The Co-Occurrence of Intimate Partner Violence and Violence Against Children: A Systematic Review on Associated Factors in Low- and Middle-Income Countries

Violence against women (VAW) and violence against children (VAC) are public health issues of global concern. Intimate partner violence (IPV) is a commonly occurring form of VAW and there is evidence to suggest that IPV and VAC frequently co-occur within the same families. This systematic literature review searched for studies published in any language between 1st January 2000 to 16th February 2021 and identified 33 studies that provided findings for co-occurring IPV and VAC in 24 low- and middle-income countries (PROSPERO: CRD42020180179). These studies were split into subgroups based on the types of co-occurring violence they present and meta-analyses were conducted to calculate pooled odds ratios (ORs) within these subgroups. Our results indicate a significant association between IPV and VAC, with all pooled ORs showing a significant positive association between the two. Almost half of the studies focused exclusively on co-occurrence between male-to-female IPV and female caregiver-to-child VAC; few authors reported on male caregiver-to-child violence. Only three studies identified risk factors for co-occurring IPV and VAC, and those that did suggested conflicting findings on the risks associated with maternal age, alcohol and drug use, and parental education level. We also found incongruity in the violence definitions and measurements used across studies. Future research should aim to develop more consistent definitions and measurements for co-occurrence and move beyond solely examining dyadic and unidirectional violence occurrence in families; this will allow us to better understand the interrelationships between these different forms of abuse.

Drug-eluting balloons and drug-eluting stents in the treatment of small vessel coronary artery disease: a systematic review and metanalysis of long-term clinical and angiographic outcomes

Introduction

Coronary artery disease is a leading cause of mortality and morbidity worldwide. For those undergoing PCI, there are 20–30% with disease of the small coronary arteries on presentation [1]. Small coronary artery disease asserts a significant risk factor for adverse events. It is often diffuse and multi-vessel on presentation and confers higher rates of major adverse cardiac events, (MACE) and target lesion failure after intervention [2,3]. Best practice guidelines on the management of SvCAD interventions remain limited.

Drug-eluting balloons are a novel therapy, which has shown promise in treating in-stent restenosis (ISR), however their use in small coronary arteries when compared to drug-eluting stents remains unclear.

Purpose

This systematic review and meta-analysis compare long-term outcomes (>1 year), of drug-eluting balloons (DEB), vs. drug-eluting stents (DES), in the treatment of small coronary artery disease (<3mm).

Methods

A systematic review was completed within PRISMA guidelines. The primary outcome was non-inferiority of DEB Vs. DES in major adverse cardiac events (MACE). Secondary outcomes include all-cause mortality, MI, vessel thrombosis, major bleeding and target vessel revascularization at one, two and three years follow-up. Two independent reviewers extracted data. All outcomes used the Mantel-Haenszel and Random effect model. Odds ratios (OR), were presented with a 95% confidence interval (CI).

Result

Of 4661 articles, four RCTs were included (1414 patients). DEB demonstrated reduced rates of non-fatal MI at one year, OR 0.44 (95% CI 0.2, 0.94) and Basket-2 small reported a significant reduction in two-year bleeding rates OR 0.3 (95% CI 0.1, 0.91). DEBs were non-inferior to DES for all other outcomes.

Conclusion

Long duration follow-up of DEB and DES use in small coronary arteries demonstrates DEB to be non-inferior to DES in all outcomes across all years of follow-up. There was a significant reduction in rates of non-fatal MI at one year in the DEB arm and a reduction in major bleeding episodes at two years in the Basket Small 2 trial. These data highlight the potential utility and long-term safety of novel DEBs in small coronary artery disease revascularization.

Funding Acknowledgement

Type of funding sources: None.

The impact of COVID-19 and associated measures on health, police, and non-government organisation service utilisation related to violence against women and children

BACKGROUND

Globally, concerns have been raised that the priority implementation of public health measures in response to COVID-19 may have unintended negative impacts on a variety of other health and wellbeing factors, including violence. This study examined the impact of COVID-19 response measures on changes in violence against women and children (VAWC) service utilisation across European countries.

METHODS

A rapid assessment design was used to compile data including a survey distributed across WHO Europe Healthy Cities Networks and Violence Injury Prevention Focal Points in WHO European Region member states, and a scoping review of media reports, journal articles, and reports. Searches were conducted in English and Russian and covered the period between 1 January 2020 and 17 September 2020. Data extracted included: country; violence type; service sector; and change in service utilisation during COVID-19. All data pertained to the period during which COVID-19 related public health measures were implemented compared to a period before restrictions were in place.

RESULTS

Overall, findings suggested that there was a median reported increase in VAWC service utilisation of approximately 20% during the COVID-19 pandemic. Crucially, however, change in service utilisation differed across sectors. After categorising each estimate as reflecting an increase or decrease in VAWC service utilisation, there was a significant association between sector and change in service utilisation; the majority of NGO estimates (95.1%) showed an increase in utilisation, compared to 58.2% of law enforcement estimates and 42.9% of health and social care estimates.

CONCLUSIONS

The variation across sectors in changes in VAWC service utilisation has important implications for policymakers in the event of ongoing and future restrictions related to COVID-19, and more generally during other times of prolonged presence in the home. The increased global attention on VAWC during the pandemic should be used to drive forward the agenda on prevention, increase access to services, and implement better data collection mechanisms to ensure the momentum and increased focus on VAWC during the pandemic is not wasted.

Systematic review of food insecurity and violence against women and girls: Mixed methods findings from low- and middle-income settings

Violence against women and girls (VAWG) is a global human rights and public health concern. Food insecurity is a sign of severe poverty, and likely to heighten women's vulnerability to VAWG and men's perpetration of it. However, the extent of the association and the multiple pathways between food insecurity and VAWG are not well understood. We systematically assessed peer reviewed quantitative and qualitative literature to explore this in low- and middle-income countries. Fixed effects meta-analysis was used to synthesize quantitative evidence. Qualitative data was analyzed using thematic analysis. From a search of 732 titles, we identified 23 quantitative and 19 qualitative or mixed-methods peer-reviewed manuscripts. In a meta-analysis of 21 cross-sectional studies with 20,378 participants, food insecurity was associated with doubled odds of reported VAWG (odds ratio [OR] = 2.38, 95% confidence interval [CI] = 1.82-3.10). This finding was consistent for both women's experience or male perpetration of VAWG. Qualitative and mixed-methods papers offered insight that underlying conditions of inequitable gender norms, economic deprivation, and social isolation frame both food insecurity and VAWG. Food insecurity may trigger survival behaviors due to household stress and lack of meeting expected gender roles, which leads to VAWG. VAWG exposure may lead to food insecurity if women are more impoverished after leaving a violent household. Potential protective factors include financial stability, the involvement of men in VAWG programming, transformation of gender norms, and supporting women to develop new networks and social ties. Strong evidence exists for a relationship between food security and VAWG. Future funding should target causal directions and preventive options through longitudinal and interventional research. Strategies to ensure households have access to sufficient food and safe relationships are urgently needed to prevent VAWG.

Measurement and prevalence of sexual harassment in low- and middle-income countries: a systematic review and meta-analysis

OBJECTIVES

We synthesise evidence on sexual harassment from studies in low-income and middle-income countries (LMICs) to estimate its prevalence and conduct a meta-analysis of the association between sexual harassment and depressive symptoms.

METHODS

We searched eight databases. We included peer-reviewed studies published in English from 1990 until April 2020 if they measured sexual harassment prevalence in LMICs, included female or male participants aged 14 and over and conceptualised sexual harassment as an independent or dependant variable. We appraised the quality of evidence, used a narrative syntheses approach to synthesise data and conducted a random effects meta-analysis.

RESULTS

From 49 included studies, 38 focused on workplaces and educational institutions and 11 on public places. Many studies used an unclear definition of sexual harassment and did not deploy a validated measurement tool. Studies either used a direct question or a series of behavioural questions to elicit information on acts considered offensive or defined as sexual harassment. Prevalence was higher in educational institutions than in workplaces although there was high heterogeneity in prevalence estimates across studies with no international comparability. This posed a challenge for calculating an overall estimate or measuring a range. Our meta-analysis showed some evidence of an association between sexual harassment and depressive symptoms (OR: 1.75; 95% CI: 1.11 to 2.76; p=0.016) although there were only three studies with a high risk of bias.

CONCLUSION

To our knowledge, this is the first systematic review to assess measurement approaches and estimate the prevalence of sexual harassment across settings in LMICs. We also contribute a pooled estimate of the association between sexual harassment and depressive symptoms in LMICs. There is limited definitional clarity, and rigorously designed prevalence studies that use validated measures for sexual harassment in LMICs. Improved measurement will enable us to obtain more accurate prevalence estimates across different settings to design effective interventions and policies.

Emerging responses implemented to prevent and respond to violence against women and children in WHO European member states during the COVID-19 pandemic: a scoping review of online media reports

OBJECTIVES

This study aims to explore the strategies that governments and civil society organisations implemented to prevent and respond to the anticipated rise in violence against women and/or children (VAWC) during the 2019 novel coronavirus (COVID-19) pandemic.

DESIGN

A scoping review and content analysis of online media reports.

SETTING

WHO European region.

METHODS

A scoping review of media reports and publications and a search of other grey literature (published from 1 January to 17 September 2020). Primary and secondary outcome measures included measures implemented by governments, public services and non-governmental and civil organisations to prevent or respond to VAWC during the early months of the COVID-19 pandemic.

RESULTS

Our study found that in 52 of the 53 member states there was at least one measure undertaken to prevent or respond to VAWC during the pandemic. Government-led or government-sponsored measures were the most common, reported in 50 member states. Non-governmental and other civil society-led prevention and response measures were reported in 40 member states. The most common measure was the use of media and social media to raise awareness of VAWC and to provide VAWC services through online platforms, followed by measures taken to expand and/or maintain helpline services for those exposed to violence.

CONCLUSION

The potential increase in VAWC during COVID-19-imposed restrictions and lockdowns resulted in adaptations and/or increases in prevention and response strategies in nearly all member states. The strength of existing public health systems influenced the requirement and choice of strategies and highlights the need for sustaining and improving violence prevention and response services. Innovative strategies employed in several member states may offer opportunities for countries to strengthen prevention and responses in the near future and during similar emergencies.

Effectiveness of influenza vaccination in preventing hospitalisation due to influenza in children: a systematic review and meta-analysis

This systematic review assesses the literature for estimates of influenza vaccine effectiveness (IVE) against laboratory-confirmed influenza-associated hospitalisation in children. Studies of any design to 08 June 2020 were included if the outcome was hospitalisation, participants were 17 years old or less and influenza infection was laboratory-confirmed. A random-effects meta-analysis of 37 studies that used a test-negative design gave a pooled seasonal IVE against hospitalisation of 53.3% (47.2-58.8) for any influenza. IVE was higher against influenza A/H1N1pdm09 (68.7%, 56.9-77.2) and lowest against influenza A/H3N2 (35.8%, 23.4-46.3). Estimates by vaccine type ranged from 44.3% (30.1-55.7) for LAIV to 68.9% (53.6-79.2) for inactivated vaccines. IVE estimates were higher in seasons when the circulating influenza strains were antigenically matched to vaccine strains (59.3%, 48.3-68.0). Influenza vaccination gives moderate overall protection against influenza-associated hospitalisation in children supporting annual vaccination. IVE varies by influenza subtype and vaccine type.

Scrub typhus ecology: a systematic review of Orientia in vectors and hosts

Scrub typhus, caused by Orientia tsutsugamushi, is an important and neglected vector-borne zoonotic disease with an expanding known distribution. The ecology of the disease is complex and poorly understood, impairing discussion of public health interventions. To highlight what we know and the themes of our ignorance, we conducted a systematic review of all studies investigating the pathogen in vectors and non-human hosts. A total of 276 articles in 7 languages were included, with 793 study sites across 30 countries. There was no time restriction for article inclusion, with the oldest published in 1924. Seventy-six potential vector species and 234 vertebrate host species were tested, accounting for over one million trombiculid mites ('chiggers') and 83,000 vertebrates. The proportion of O. tsutsugamushi positivity was recorded for different categories of laboratory test and host species. Vector and host collection sites were geocoded and mapped. Ecological data associated with these sites were summarised. A further 145 articles encompassing general themes of scrub typhus ecology were reviewed. These topics range from the life-cycle to transmission, habitats, seasonality and human risks. Important gaps in our understanding are highlighted together with possible tools to begin to unravel these. Many of the data reported are highly variable and inconsistent and minimum data reporting standards are proposed. With more recent reports of human Orientia sp. infection in the Middle East and South America and enormous advances in research technology over recent decades, this comprehensive review provides a detailed summary of work investigating this pathogen in vectors and non-human hosts and updates current understanding of the complex ecology of scrub typhus. A better understanding of scrub typhus ecology has important relevance to ongoing research into improving diagnostics, developing vaccines and identifying useful public health interventions to reduce the burden of the disease.

Abstract P3-10-14: Clinical and economic burden of HER2-positive breast cancer recurrence in the US: A literature review

Background: Despite available treatment for early-stage breast cancer (BC), 15%-25% of patients with early-stage human epidermal growth factor receptor 2–positive (HER2+) BC eventually experience recurrence after initial treatment. The prognosis for women with HER2+ disease recurrence is poor. Most recurrences involve incurable metastatic disease. In the US, the total cost to society attributable to metastatic BC of any subtype was $12.2 billion accrued over 5 years, or $2.4 billion per year ($98,571 per patient-year). Treatment-related cost, 57% of total costs, was the largest contribution, with over $1.0 billion per year. The purpose of this study was to assess the clinical and economic burden of recurrence in patients with early-stage HER2+ BC.

Methods: We conducted two systematic literature reviews (SLRs) and one targeted literature review (TLR) in PubMed, Embase, and Cochrane databases. The SLRs (no publication date limit; clinical SLR conducted on November 8, 2016; economic SLR conducted on October 25, 2016) searched for randomized clinical trials of neratinib and other treatments and economic data (models, utility, resource use, and cost), and the TLR (publications published from January 2006 to September 2016) searched for burden-of-illness studies in early-stage HER2+ BC.

Results: A total of 4,708 abstracts (2,649 clinical SLR; 969 economic SLR; 1,090 TLR) were identified from all searches, and full-text review was conducted for 796 articles (507 clinical SLR; 151 economic SLR; 138 TLR). Of these, 159 (72 clinical SLR; 33 economic SLR; 54 TLR) followed protocol-specified criteria for inclusion. Based on clinical trials in the neoadjuvant and/or adjuvant setting, disease-free survival rates at 4 years ranged from 78% to 90%. HER2-targeting adjuvant regimens such as lapatinib added to trastuzumab and extending trastuzumab to 2 years have been unsuccessful in reducing the risk of recurrence. Women who had a recurrence, regardless of HER2 status, reported significantly poorer functioning on various quality of life (QoL) domains compared with women who remained disease free. All patients with early-stage BC, regardless of HER2 status, diagnosed with their first recurrence experienced cancer-related distress and no improvement in QoL (physical health and functioning) after 1 year. In the US, the total expected per-patient costs for all BC, regardless of HER2 status, over 10 years was $53,454 with metastatic recurrence, $61,601 with locoregional recurrence, and $61,188 with contralateral recurrence as compared with $42,005 (background costs) with no recurrence (2004 US $). The overall cost of recurrence in women with HER2+ BC in the US was estimated to be $240 million to $1.7 billion over the lifetimes of each 1-year cohort of 7,298 patients (2008 US $).

Conclusions: These results identified few studies on patients with early-stage HER2+ BC and suggest that future studies are warranted. Recurrence in women with HER2+ BC is associated with decreased QoL and high costs. After adjuvant therapy, there is still risk of recurrence, thus the clinical and economic burden remains. There is an unmet medical need in early-stage HER2+ BC, and new therapies are needed to reduce the risk of recurrence.

Citation Format: Masaquel C, Hurley D, Barnett B, Krieger T, Pearson I, Copley-Merriman C, Kaye JA, Moy B. Clinical and economic burden of HER2-positive breast cancer recurrence in the US: A literature review [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-10-14.

Development and validation of a cost-utility model for Type 1 diabetes mellitus

AIMS

To develop a health economic model to evaluate the cost-effectiveness of new interventions for Type 1 diabetes mellitus by their effects on long-term complications (measured through mean HbA1c ) while capturing the impact of treatment on hypoglycaemic events.

METHODS

Through a systematic review, we identified complications associated with Type 1 diabetes mellitus and data describing the long-term incidence of these complications. An individual patient simulation model was developed and included the following complications: cardiovascular disease, peripheral neuropathy, microalbuminuria, end-stage renal disease, proliferative retinopathy, ketoacidosis, cataract, hypoglycemia and adverse birth outcomes. Risk equations were developed from published cumulative incidence data and hazard ratios for the effect of HbA1c , age and duration of diabetes. We validated the model by comparing model predictions with observed outcomes from studies used to build the model (internal validation) and from other published data (external validation). We performed illustrative analyses for typical patient cohorts and a hypothetical intervention.

RESULTS

Model predictions were within 2% of expected values in the internal validation and within 8% of observed values in the external validation (percentages represent absolute differences in the cumulative incidence).

CONCLUSIONS

The model utilized high-quality, recent data specific to people with Type 1 diabetes mellitus. In the model validation, results deviated less than 8% from expected values.

[Not Available]

OBJECTIVE

To translate the Sport Concussion Assessment Tool 2 (SCAT2) based on the French spoken in Quebec and to confirm its acceptability for Quebec's francophone population.

METHODOLOGY

The original SCAT2 was translated using a modified approach of the tool translation and adaptation method as proposed by the World Health Organization. A parallel translation was done first. A review of that translation by a committee then led to a preliminary SCAT2-Qc version. A parallel back-translation was then done and compared to the original version. The preliminary version was subsequently modified. The final version was then obtained through comments and suggestions during testing of the tool on two healthy subjects and from the comparison of the SCAT2-Qc with the existing French version by three reviewers from the health field. The final version of the SCAT2-Qc was eventually tested on 12 healthy subjects to ensure its acceptability.

RESULTS

The 12 healthy subjects did not experience any comprehension difficulties when using the SCAT2-Qc.

CONCLUSION

The translation steps undertaken made it possible to create the SCAT2-Qc that can now be validly used in the Quebec sport and scientific community.

Incidence and effects of increased cerebral blood flow velocity after severe head injury: a transcranial Doppler ultrasound study I. Prediction of post-traumatic vasospasm and hyperemia

Cerebral blood flow velocity was monitored in 50 patients with severe head injury (GCS 8 or less) within 24 h of injury and at least once daily thereafter, using transcranial Doppler ultrasonography (TCD). Delayed post-traumatic vasospasm occurred in 20, and cerebral hyperemia in another 15. Doppler velocities were higher in vasospasm, which also lasted significantly longer than hyperemia. The presence of visible blood on an early CT scan was of some value in predicting vasospasm only (accuracy 59%). Xenon-133 cerebral blood flow (CBF) was also measured within 24 h of injury. An abnormal early cerebral blood flow level, either above or below a narrow central range, was more effective than CT in predicting vasospasm or hyperemia (accuracy 80%), while the combination of an abnormal blood flow and hemorrhagic findings on CT scan helped to determine which of these would occur later. Patients with an abnormal early cerebral blood flow and hemorrhagic findings on CT were more likely to develop vasospasm--accuracy for prediction of vasospasm 73%. This distinction may be of great importance, since these different groups of patients may well need different management.

Dynamic cardiomyoplasty in chronic left ventricular failure: an experimental model

Dynamic cardiomyoplasty continues to attract interest as a therapeutic option in the management of heart failure. In a large animal model of ischemic heart failure, we have compared dynamic cardiomyoplasty with both adynamic cardiomyoplasty and a control group. Heart failure was induced by coronary artery ligation in sheep, and under the same anesthetic dynamic cardiomyoplasty (n = 5), adynamic cardiomyoplasty (n = 4), or no further procedure was performed (n = 5). After recovery the animals were housed for a further 3 months. The dynamic cardiomyoplasty underwent a recognized muscle transformation protocol during this period. At terminal studies, the animals were hemodynamically assessed, both under baseline conditions and after colloid volume loading. The data at baseline were compared with unpaired t tests, and the function curves created by volume loading were compared by analysis of variance. Although the changes at baseline were small, there were highly significant improvements in the function curves in the dynamic cardiomyoplasty group when the stimulators were turned on compared with stimulators off (p = 0.005) for cardiac output; p = 0.035 for left ventricular end-diastolic pressure; p = 0.002 for pulmonary artery capillary wedge pressure; p = 0.004 for stroke volume; and p = 0.003 for cardiac power). There were also significant improvements in indices of cardiac performance when the dynamic cardiomyoplasty group was compared with both the control and adynamic cardiomyoplasty groups. We conclude that there is experimental evidence that cardiomyoplasty augments cardiac function in a model of chronic left ventricular failure.

Transcranial Doppler ultrasound in brain death: experience in 140 patients

The interpretation of clinical tests for brain death is often complicated by the presence of facial trauma, or the use of barbiturate therapy for reduction of intracranial pressure. We propose a non-invasive technique--transcranial Doppler (TCD) sonography for the diagnosis of brain death. One hundred and forty comatose patients, 111 of whom were believed to be brain dead underwent TCD examinations. TCD assessments of the middle cerebral arteries (MCAs) and the basilar artery were performed before formal clinical testing for brain death. The TCD spectra recorded in the brain dead (BD) patients consisted of short, sharp systolic peaks followed by retrograde flow during diastole or just systolic peaks with absent flow in either direction. There were no survivors among patients who displayed these two TCD patterns. The 29 comatose control patients always showed flow throughout the cardiac cycle--no retrograde flow was ever recorded in these patients all of whom survived. Of particular interest were the basilar artery results. In nine BD patients no MCA signals could be obtained while good quality signals were recorded from the basilar artery. The TCD results agreed essentially with 100% accuracy with clinical testing and four vessel cerebral angiography. This paper illustrates the usefulness of TCD examination of the MCAs and especially the basilar artery in the diagnosis of brain death.

Experimental model of left ventricular failure

A model of chronic cardiac failure has undergone extensive hemodynamic investigation. Under anesthesia the homonymous and second diagonal coronary arteries of sheep have been ligated. The resulting myocardial infarction caused significant acute hemodynamic impairment (paired two-tailed t tests), mean pulmonary artery pressure increasing from 7.31 +/- 0.94 to 13.80 +/- 1.19 mm Hg (p less than 0.001), pulmonary artery diastolic pressure increasing from 4.94 +/- 1.03 to 11.13 +/- 1.27 mm Hg (p less than 0.001), and directly measured left ventricular end-diastolic pressure increasing from 9.31 +/- 1.52 to 17.42 +/- 1.82 mm Hg (p less than 0.001) after infarction documented with invasive monitoring. There was a hemodynamically significant left ventricular aneurysm (paired two-tailed t tests) in animals studied 3 months later, with increased mean pulmonary artery pressure from 7.20 +/- 1.15 to 13.80 +/- 2.00 mm Hg (p = 0.009), an increase in pulmonary artery diastolic pressure from 4.60 +/- 1.30 to 12.10 +/- 2.06 mm Hg (p = 0.006), and an increase in left ventricular end-diastolic pressure from 11.00 +/- 1.94 mm Hg before infarction to 17.00 +/- 2.69 mm Hg (p = 0.038). We conclude that this is a useful model of chronic left ventricular failure that is reproducible and applicable to investigations of therapeutic options in chronic heart failure.

The hospital trauma team: a model for trauma management

A triage system was established as the initiating mechanism for a trauma team response to assist the assessment and early management of patients presenting to an accident and emergency department. A checklist of triage criteria was used. During a 6-month period, 342 patients (29.7% of trauma admissions) satisfied the triage criteria, which should have resulted in an average of 1.9 trauma team calls per day. Staff compliance with the triage tool was 75.4%. The overtriage rate for the checklist criteria was 52.7%. The triage tool identified patients with severe injuries who were not initially considered sufficiently injured to justify initiation of the trauma team response. The sensitivity of the triage tool in identifying patients with serious injury was 95.0%. Comparison of the review with a similar review performed 12 months earlier demonstrated that staff compliance with initiating the trauma team response had improved. Using data from 564 patients from both series, logistic regression analysis of the power of the triage criteria to predict serious injury contributed to a revision of the triage criteria. This trauma triage tool and trauma team response constitute a valid approach to the early hospital management of trauma patients. This system may be more appropriate or achievable in many hospitals than the construction of dedicated trauma reception units or permanent surgical staffing of general Accident and Emergency departments.

The Use of Transcranial Doppler Sonography in the Diagnosis of Brain Death

The diagnosis of brain death is important for many reasons. Clinical testing may not be feasible, so that cerebral angiography is needed to confirm circulatory arrest. Angiography is, however, cumbersome and expensive. We present the results of transcranial Doppler (TCD) studies on the middle cerebral arteries of 40 patients with brain death. In six, no cranial signals could be obtained. All except two of the remaining patients had typical TCD appearances, with a reverberating pattern and little or no net forward flow. One patient had this appearance on one side and a carotid-cavernous fistula on the other side, and another had preserved middle cerebral artery flow. Sixteen control patients all had quite different signals, with some showing evidence of raised intracranial pressure and some of vasospasm. There were thus few false-negative results, and more importantly no false-positives. Refinement of this technique, especially looking to a numerical value for the net flow velocity below which circulatory arrest is certain, is needed. The possibility of a changing pattern on serial studies, with prediction of brain death before it actually occurs, is also to be explored.

Implementation of a trauma team

A team approach to the initial assessment, investigation and management of potentially seriously injured patients has been instituted. Team members are alerted through an emergency paging system which is activated when a patient fulfills one of a predetermined list of criteria relating to the injury incident, physiological status of the patients and anatomic injuries. Medical members of the team include surgical, intensive care, anaesthetic, and accident and emergency staff. The surgical representative acts as team co-ordinator. Aspects of the function of the trauma team system were assessed over 4 months during which time 721 injured patients were admitted, 240 patients satisfied the trauma team criteria, and the team was called 152 times. The observed 'false alarm' rate was 38% but the true false alarm rate would have been 46%. Injuries sustained by some patients, who satisfied the criteria but who were not evaluated by the team, were of sufficient severity to justify a greater compliance with the system than was observed at this early stage after its implementation. Although a false alarm rate of 46% is higher than desirable, the number of calls per day would still only average 2 in a hospital with a high trauma patient load. The checklist criteria were highly sensitive (97%) in identifying those patients who should have been evaluated by the trauma team. Although hospitals differ in workload and staffing, this trauma team model is recommended for more widespread use and for further evaluation and modification.

Sepsis associated with central vein catheters in critically ill patients

In 440 critically ill patients, the association between different central vein catheter insertion sites, the duration of catheter insertion and catheter-associated sepsis was examined. Of 780 catheter tips studied, 19% were colonized by microorganisms. The incidence of colonization varied with the different insertion sites. The lowest percentage of colonized catheters occurred with catheters inserted via the subclavian vein (15%) and the highest, at the femoral vein insertion site (34%, p less than 0.01). The percentage of catheters colonized increased as the duration of insertion increased, at all insertion sites studied. Catheter colonization was closely related to the development of bacteraemia and was associated with approximately 10% of colonized catheters. Our results suggest that the subclavian site is associated with the lowest infective complication rate. To minimize catheter associated sepsis, catheters at all insertion sites should be used with parsimony and only kept in place for the minimum amount of time that their continuing use is necessary.

Ingestion of hydrochloric acid

A case of intentional ingestion of concentrated acid, in which both disseminated intravascular coagulation and acute respiratory insufficiency complicated initial resuscitation, is reported. The assessment and the acute management of this unusual problem are reviewed, with emphasis on early endoscopy and laparotomy.