Pelvic Ring Injury Mortality: Are We Getting Better?

OBJECTIVES

To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

A total of 3314 patients with pelvic ring injuries who presented to a single referral center from 1999 to 2018 were included in the study.

INTERVENTION

Pelvic ring management, years 1999-2006 versus years 2007-2018.

MAIN OUTCOME MEASUREMENTS

In hospital mortality. Other examined variables included change in patient demographics, fracture characteristics, date of injury, associated injuries, length of hospital stay, Abbreviated Injury Severity Score.

RESULTS

The composite mortality rate was 6.5% (214/3314). The earliest cohort presented a mortality rate of 9.1% [111/1224; 95% confidence interval (CI), 7.6%-10.8%] compared with the more recent cohort mortality rate of 4.9% (103/2090; 95% CI, 4.1%-5.9%). Overall mortality was significantly lower in the more recent period, a risk difference of 4.1% (95% CI, 2.3%-6.1%; P < 0.01). After adjusting for age and Abbreviated Injury Severity Score of the brain, chest, and abdomen, the mortality reduction was more pronounced with an adjusted risk difference of 6.4% (95% CI, 4.7%-8.1%; P < 0.01).

CONCLUSION

Significant improvement in the mortality rate of pelvic ring injuries has been demonstrated in recent years (4.9% vs. 9.1%) and the difference is even large when accounting for known confounders. Improvement appears to coincide chronologically with changes in trauma resuscitation and implementation of adjuvant treatments for managing patients with severe hemorrhagic shock. Although the exact benefit of each treatment awaits further research, these data might indicate improved care over time for these difficult patients.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Endoscopic training-is the future three-dimensional?

Background/Objectives

Endoscopic surgery has a distinct disadvantage compared to direct vision: loss of binocular vision. Three-dimensional endoscopy has been welcomed due to the promise of improving stereopsis.

Methods

Prospective randomized study of junior doctors with minimal endoscopic experience, using both two-dimensional and three-dimensional, zero-degree, 4-mm Storz endoscopes. Data was collected using validated, standardized training models, both objectively and subjectively. Paired comparisons between variables relating to the endoscopes were performed using Wilcoxon's tests. Operators were then split into groups based on their endoscope preference, with comparisons made using Mann-Whitney tests for Likert scale responses, Kendall's tau for ordinal variables, and Fisher's exact tests for nominal variables.

Results

Reduction of field of vision of three-dimensional endoscopy by 2%. Significant findings included decreased past-pointing, improved depth and perception and image quality.

Conclusion

The use of an endoscopic endonasal approach with three-dimensional technology has measurable advantages for novice users, and highlights potential tailoring of future surgical training.

Level of Evidence

1b.

Prothrombotic markers in Thalassemia major patients: A paradigm shift

BACKGROUND

It is being increasingly recognised that thalassemia major patients, like intermedia, have increased propensity for thromboembolism. Deficiency of natural anticoagulants is more recently defined finding contributing to the hypercoagulable state. The aim this study is to determine natural anticoagulants levels and their correlation with maternal characteristics, haematological and biochemical markers.

METHODS

This is a prospective case-control study. We registered 80 patients and 60 healthy controls from Jan 2009 to Dec 2013. Complete blood counts, prothrombin time, activated partial thromboplastin time, protein C, protein S, antithrombin, serum ferritin, liver enzymes; HbsAg and Anti- HCV were evaluated.

RESULT

There were 42 males and 38 females with mean age of 12.30±5.50 years. The mean protein C, protein S and antithrombin in patients and control were 58.25±22.5 versus 110.67±22.60, 67.90±19.58 versus 98.70±21.54 and 89.73±18.09 versus 104.0±10.98 (p<0.001) respectively. Protein C was predominantly deficient in 65% followed by protein S and antithrombin in 35% and 20% respectively. Protein C deficiency divulged positive correlation with protein S deficiency (p = 0.035) and antithrombin deficiency with hemoglobin of ≤8gm% (p<0.0025). No significant correlation of prothrombotic markers was established with maternal characteristics, hepatic dysfunction, hepatitis and serum ferritin.

CONCLUSION

Substantial decrement in prothrombotic markers, primarily protein C, may be implicated in elevated thrombosis; however follow-up data is required to establish definitive thromboembolic events.

Training workshops in problem-based learning: changing faculty attitudes and perceptions in a Pakistani medical college

BACKGROUND

Problem-based learning (PBL) has over the years become a learning strategy established for teaching students in medicine. In order to use PBL as a teaching tool, faculty must be familiar with PBL and comfortable with the role transition from 'teacher' to 'facilitator'. This transition is critical for the success of PBL. This article describes the faculty development process undertaken in Pakistan at the onset of introduction of PBL in the curriculum.

METHODS

At the Foundation University Medical College (FUMC), we initiated a faculty development program in PBL. The program consisted of two-day, hands-on facilitator training workshops conducted five times over the year and led by in-house faculty. A total of 180 faculty members completed these workshops. The workshops consisted of interactive sessions on the philosophy of PBL, small group dynamics, the role of the facilitator, an introduction to case design, wrap-up PBL sessions and assessment in PBL. Participants were provided with pre-workshop reading material in the form of 'PBL Handbooks', which contained details of the PBL process and specific responsibilities of the facilitator. Participants were also given a chance to experience the role of the facilitator by facilitating the faculty-learner group through a PBL session and receiving feedback. A retrospective pre-post survey was conducted to gauge changes in participants' perceptions of PBL.

RESULTS

The faculty reported a significant increase in their regard for PBL as an instructional paradigm (p=<0.001). They also generally became more interested in empowering students with self-directed learning using PBL as a teaching tool and showed a greater desire to be facilitators (p=<0.001).

CONCLUSION

This evaluation reveals that facilitator training workshops can help not just to improve the facilitation skills of participants but also to stimulate interest amongst faculty to use PBL in the curriculum. Such workshops can be run in Pakistan at minimal cost: the only cost we incurred was for photocopying the reading material. How much difficulty the faculty will actually have serving as facilitator in the PBL process will only become evident when they lead PBL groups over the coming year.

Cefuroxime-induced thrombocytopenia?

We present the case of a 77-year-old man who became thrombocytopenic whilst treated parenterally with cefuroxime in the absence of proven infection and recovered when the cefuroxime was discontinued.

Programme development of drug abuse control in Baluchistan, Pakistan

The drug abuse control programme in Baluchistan is inter-disciplinary and progressive. Its main thrust consists of constant vigilance on border check-points by law enforcement agencies, developing in-patient and out-patient facilities for treatment and rehabilitation of addicted persons, and a preventive education programme using the mass media and students from higher educational institutions.

New anti-mycobacterial hydantoins

Ten 1-(4-substituted-thiazol-2-yl)hydantoins have been synthesized. Some of them have shown antitubercular activity against Mycobacterium smegmatis.

Search for non-steroidal anti-inflammatory agents. Part 1: Synthesis of 2-alkyl/aryl-3-benzimidazolylalkylquinazolon-4(3H)-ones

Sixteen title compounds have been synthesized and some of them have shown interesting results in antiinflammatory screening against carrageenin-induced inflammation. In addition, the compounds were found to be central nervous system depressants and relatively non-toxic.