undergoing PPV at enrollment had a TPTX, which was treated with urgent tube thoracostomy without sequelae. Drainage complications occurred in 15% of those randomized to drainage, while suboptimal tube thoracostomy position occurred in an additional 15%. There were three times (24% vs. 8%) more failures and more RDs (p = 0.01) among those observed with OPTXs requiring sustained PPV versus just for an operation, which increases threefold after a week in the ICU (p = 0.07). CONCLUSION: Our results suggest that OPTXs may be safely observed in hemodynamically stable patients undergoing PPV just for an operation, although one third of those requiring a week or more of ICU care received drainage, and TPTXs still occur. Complications of pleural drainage remain unacceptably high, and future work should attempt to delineate specific factors among those observed that warrant prophylactic drainage. LEVEL OF EVIDENCE: Therapeutic study, level III.

Avoidance of total abdominal wall loss despite torso soft tissue clostridial myonecrosis: a case report.

INTRODUCTION: Clostridial necrotizing soft tissue infections are often fatal. Myonecrosis of the torso is a particularly lethal combination given the classic need for radical debridement of the abdominal and thoracic walls, and therefore total exposure of the intraperitoneal and intrathoracic viscera. This case is unusual do to our ability to preserve anatomical separation between the viscera and the atmosphere. CASE PRESENTATION: We present a 42-year-old Caucasian man with obesity and diabetes who developed clostridial myonecrosis of his right torso following a mesenteric lymph node biopsy. This required an aggressive debridement (sparing subcutaneous flaps and internal oblique aponeurosis) followed by reconstruction of his right hemi-torso with a biologic prosthesis to prevent subsequent hernia formation. CONCLUSION: Although basic principles associated with radical debridement were maintained, a full thickness torso wall resection was avoided. This provided reconstruction advantages that included endogenous subcutaneous flap coverage, separation of the peritoneal cavity by the internal oblique aponeurosis, and prevention of a subsequent hernia below the arcuate line. This technique would be of interest to any surgeon or clinician who treats patients with life-threatening torso soft tissue infections.

Metals, trace elements, polychlorinated biphenyls, organochlorine pesticides, and brominated flame retardants in tissues of Barrow's goldeneyes (Bucephala islandica) wintering in the St. Lawrence marine ecosystem, eastern Canada.

The eastern North American population of Barrow's goldeneyes winters in the St. Lawrence Estuary and Gulf of St. Lawrence where the sediments and food web are known to be contaminated with inorganic and organic compounds. Therefore, there is a potential for contamination of this population, which is designated of Special Concern by the Committee on the Status of Endangered Wildlife in Canada. Specimens were collected during three consecutive winters (2005-2007) in three regions (Manicouagan, Charlevoix, and Chaleur Bay) and analysed for metals, trace elements, polychlorinated biphenyls (PCBs), organochlorine pesticides, and brominated flame retardants (BFRs). Liver mercury levels were greater in the St. Lawrence Estuary (4.4 mg/kg in Manicouagan, 3.8 mg/kg in Charlevoix) than in Chaleur (2.4 mg/kg), whereas selenium showed the opposite pattern (7.3 mg/kg in Manicouagan, 7.0 mg/kg in Charlevoix, and 36.9 mg/kg in Chaleur). Liver PCB levels were greater in specimens from Manicouagan (236 ng/g) than in those from the two other regions (72 ng/g in Charlevoix, 35 ng/g in Chaleur). DDT was greater in Chaleur (66 ng/g) versus 10 ng/g in Manicouagan and 16 ng/g in Charlevoix. BFRs were not compared among regions because of smaller sample sizes, but mean total concentration was low (4.02 ng/g). Overall, although significant differences were found across regions, levels of all contaminants measured are generally low and not of toxicological concern for this population.