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Injury outcomes across Canadian trauma systems: a historical cohort study. Can J Anaesth 2023; 70:1350-1361. [PMID: 37386268 DOI: 10.1007/s12630-023-02522-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 07/01/2023] Open
Abstract
PURPOSE Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems. METHODS In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province. RESULTS The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high. CONCLUSIONS Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.
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A novel computerized approach to scoping reviews using Synthesis software: the first 15 years of The American College of Surgeons National Surgical Quality Improvement Program. Can J Surg 2023; 66:E156-E161. [PMID: 37001974 PMCID: PMC10069414 DOI: 10.1503/cjs.001722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 04/03/2023] Open
Abstract
SummaryScoping reviews of innovations in health care characterized by large numbers and types of publications present a unique challenge. A novel software application, Synthesis, can efficiently scan the literature to map the evidence and inform practice. We applied Synthesis to the National Surgical Quality Improvement Program (NSQIP), a high-quality database designed to measure risk-adjusted 30-day surgical outcomes for national and international benchmarking. The scoping review describes the breadth of studies in the NSQIP literature. We performed a comprehensive electronic literature search using PubMed, MEDLINE, Web of Knowledge and Scopus to capture all NSQIP articles published between Jan. 1, 2000, and Dec. 31, 2020. Two reviewers independently reviewed articles to determine their relevance using predefined inclusion criteria. We imported references into Synthesis to semiautomate data management. Extracted data included surgical specialty, study type and year of publication. Of the 4661 NSQIP articles included, 3631 (77.9%) were published within the last 5 years. Among NSQIP-related articles, the most common study types were based on outcomes (46.7%) and association (41.7%), and the most common surgical specialties were general surgery and orthopedic surgery, representing 35.7% and 24.0% of the articles, respectively. Synthesis enabled a rapid review of thousands of NSQIP publications. The scoping review provided an overview of the articles in the NSQIP literature and suggested that the NSQIP is increasingly being described in publications of quality and safety in surgery.
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Validation of Quality Indicators Targeting Low-Value Trauma Care. JAMA Surg 2022; 157:2796291. [PMID: 36103195 PMCID: PMC9475433 DOI: 10.1001/jamasurg.2022.3912] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/18/2022] [Indexed: 09/16/2023]
Abstract
Importance Reducing low-value care has the potential to improve patient experiences and outcomes and free up health care resources. Sixteen quality indicators were recently developed targeting reductions in low-value trauma care based on a synthesis of the best available evidence, expert consensus, and patient preferences. Objective To assess the validity of quality indicators on low-value trauma care using trauma registry data. Design, Setting, and Participants Data from an inclusive Canadian provincial trauma system were used in this analysis. Included were all admissions for injury to any of the 57 provincial adult trauma centers between April 1, 2013, and March 31, 2020. Metrics for quality indicators were developed iteratively with clinical experts. Main Outcomes and Measures Validity was assessed using a priori criteria based on 5 parameters: frequency (incidence and case volume), discrimination (interhospital variation), construct validity (correlation with quality indicators on high-value care), predictive validity (correlation with quality indicators on risk-adjusted outcomes), and forecasting (correlation over time). Results The study sample included 136 783 patient admissions (mean [SD] age, 63 [22] years; 68 428 men [50%]). Metrics were developed for 12 of the 16 quality indicators. Six quality indicators showed moderate or high validity on all measurable parameters: initial head, cervical spine, or whole-body computed tomography for low-risk patients; posttransfer repeated computed tomography; neurosurgical consultation for mild complicated traumatic brain injury; and spine service consultation for isolated thoracolumbar process fractures. Red blood cell transfusion in low-risk patients had low frequency but had moderate or high validity on all other parameters. Five quality indicators had low validity on at least 2 parameters: repeated head CT and intensive care unit admission for mild complicated traumatic brain injury, hospital admission for minor blunt abdominal trauma, orthosis for thoracolumbar burst fractures, and surgical exploration in penetrating neck injury without hard signs. Conclusions and Relevance This cohort study shows the feasibility of assessing low-value trauma care using routinely collected data. It provided data on quality indicators properties that can be used to decide which quality indicators are most appropriate in a given system. Results suggest that 6 quality indicators have moderate to high validity. Their implementation now needs to be tested.
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Abstract
Importance The use of quality indicators has been shown to improve injury care processes and outcomes. However, trauma quality indicators proposed to date exclusively target the underuse of recommended practices. Initiatives such as Choosing Wisely publish lists of practices to be questioned, but few apply to trauma care, and most have not successfully been translated to quality indicators. Objective To develop a set of evidence and patient-informed, consensus-based quality indicators targeting reductions in low-value clinical practices in acute, in-hospital trauma care. Design, Setting, and Participants This 2-round Research and Development/University of California at Los Angeles (RAND/UCLA) consensus study, conducted from April 20 to June 9, 2021, comprised an online questionnaire and a virtual workshop led by 2 independent moderators. Two panels of international experts from Canada, Australia, the US, and the UK, and local stakeholders from Québec, Canada, represented key clinical expertise involved in trauma care and included 3 patient partners. Main Outcomes and Measures Panelists were asked to rate 50 practices on a 7-point Likert scale according to 4 quality indicator criteria: importance, supporting evidence, actionability, and measurability. Results Of 49 eligible experts approached, 46 (94%; 18 experts [39%] aged ≥50 years; 37 men [80%]) completed at least 1 round and 36 (73%) completed both rounds. Eleven quality indicators were selected overall, 2 more were selected by the international panel and a further 3 by the local stakeholder panel. Selected indicators targeted low-value clinical practices in the following aspects of trauma care: (1) initial diagnostic imaging (head, cervical spine, ankle, and pelvis), (2) repeated diagnostic imaging (posttransfer computed tomography [CT] and repeated head CT), (3) consultation (neurosurgical and spine), (4) surgery (penetrating neck injury), (5) blood product administration, (6) medication (antibiotic prophylaxis and late seizure prophylaxis), (7) trauma service admission (blunt abdominal trauma), (8) intensive care unit admission (mild complicated traumatic brain injury), and (9) routine blood work (minor orthopedic surgery). Conclusions and Relevance In this consensus study, a set of consensus-based quality indicators were developed that were informed by the best available evidence and patient priorities, targeting low-value trauma care. Selected indicators represented a trauma-specific list of practices, the use of which should be questioned. Trauma quality programs in high-income countries may use these study results as a basis to select context-specific quality indicators to measure and reduce low-value care.
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2021 Canadian Surgery Forum01. Design and validation of a unique endoscopy simulator using a commercial video game03. Is ethnicity an appropriate measure of health care marginalization?: A systematic review and meta-analysis of the outcomes of diabetic foot ulceration in the Aboriginal population04. Racial disparities in surgery — a cross-specialty matched comparison between black and white patients05. Starting late does not increase the risk of postoperative complications in patients undergoing common general surgical procedures06. Ethical decision-making during a health care crisis: a resource allocation framework and tool07. Ensuring stability in surgical training program leadership: a survey of program directors08. Introducing oncoplastic breast surgery in a community hospital09. Leadership development programs for surgical residents: a review of the literature10. Superiority of non-opioid postoperative pain management after thyroid and parathyroid operations: a systematic review and meta-analysis11. Timing of ERCP relative to cholecystectomy in patients with ductal gallstone disease12. A systematic review and meta-analysis of randomized controlled trials comparing intraoperative red blood cell transfusion strategies13. Postoperative outcomes after frail elderly preoperative assessment clinic: a single-institution Canadian perspective14. Selective opioid antagonists following bowel resection for prevention of postoperative ileus: a systematic review and meta-analysis15. Peer-to-peer coaching after bile duct injury16. Laparoscopic median arcuate ligament release: a video abstract17. Retroperitoneoscopic approach to adrenalectomy19. Endoscopic Zenker diverticulotomy: a video abstract20. Variability in surgeons’ perioperative management of pheochromocytomas in Canada21. The contribution of surgeon and hospital variation in transfusion practice to outcomes for patients undergoing elective gastrointestinal cancer surgery: a population-based analysis22. Perioperative transfusions for gastroesophageal cancers: risk factors and short- and long-term outcomes23. The association between frailty and time alive and at home after cancer surgery among older adults: a population-based analysis24. Psychological and workplace-related effects of providing surgical care during the COVID-19 pandemic in British Columbia, Canada25. Safety of venous thromboembolism prophylaxis in endoscopic retrograde cholangiopancreatography: a systematic review26. Complications and reintervention following laparoscopic subtotal cholecystectomy: a systematic review and meta-analysis27. Synchronization of pupil dilations correlates with team performance in a simulated laparoscopic team coordination task28. Receptivity to and desired design features of a surgical peer coaching program: an international survey9. Impact of the COVID-19 pandemic on rates of emergency department utilization due to general surgery conditions30. The impact of the current COVID-19 pandemic on the exposure of general surgery trainees to operative procedures31. Association between academic degrees and research productivity: an assessment of academic general surgeons in Canada32. Laparoscopic endoscopic cooperative surgery (LECS) for subepithelial gastric lesion: a video presentation33. Effect of the COVID-19 pandemic on acute care general surgery at an academic Canadian centre34. Opioid-free analgesia after outpatient general surgery: a pilot randomized controlled trial35. Impact of neoadjuvant immunotherapy or targeted therapies on surgical resection in patients with solid tumours: a systematic review and meta-analysis37. Surgical data recording in the operating room: a systematic review of modalities and metrics38. Association between nonaccidental trauma and neighbourhood socioeconomic status during the COVID-19 pandemic: a retrospective analysis39. Laparoscopic repair of a transdiaphragmatic gastropleural fistula40. Video-based interviewing in medicine: a scoping review41. Indocyanine green fluorescence angiography for prevention of anastomotic leakage in colorectal surgery: a cost analysis from the hospital payer’s perspective43. Perception or reality: surgical resident and faculty assessments of resident workload compared with objective data45. When illness and loss hit close to home: Do health care providers learn how to cope?46. Remote video-based suturing education with smartphones (REVISE): a randomized controlled trial47. The evolving use of robotic surgery: a population-based analysis48. Prophylactic retromuscular mesh placement for parastomal hernia prevention: a retrospective cohort study of permanent colostomies and ileostomies49. Intracorporeal versus extracorporeal anastomosis in laparoscopic right hemicolectomy: a retrospective cohort study on anastomotic complications50. A lay of the land — a description of Canadian academic acute care surgery models51. Emergency general surgery in Ontario: interhospital variability in structures, processes and models of care52. Trauma 101: a virtual case-based trauma conference as an adjunct to medical education53. Assessment of the National Surgical Quality Improvement Program Surgical Risk Calculator for predicting patient-centred outcomes of emergency general surgery patients in a Canadian health care system54. Sustainability of a narcotic reduction initiative: 1 year following the Standardization of Outpatient Procedure (STOP) Narcotics Study55. Barriers to transanal endoscopic microsurgery referral56. Geospatial analysis of severely injured rural patients in a geographically complex landscape57. Implementation of an incentive spirometry protocol in a trauma ward: a single-centre pilot study58. Impostor phenomenon is a significant risk factor for burnout and anxiety in Canadian resident physicians: a cross-sectional survey59. Understanding the influence of perioperative education on performance among surgical trainees: a single-centre experience60. The effect of COVID-19 pandemic on current and future endoscopic personal protective equipment practices: a national survey of 77 endoscopists61. Case report: delayed presentation of perforated sigmoid diverticulitis as necrotizing infection of the lower limb62. Investigating disparities in surgical outcomes in Canadian Indigenous populations63. Fundoplication is superior to medical therapy for Barrett esophagus disease regression and progression: a systematic review and meta-analysis64. Development of a novel online general surgery learning platform and a qualitative preimplementation analysis65. Hagfish slime exudate as a potential novel hemostatic agent: developing a standardized assessment protocol66. The effect of the first wave of the COVID-19 pandemic on surgical oncology case volumes and wait times67. Safety of same-day discharge in high-risk patients undergoing ambulatory general surgery68. External validation of the Codman score in colorectal surgery: a pragmatic tool to drive quality improvement69. Improved morbidity and gastrointestinal restoration rates without compromising survival rates for diverting loop ileostomy with colonic lavage versus total abdominal colectomy for fulminant Clostridioides difficile colitis: a multicentre retrospective cohort study70. Potential access to emergency general surgical care in Ontario71. Immersive virtual reality (iVR) improves procedural duration, task completion and accuracy in surgical trainees: a systematic review01. Clinical validation of the Canada Lymph Node Score for endobronchial ultrasound02. Venous thromboembolism in surgically treated esophageal cancer patients: a provincial population-based study03. Venous thromboembolism in surgically treated lung cancer patients: a population-based study04. Is frailty associated with failure to rescue after esophagectomy? A multi-institutional comparative analysis of outcomes05. Routine systematic sampling versus targeted sampling of lymph nodes during endobronchial ultrasound: a feasibility randomized controlled trial06. Gastric ischemic conditioning reduces anastomotic complications in patients undergoing esophagectomy: a systematic review and meta-analysis07. Move For Surgery, a novel preconditioning program to optimize health before thoracic surgery: a randomized controlled trial08. In case of emergency, go to your nearest emergency department — Or maybe not?09. Does preoperative SABR increase the risk of complications from lung cancer resection? A secondary analysis of the MISSILE trial10. Segmental resection for lung cancer: the added value of near-infrared fluorescence mapping diminishes with surgeon experience11. Toward competency-based continuing professional development for practising surgeons12. Stereotactic body radiotherapy versus surgery in older adults with NSCLC — a population-based, matched analysis of long-term dependency outcomes13. Role of adjuvant therapy in esophageal cancer patients after neoadjuvant therapy and curative esophagectomy: a systematic review and meta-analysis14. Evaluation of population characteristics on the incidence of thoracic empyema: an ecological study15. Determining the optimal stiffness colour threshold and stiffness area ratio cut-off for mediastinal lymph node staging using EBUS elastography and AI: a pilot study16. Quality assurance on the use of sequential compression stockings in thoracic surgery (QUESTs)17. The relationship between fissureless technique and prolonged air leak for patients undergoing video-assisted thoracoscopic lobectomy18. CXCR2 inhibition as a candidate for immunomodulation in the treatment of K-RAS-driven lung adenocarcinoma19. Assessment tools for evaluating competency in video-assisted thoracoscopic lobectomy: a systematic review20. Understanding the current practice on chest tube management following lung resection among thoracic surgeons across Canada21. Effect of routine jejunostomy tube insertion in esophagectomy: a systematic review and meta-analysis22. Recurrence of primary spontaneous pneumothorax following bullectomy with pleurodesis or pleurectomy: a retrospective analysis23. Surgical outcomes following chest wall resection and reconstruction24. Outcomes following surgical management of primary mediastinal nonseminomatous germ cell tumours25. Does robotic approach offer better nodal staging than thoracoscopic approach in anatomical resection for non–small cell lung cancer? A single-centre propensity matching analysis26. Competency assessment for mediastinal mass resection and thymectomy: design and Delphi process27. The contemporary significance of venous thromboembolism (deep venous thrombosis [DVT] and pulmonary embolus [PE]) in patients undergoing esophagectomy: a prospective, multicentre cohort study to evaluate the incidence and clinical outcomes of VTE after major esophageal resections28. Esophageal cancer: symptom severity at the end of life29. The impact of pulmonary artery reconstruction on postoperative and oncologic outcomes: a systematic review30. Association with surgical technique and recurrence after laparoscopic repair of paraesophageal hernia: a single-centre experience31. Enhanced recovery after surgery (ERAS) in esophagectomy32. Surgical treatment of esophageal cancer: trends in surgical approach and early mortality at a single institution over the past 18 years34. Adverse events and length of stay following minimally invasive surgery in paraesophageal hernia repair35. Long-term symptom control comparison of Dor and Nissen fundoplication following laparoscopic para-esophageal hernia repair: a retrospective analysis36. Willingness to pay: a survey of Canadian patients’ willingness to contribute to the cost of robotic thoracic surgery37. Radiomics in early-stage lung adenocarcinoma: a prediction tool for tumour immune microenvironments38. Effectiveness of intraoperative pyloric botox injection during esophagectomy: how often is endoscopic intervention required?39. An artificial intelligence algorithm for predicting lymph node malignancy during endobronchial ultrasound40. The effect of major and minor complications after lung surgery on length of stay and readmission41. Measuring cost of adverse events following thoracic surgery: a scoping review42. Laparoscopic paraesophageal hernia repair: characterization by hospital and surgeon volume and impact on outcomes43. NSQIP 5-Factor Modified Frailty Index predicts morbidity but not mortality after esophagectomy44. Trajectory of perioperative HRQOL and association with postoperative complications in thoracic surgery patients45. Variation in treatment patterns and outcomes for resected esophageal cancer at designated thoracic surgery centres46. Patient-reported pretreatment health-related quality of life (HRQOL) predicts short-term survival in esophageal cancer patients47. Analgesic efficacy of surgeon-placed paravertebral catheters compared with thoracic epidural analgesia after Ivor Lewis esophagectomy: a retrospective noninferiority study48. Rapid return to normal oxygenation after lung surgery49. Examination of local and systemic inflammatory changes during lung surgery01. Implications of near-infrared imaging and indocyanine green on anastomotic leaks following colorectal surgery: a systematic review and meta-analysis02. Repeat preoperative endoscopy after regional implementation of electronic synoptic endoscopy reporting: a retrospective comparative study03. Consensus-derived quality indicators for operative reporting in transanal endoscopic surgery (TES)04. Colorectal lesion localization practices at endoscopy to facilitate surgical and endoscopic planning: recommendations from a national consensus Delphi process05. Black race is associated with increased mortality in colon cancer — a population-based and propensity-score matched analysis06. Improved survival in a cohort of patients 75 years and over with FIT-detected colorectal neoplasms07. Laparoscopic versus open loop ileostomy reversal: a systematic review and meta-analysis08. Posterior mesorectal thickness as a predictor of increased operative time in rectal cancer surgery: a retrospective cohort study09. Improvement of colonic anastomotic healing in mice with oral supplementation of oligosaccharides10. How can we better identify patients with rectal bleeding who are at high risk of colorectal cancer?11. Assessment of long-term bowel dysfunction in rectal cancer survivors: a population-based cohort study12. Observational versus antibiotic therapy for acute uncomplicated diverticulitis: a noninferiority meta-analysis based on a Delphi consensus13. Radiotherapy alone versus chemoradiotherapy for stage I anal squamous cell carcinoma: a systematic review and meta-analysis14. Is the Hartmann procedure for diverticulitis obsolete? National trends in colectomy for diverticulitis in the emergency setting from 1993 to 201515. Sugammadex in colorectal surgery: a systematic review and meta-analysis16. Sexuality and rectal cancer treatment: a qualitative study exploring patients’ information needs and expectations on sexual dysfunction after rectal cancer treatment17. Video-based interviews in selection process18. Impact of delaying colonoscopies during the COVID-19 pandemic on colorectal cancer detection and prevention19. Opioid use disorder associated with increased anastomotic leak and major complications after colorectal surgery20. Effectiveness of a rectal cancer education video on patient expectations21. Robotic-assisted rectosigmoid and rectal cancer resection: implementation and early experience at a Canadian tertiary centre22. An online educational app for rectal cancer survivors with low anterior resection syndrome: a pilot study23. The effects of surgeon specialization on the outcome of emergency colorectal surgery24. Outcomes after colorectal cancer resections in octogenarians and older in a regional New Zealand setting — What are the predictors of mortality?25. Long-term outcomes after seton placement for perianal fistulae with and without Crohn disease26. A survey of patient and surgeon preference for early ileostomy closure following restorative proctectomy for rectal cancer — Why aren’t we doing it?27. Crohn disease independently associated with longer hospital admission after surgery28. Short-stay (≤ 1 d) diverting loop ileostomy closure can be selectively implemented without an increase in readmission and complication rates: an ACS-NSQIP analysis29. A comparison of perineal stapled rectal prolapse resection and the Altemeier procedure at 2 Canadian academic hospitals30. Mental health and substance use disorders predict 90-day readmission and postoperative complications following rectal cancer surgery31. Early discharge after colorectal cancer resection: trends and impact on patient outcomes32. Oral antibiotics without mechanical bowel preparation prior to emergency colectomy reduces the risk of organ space surgical site infections: a NSQIP propensity score matched study33. The impact of robotic surgery on a tertiary care colorectal surgery program, an assessment of costs and short-term outcomes — a Canadian perspective34. Should we scope beyond the age limit of guidelines? Adenoma detection rates and outcomes of screening and surveillance colonoscopies in patients aged 75–79 years35. Emergency department admissions for uncomplicated diverticulitis: a nationwide study36. Obesity is associated with a complicated episode of acute diverticulitis: a nationwide study37. Green indocyanine angiography for low anterior resection in patients with rectal cancer: a prospective before-and-after study38. The impact of age on surgical recurrence of fibrostenotic ileocolic Crohn disease39. A qualitative study to explore the optimal timing and approach for the LARS discussion01. Racial, ethnic and socioeconomic disparities in diagnosis, treatment and survival of patients with breast cancer: a SEER-based population analysis02. First-line palliative chemotherapy for esophageal and gastric cancer: practice patterns and outcomes in the general population03. Frailty as a predictor for postoperative outcomes following pancreaticoduodenectomy04. Synoptic electronic operative reports identify practice variation in cancer surgery allowing for directed interventions to decrease variation05. The role of Hedgehog signalling in basal-like breast cancer07. Clinical and patient-reported outcomes in oncoplastic breast conservation surgery from a single surgeon’s practice in a busy community hospital in Canada08. Upgrade rate of atypical ductal hyperplasia: 10 years of experience and predictive factors09. Time to first adjuvant treatment after oncoplastic breast reduction10. Preparing to survive: improving outcomes for young women with breast cancer11. Opioid prescription and consumption in patients undergoing outpatient breast surgery — baseline data for a quality improvement initiative12. Rectal anastomosis and hyperthermic intraperitoneal chemotherapy: Should we avoid diverting loop ileostomy?13. Delays in operative management of early-stage, estrogen-receptor positive breast cancer during the COVID-19 pandemic — a multi-institutional matched historical cohort study14. Opioid prescribing practices in breast oncologic surgery15. Oncoplastic breast reduction (OBR) complications and patient-reported outcomes16. De-escalating breast cancer surgery: Should we apply quality indicators from other jurisdictions in Canada?17. The breast cancer patient experience of telemedicine during COVID-1918. A novel ex vivo human peritoneal model to investigate mechanisms of peritoneal metastasis in gastric adenocarcinoma (GCa)19. Preliminary uptake and outcomes utilizing the BREAST-Q patient-reported outcomes questionnaire in patients following breast cancer surgery20. Routine elastin staining improves detection of venous invasion and enhances prognostication in resected colorectal cancer21. Analysis of exhaled volatile organic compounds: a new frontier in colon cancer screening and surveillance22. A clinical pathway for radical cystectomy leads to a shorter hospital stay and decreases 30-day postoperative complications: a NSQIP analysis23. Fertility preservation in young breast cancer patients: a population-based study24. Investigating factors associated with postmastectomy unplanned emergency department visits: a population-based analysis25. Impact of patient, tumour and treatment factors on psychosocial outcomes after treatment in women with invasive breast cancer26. The relationship between breast and axillary pathologic complete response in women receiving neoadjuvant chemotherapy for breast cancer01. The association between bacterobilia and the risk of postoperative complications following pancreaticoduodenectomy02. Surgical outcome and quality of life following exercise-based prehabilitation for hepatobiliary surgery: a systematic review and meta-analysis03. Does intraoperative frozen section and revision of margins lead to improved survival in patients undergoing resection of perihilar cholangiocarcinoma? A systematic review and meta-analysis04. Prolonged kidney procurement time is associated with worse graft survival after transplantation05. Venous thromboembolism following hepatectomy for colorectal metastases: a population-based retrospective cohort study06. Association between resection approach and transfusion exposure in liver resection for gastrointestinal cancer07. The association between surgeon volume and use of laparoscopic liver resection for gastrointestinal cancer08. Immune suppression through TIGIT in colorectal cancer liver metastases09. “The whole is greater than the sum of its parts” — a combined strategy to reduce postoperative pancreatic fistula after pancreaticoduodenectomy10. Laparoscopic versus open synchronous colorectal and hepatic resection for metastatic colorectal cancer11. Identifying prognostic factors for overall survival in patients with recurrent disease following liver resection for colorectal cancer metastasis12. Modified Blumgart pancreatojejunostomy with external stenting in laparoscopic Whipple reconstruction13. Laparoscopic versus open pancreaticoduodenectomy: a single centre’s initial experience with introduction of a novel surgical approach14. Neoadjuvant chemotherapy versus upfront surgery for borderline resectable pancreatic cancer: a single-centre cohort analysis15. Thermal ablation and telemedicine to reduce resource utilization during the COVID-19 pandemic16. Cost-utility analysis of normothermic machine perfusion compared with static cold storage in liver transplantation in the Canadian setting17. Impact of adjuvant therapy on overall survival in early-stage ampullary cancers: a single-centre retrospective review18. Presence of biliary anaerobes enhances response to neoadjuvant chemotherapy in pancreatic ductal adenocarcinoma19. How does tumour viability influence the predictive capability of the Metroticket model? Comparing predicted-to-observed 5-year survival after liver transplant for hepatocellular carcinoma20. Does caudate resection improve outcomes in patients undergoing curative resection for perihilar cholangiocarcinoma? A systematic review and meta-analysis21. Appraisal of multivariable prognostic models for postoperative liver decompensation following partial hepatectomy: a systematic review22. Predictors of postoperative liver decompensation events following resection in patients with cirrhosis and hepatocellular carcinoma: a population-based study23. Characteristics of bacteriobilia and impact on outcomes after Whipple procedure01. Inverting the y-axis: the future of MIS abdominal wall reconstruction is upside down02. Progressive preoperative pneumoperitoneum: a single-centre retrospective study03. The role of radiologic classification of parastomal hernia as a predictor of the need for surgical hernia repair: a retrospective cohort study04. Comparison of 2 fascial defect closure methods for laparoscopic incisional hernia repair01. Hypoalbuminemia predicts serious complications following elective bariatric surgery02. Laparoscopic adjustable gastric band migration inducing jejunal obstruction associated with acute pancreatitis: aurgical approach of band removal03. Can visceral adipose tissue gene expression determine metabolic outcomes after bariatric surgery?04. Improvement of kidney function in patients with chronic kidney disease and severe obesity after bariatric surgery: a systematic review and meta-analysis05. A prediction model for delayed discharge following gastric bypass surgery06. Experiences and outcomes of Indigenous patients undergoing bariatric surgery: a mixed-methods scoping review07. What is the optimal common channel length in revisional bariatric surgery?08. Laparoscopic management of internal hernia in a 34-week pregnant woman09. Characterizing timing of postoperative complications following elective Roux-en-Y gastric bypass and sleeve gastrectomy10. Canadian trends in bariatric surgery11. Common surgical stapler problems and how to correct them12. Management of choledocholithiasis following Roux-en-Y gastric bypass: a systematic review and meta-analysis. Can J Surg 2021; 64:S80-S159. [PMID: 35483046 PMCID: PMC8677574 DOI: 10.1503/cjs.021321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Esophageal Cooling for Hypoxic Ischemic Encephalopathy: A Feasibility Study. Ther Hypothermia Temp Manag 2020; 11:179-184. [PMID: 33370218 DOI: 10.1089/ther.2020.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Targeted temperature management (TTM) is a recognized treatment to decrease mortality and improve neurological function in hypoxic ischemic encephalopathy. An esophageal cooling device (ECD) has been studied in animal models, but human data are limited. An ECD appears to offer similar benefits to intravascular cooling catheters, with potentially less risk to the patient. We studied whether the ECD could act as a substitute for intravascular cooling catheters in delivering adequate TTM after cardiac arrest. Nine patients admitted to the intensive care unit after cardiac arrest who required TTM were enrolled prospectively. The primary outcome measures were timeliness of insertion, ease of insertion, user Likert ratings, time to achieve a target temperature of 36°C, and time during which target temperature was maintained within 1°C of the 36°C goal for 24 hours by using an ECD. Time to reach target temperature was 0 to 540 minutes (mean: 113.33 minutes, median: 0 minute, standard deviation [SD]: 179.22). Maintenance of a target temperature of 36°C over 24 hours had a range of 58.33% to 100% (mean: 91.67%, median: 95.83%, SD: 13.34). Ease of insertion related to Likert ratings with a range of 1-9 (mean: 5.38, median: 5.5, SD: 3.43) and a simplicity of ECD uses a range of 4-10 (mean: 7.63, median: 8.0, SD: 1.65). Overall, there was preference for the ECD over intravascular cooling methods (mean: 6.71, mean: 6, SD: 3.01) and external cooling methods (mean: 8.0, median: 9.0, SD: 2.33). For patients requiring TTM, use of an ECD adequately allowed for TTM goals to be achieved and maintained. Overall, user evaluation was positive.
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Low-Value Clinical Practices in Adult Traumatic Brain Injury: An Umbrella Review. J Neurotrauma 2020; 37:2605-2615. [PMID: 32791886 DOI: 10.1089/neu.2020.7044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Despite numerous interventions and treatment options, the outcomes of traumatic brain injury (TBI) have improved little over the last 3 decades, which raises concern about the value of care in this patient population. We aimed to synthesize the evidence on 14 potentially low-value clinical practices in TBI care. Using umbrella review methodology, we identified systematic reviews evaluating the effectiveness of 14 potentially low-value practices in adults with acute TBI. We present data on methodological quality (Assessing the Methodological Quality of Systematic Reviews), reported effect sizes, and credibility of evidence (I to IV). The only clinical practice with evidence of benefit was therapeutic hypothermia (credibility of evidence II to IV). However, the most recent meta-analysis on hypothermia based on high-quality trials suggested harm (credibility of evidence IV). Meta-analyses on platelet transfusion for patients on antiplatelet therapy were all consistent with harm but were statistically non-significant. For the following practices, effect estimates were consistently close to the null: computed tomography (CT) in adults with mild TBI who are low-risk on a validated clinical decision rule; repeat CT in adults with mild TBI on anticoagulant therapy with no clinical deterioration; antibiotic prophylaxis for external ventricular drain placement; and decompressive craniectomy for refractory intracranial hypertension. We identified five clinical practices with evidence of lack of benefit or harm. However, evidence could not be considered to be strong for any clinical practice as effect measures were imprecise and heterogeneous, systematic reviews were often of low quality, and most included studies had a high risk of bias.
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Abstract
The practical component of the Advanced Trauma Life Support (ATLS®) course typically includes a TraumaMan® manikin. This manikin is expensive; hence, a low-cost alternative (SurgeMan®) was developed in Brazil. Our primary objective was to compare user satisfaction among Surge-Man, TraumaMan, and porcine models during the course. Our secondary objective was to determine the user satisfaction scores for SurgeMan. This study included 36 ATLS students and nine instructors (4:1 ratio). Tube thoracostomy, cricothyroidotomy, pericardiocentesis, and diagnostic peritoneal lavage were performed on all the three models. The participants then rated their satisfaction both after each activity and after the course. The porcine and TraumaMan models fared better than SurgeMan for all skills except pericardiocentesis. In the absence of ethical or financial constraints, 58 per cent of the students and 66 per cent of the instructors indicated preference for the porcine model. When ethical and financial factors were considered, no preference was evident among the students, whereas 66 per cent of instructors preferred SurgeMan over the others. The students gave all three models an overall adequacy rating of >80 per cent; the instructors gave only the animal models an adequacy rating of <80 per cent. Although the users were more satisfied with TraumaMan than with SurgeMan, both were considered acceptable for the ATLS course.
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Efficacy of a Novel Surgical Manikin for Simulating Emergency Surgical Procedures. Am Surg 2019; 85:1318-1326. [PMID: 31908212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The practical component of the Advanced Trauma Life Support (ATLS®) course typically includes a TraumaMan® manikin. This manikin is expensive; hence, a low-cost alternative (SurgeMan®) was developed in Brazil. Our primary objective was to compare user satisfaction among SurgeMan, TraumaMan, and porcine models during the course. Our secondary objective was to determine the user satisfaction scores for SurgeMan. This study included 36 ATLS students and nine instructors (4:1 ratio). Tube thoracostomy, cricothyroidotomy, pericardiocentesis, and diagnostic peritoneal lavage were performed on all the three models. The participants then rated their satisfaction both after each activity and after the course. The porcine and TraumaMan models fared better than SurgeMan for all skills except pericardiocentesis. In the absence of ethical or financial constraints, 58 per cent of the students and 66 per cent of the instructors indicated preference for the porcine model. When ethical and financial factors were considered, no preference was evident among the students, whereas 66 per cent of instructors preferred SurgeMan over the others. The students gave all three models an overall adequacy rating of >80 per cent; the instructors gave only the animal models an adequacy rating of <80 per cent. Although the users were more satisfied with TraumaMan than with SurgeMan, both were considered acceptable for the ATLS course.
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Abstract
INTRODUCTION Traumatic brain injury (TBI) leads to 50 000 deaths, 85 000 disabilities and costs $60 billion each year in the USA. Despite numerous interventions and treatment options, the outcomes of TBI have improved little over the last three decades. In a previous scoping review and expert consultation survey, we identified 13 potentially low-value clinical practices in acute TBI. The objective of this umbrella review is to synthesise the evidence on potentially low-value clinical practices in the care of acute TBI. METHODS AND ANALYSIS Using umbrella review methodology, we will search Cochrane Central Register of Controlled Trials, Embase, Epistemonikos, International Prospective Register of Systematic Reviews (PROSPERO) and PubMed to identify systematic reviews evaluating the effect of potential intrahospital low-value practices using tailored population, intervention, comparator, outcome and study design questions based on the results of a previous scoping review. We will present data on the methodological quality of these reviews (Assessing the Methodological Quality of Systematic Reviews-2), reported effect sizes and strength of evidence (Grading of Recommendations, Assessment, Development and Evaluation). ETHICS AND DISSEMINATION Ethics approval is not required as original data will not be collected. Knowledge users from five healthcare quality organisations and clinical associations are involved in the design and conduct of the study. Results will be disseminated in a peer-reviewed journal, at international scientific meetings and to clinical, healthcare quality and patient-partner associations. This work will support the development of metrics to measure the use of low-value practices, inform policy makers on potential targets for deimplementation and in the long term reduce the use of low-value clinical practices in acute TBI care. PROSPERO REGISTRATION NUMBER CRD42019132428.
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Low-value clinical practices in injury care: A scoping review and expert consultation survey. J Trauma Acute Care Surg 2019; 86:983-993. [PMID: 31124896 DOI: 10.1097/ta.0000000000002246] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Tests and treatments that are not supported by evidence and could expose patients to unnecessary harm, referred to here as low-value clinical practices, consume up to 30% of health care resources. Choosing Wisely and other organizations have published lists of clinical practices to be avoided. However, few apply to injury and most are based uniquely on expert consensus. We aimed to identify low-value clinical practices in acute injury care. METHODS We conducted a scoping review targeting articles, reviews and guidelines that identified low-value clinical practices specific to injury populations. Thirty-six experts rated clinical practices on a five-point Likert scale from clearly low value to clearly beneficial. Clinical practices reported as low value by at least one level I, II, or III study and considered clearly or potentially low-value by at least 75% of experts were retained as candidates for low-value injury care. RESULTS Of 50,695 citations, 815 studies were included and led to the identification of 150 clinical practices. Of these, 63 were considered candidates for low-value injury care; 33 in the emergency room, 9 in trauma surgery, 15 in the intensive care unit, and 5 in orthopedics. We also identified 87 "gray zone" practices, which did not meet our criteria for low-value care. CONCLUSION We identified 63 low-value clinical practices in acute injury care that are supported by empirical evidence and expert opinion. Conditional on future research, they represent potential targets for guidelines, overuse metrics and de-implementation interventions. We also identified 87 "gray zone" practices, which may be interesting targets for value-based decision-making. Our study represents an important step toward the deimplementation of low-value clinical practices in injury care. LEVEL OF EVIDENCE Systematic Review, Level IV.
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2019 Trauma Association of Canada Annual Scientific Meeting Abstracts. Can J Surg 2019; 62:S3-S35. [PMID: 31091053 DOI: 10.1503/cjs.008619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis. World J Surg 2018; 42:1327-1339. [PMID: 29071424 DOI: 10.1007/s00268-017-4292-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. METHODS We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. RESULTS We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. CONCLUSIONS This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.
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Breast cancer care in Alberta: a Patients perspective. Int J Popul Data Sci 2018. [DOI: 10.23889/ijpds.v3i4.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
IntroductionEach year in Alberta, over 2,300 women are affected by breast cancer. In Alberta, a multi-year Breast Health Initiative is underway to improve breast cancer care; reduce wait times, coordinate care, and enhance patient experience. Patient reported experience measurements are important to inform and advance patient and family-centred care.
Objectives and ApproachThe aim is to assess breast cancer patients’ experiences at two survey points; after surgeon consult and after breast surgery. Patients meeting inclusion criteria; highly suspicious of cancer on imaging result (i.e. BI-RADS 5), referral to Calgary or Edmonton breast program, English speaking, and having an email address are recruited by RN coordinators or nurse navigators. Automated survey invitations from REDCap are used. Seven days after the surgeon consult the first survey is sent and seven days after breast surgery the second survey is sent.
ResultsPatient recruitment began November 27, 2017 and January 2, 2018 for Edmonton and Calgary, respectively. As of February, 2018, 45 patients had been recruited. Of these, the first survey was sent to 34 (i.e. seven days post surgeon consult) and 19 (56%) had completed the survey. All those eligible (18) agreed to participate in the upcoming second survey. Of those, six had provided their surgery date and the second survey which both were completed. Recruitment is ongoing until the conference, at that time there will be sufficient numbers to report findings.
Conclusion/ImplicationsPatient and family-centred care is an element of high-quality healthcare which AHS has identified as a priority. These results will report on the breast cancer patients’ perspectives and generate important information for clinicians and administrators to use for decision making and quality improvement of health services.
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Abstract
BACKGROUND Acute care injury outcomes vary substantially across Canadian provinces and trauma centres. Our aim was to develop Canadian benchmarks to monitor mortality and hospital length of stay (LOS) for injury admissions. METHODS Benchmarks were derived using data from the Canadian National Trauma Registry on patients with major trauma admitted to any level I or II trauma centre in Canada and from the following patient subgroups: isolated traumatic brain injury (TBI), isolated thoracoabdominal injury, multisystem blunt injury, age 65 years or older. We assessed predictive validity using measures of discrimination and calibration, and performed sensitivity analyses to assess the impact of replacing analytically complex methods (multiple imputation, shrinkage estimates and flexible modelling) with simple models that can be implemented locally. RESULTS The mortality risk adjustment model had excellent discrimination and calibration (area under the receiver operating characteristic curve 0.886, Hosmer-Lemeshow 36). The LOS risk-adjustment model predicted 29% of the variation in LOS. Overall, observed:expected ratios of mortality and mean LOS generated by an analytically simple model correlated strongly with those generated by analytically complex models (r > 0.95, κ on outliers > 0.90). CONCLUSION We propose Canadian benchmarks that can be used to monitor quality of care in Canadian trauma centres using Excel (see the appendices, available at canjsurg.ca). The program can be implemented using local trauma registries, providing that at least 100 patients are available for analysis.
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Short form version of the Quality of Trauma Care Patient-Reported Experience Measure (SF QTAC-PREM). BMC Res Notes 2017; 10:693. [PMID: 29208046 PMCID: PMC5718023 DOI: 10.1186/s13104-017-3031-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/29/2017] [Indexed: 12/15/2022] Open
Abstract
Objective To enable the valid and reliable measurement of patient experiences we previously published a multicenter multi-center validation of the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM). The purpose of this study was to derive a simplified, short form version of the QTAC-PREM to further enhance the feasibility of measuring patient experiences in injury care. To identify candidate items for the short form we reviewed the results of the original multi-center long form validation cohort study, which included 400 injury care patients and their family members recruited from three trauma centers. We only included the best performing items on the revised short form. Results The acute care component of the measure was shortened by 30% and the post-acute care component was shortened by 42%. We identified two subscales on the acute measure (information and communication; clinical and ancillary care) and one subscale on the post-acute measure (post-discharge information and communication). The measurement properties of the short form measure were similar to that of the validated long form. This short form assessment of patient injury care experiences offers a useful, practical, and easy tool for trauma centers to implement for service evaluation, quality improvement, and injury care research. Electronic supplementary material The online version of this article (10.1186/s13104-017-3031-9) contains supplementary material, which is available to authorized users.
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Abstract
Importance In response to the burden of injury, the structure of injury care has changed considerably across Canada in the past decade. However, little is known about how patient outcomes have evolved. Objective To evaluate trends in mortality, hospital length of stay, and unplanned readmission in Canadian trauma systems between 2006 and 2012. Design, Setting, and Participants A pan-Canadian retrospective cohort study was conducted among adults admitted for major injury to a Canadian level I or II trauma center between April 1, 2006, and March 31, 2012. Data analysis was conducted from April 15 to December 3, 2015. Exposures Trauma centers and systems. Main Outcomes and Measures Multilevel generalized linear models were used to evaluate trends in the risk-adjusted incidence of mortality and readmission and risk-adjusted mean length of stay. Trend analyses were conducted globally and by province. Results Among 78 807 patients (mean [SD] age, 50.7 [22.0] years; 22 540 women and 56 267 men) admitted for major injury during the study period, risk-adjusted mortality decreased from 12.1% (95% CI, 9%-16.1%) to 9.9% (95% CI, 7.4%-13.3%; P < .001) and mean length of hospital stay decreased from 11.6 (95% CI, 9.9-13.6) to 10.6 (95% CI, 9.1-12.5) days (P < .001). Statistically significant reductions in mortality were observed for Ontario (12% [95% CI, 10.7%-13.6%] to 8% [95% CI, 6.9%-9.2%]; P < .001), Alberta (12% [95% CI, 10%-14.3%] to 9.1% [95% CI, 7.7%-10.8%]; P = .02), and Manitoba (13% [95% CI, 9.1%-18.4%] to 11.1% [95% CI, 8.3%-14.7%]; P = .04). Risk-adjusted hospital stay decreased significantly in Québec (11.6 [95% CI, 11.1-12] to 9.1 [95% CI, 8.9-9.5] days; P < .001), British Columbia (12.5 [95% CI, 12-13.1] to 11.4 [10.9-11.9] days; P < .001), and Ontario (10.1 [95% CI, 9.8-10.4] to 9.8 [95% CI, 9.5-10.1] days; P < .001). No change in the incidence of readmission was observed. Conclusions and Relevance We observed an 18.2% relative decrease in risk-adjusted mortality in Canadian trauma centers during the study period, representing 248 additional lives saved in 2012 vs 2006. Risk-adjusted mean hospital stay decreased by 8.6%, representing nearly 10 000 hospital days saved. A better understanding of the structures and processes behind observed improvements is needed to further reduce the burden of injury in Canada.
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Derivation and Validation of a Quality Indicator to Benchmark In-Hospital Complications Among Injury Admissions. JAMA Surg 2017; 151:622-30. [PMID: 26842660 DOI: 10.1001/jamasurg.2015.5484] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The rate of complications among injury admissions has been estimated to be more than 3 times that observed for general admissions, and complications have been targeted as an important quality-of-care metric. Despite the negative effect of complications on resource use and patient mortality and morbidity, there is no standardized method to benchmark trauma centers in terms of in-hospital complications, to our knowledge. OBJECTIVES To develop a quality indicator (QI) for in-hospital complications that can be used to evaluate the quality of acute injury care and to assess its validity. DESIGN, SETTING, AND PARTICIPANTS Multicenter retrospective cohort study. The setting was a well-established inclusive trauma system in Canada. Participants included all 66 048 moderate or major injury admissions to an adult trauma center between April 1, 2006, and March 31, 2012. The dates of the analysis were January to April 2015. MAIN OUTCOMES AND MEASURES The primary outcome was the occurrence of at least 1 in-hospital complication. We selected risk-adjustment variables by expert consultation and bootstrap resampling. We evaluated internal validity using measures of discrimination, construct validity, and forecasting. RESULTS The study cohort comprised 66 048 patients. Their mean (SD) age was 59 (22) years, and 48.0% were female. Fifteen percent of patients had at least 1 in-hospital complication. The risk-adjustment model has excellent discrimination (area under the curve, 0.81) and calibration. The QI was correlated with the risk-adjusted incidence of mortality (r = 0.71), unplanned readmission (r = 0.43), and mean length of stay (r = 0.68). Hospital performance on the QI from 2007 to 2009 was predictive of performance from 2010 to 2012 (r = 0.82). CONCLUSIONS AND RELEVANCE We developed a QI to benchmark trauma centers on in-hospital complications among injury admissions. The QI is based on data that are routinely collected in most trauma systems and demonstrates good internal validity. The integration of this QI in trauma quality improvement programs will facilitate the identification of quality problems, the implementation of solutions, and the evaluation of their effectiveness. Therefore, the QI has the potential to lead to reductions in mortality, morbidity, and resource use after injury.
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Abstract
BACKGROUND Injury represents one of the greatest public health challenges of our time with over 5 million deaths and 100 million people temporarily or permanently disabled every year worldwide. The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, the organisation of trauma care varies significantly across trauma systems and we know little about which components of trauma systems contribute to their effectiveness. The objective of the study described in this protocol is to systematically review evidence of the impact of trauma system components on clinically significant outcomes including mortality, function and disability, quality of life, and resource utilization. METHODS We will perform a systematic review of studies evaluating the association between at least one trauma system component (e.g. accreditation by a central agency, interfacility transfer agreements) and at least one injury outcome (e.g. mortality, disability, resource use). We will search MEDLINE, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, thesis holdings, key injury organisation websites and conference proceedings for eligible studies. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles. Methodological quality will be evaluated using elements of the ROBINS-I tool and the Cochrane risk of bias tool for non-randomized and randomized studies, respectively. Strength of evidence will be evaluated using the GRADE tool. DISCUSSION We expect to advance knowledge on the components of trauma systems that contribute to their effectiveness. This may lead to recommendations on trauma system structure that will help policy-makers make informed decisions as to where resources should be focused. The review may also lead to specific recommendations for future research efforts. SYSTEMATIC REVIEW REGISTRATION This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 28-06-2016. PROSPERO 2016:CRD42016041336 Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016041336 .
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Trauma Association of Canada Annual Scientific Meeting, Westin Calgary Calgary, Alberta, Apr. 10–11, 2015Outcomes and opportunities for improvement in self-inflicted blunt and penetrating traumaAbdominal compartment syndrome in the childActive negative pressure peritoneal therapy after abbreviated laparotomy: The intraperitoneal vacuum randomized controlled trialUse of a novel combined RFA/saline energy instrument for arresting ongoing hemorrhage from solid organ injuriesHealth care costs of burn patients from homes without fire sprinklersPenetrating trauma in eastern Ontario: a descriptive analysisThresholds of rotational thrombelastometry (ROTEM) used for the diagnosis and management of bleeding trauma patients: a systematic reviewA quality indicator to measure hospital complications for injury admissionsThromboelastography (TEG) in the management of trauma: implications for the developing worldPotential role of the rural trauma team development course (RTTDC) in the United Arab Emirates (UAE)Applicability of the advanced disaster medical response (ADMR) course, Trinidad and TobagoInflammatory mediators in intra-abdominal sepsis or injury: a scoping reviewEvaluation of the online Concussion Awareness Training Toolkit (CATT) for parents, players and coachesUltrasound assessment of optic nerve sheath diameter (ONSD) in healthy volunteersThe benefits of epidural analgesia in flail chest injuriesMandatory reporting rates of injured alcohol-impaired drivers with suspected alcohol dependence in a level 1 Canadian trauma centre: a single institution’s experienceSimulation implementation in a new pediatric residency program in Haiti: trauma specificsManagement of skull fractures in children younger than 1 year of ageResource use in patients who have sustained a traumatic brain injury within an integrated Canadian trauma system: a multicentre cohort studyResource use intensity in a mature, integrated Canadian trauma system: a multicentre cohort studyRates and determinants of unplanned emergency department visits and readmissions within 30 days following discharge from the trauma service — the Ottawa Hospital experienceAlcohol — screening, brief intervention and referral to treatment (SBIRT): Is it readily available in Canadian trauma centres?Management of traumatic occult hemothorax: a survey among trauma providers in CanadaAn audit of venous thromboembolism prophylaxis: a quality assurance project at our level 1 trauma centreCatecholamines as outcome markers in traumatic brain injuryAre we missing the missed injury? The burden of traumatic missed injuries diagnosed after hospital dischargeThe use of fibrinogen concentrate in trauma: a descriptive systematic reviewVery early initiation of chemical venous thromboembolism prophylaxis after solid organ injury is safe: a call for a national prospective multicentre studyThe 2 student to 1 faculty (2:1) model of teaching the Advanced Trauma Operative Management (ATOM) courseTrauma transfusion in the elderlyCocaine and benzodiazepines are more predictive of an injury severity score greater than 15 compared to alcohol or tetrahydrocannabinol in trauma patients under 18 years oldAre we missing traumatic bowel and mesenteric injuries?The marriage of surgical simulation and telementoring for damage control surgical training of operational first-respondersAdding remote ultrasound control to remote just-in-time telementored trauma ultrasound: a pilot studyDescriptive analysis of morbidity and mortality associated with falls at a level 1trauma centreDevelopment of an ICU transition questionnaire: evaluating the transfer process from ICU, ward, and patient/family stakeholder perspectivesUse of IO devices in trauma: A survey of trauma practitioners in Canada, Australia and New ZealandTime to reversal of medication-induced coagulopathy in traumatic intracranial hemorrhageMeta-analysis of randomized control trials of hospital based violence interventions on repeat intentional injuryBlunt injury of a horseshoe kidney, case report and review of the literatureLegal consequences for alcohol-impaired drivers involved in motor vehicle collisions: a systematic reviewA characterization of major adult sport-related trauma in Nova Scotia, 2000–2013Is hockey the most dangerous pediatric sport? An evaluation of pediatric sport-related injuries treated in Nova ScotiaInterim results of a pilot randomized control trial of an ED-based violence intervention programPre-intubation resuscitation by Canadian physicians: results of a national surveyFirst-responder accuracy using SALT during mass-casualty incident simulationEmergent endotracheal intubation: medications and device choices by Canadian resuscitation physicians“Oh the weather outside is frightful”: Severe injury secondary to falls while installing residential Christmas lightsCan we speak the same language? Understanding Quebec’s inclusive trauma systemAn unusual segmental clavicle fracture treated with titanium elastic nailImpact of the age of stored blood on trauma patient mortality: a systematic reviewInterhospital transfer of traumatic brain injury: utilization of helicopter transportCheerleading injuries: a Canadian perspectivePre-hospital mode of transport in a rural trauma system: air versus groundAnalysis of 15 000 patient transfers to level 1 trauma centre: Injury severity does not matter — just drive, drive, drive!The effects of legislation on morbidity and mortality associated with all-terrain vehicle and motorcycle crashes in Puerto RicoAssessing how pediatric trauma patients are supported nutritionally at McMaster Children’s HospitalOutcomes of conservative versus operative management of stable penetrating abdominal traumaS.T.A.R.T.T. — Evolution of a true multidisciplinary trauma crisis resource management simulation courseDevelopment of criteria to identify traumatic brain injury patients NOT requiring intensive care unit monitoringAssigning costs to visits for injuries due to youth violence — the first step in a cost-effectiveness analysisThere’s no TRIK to it — development of the Trauma Resuscitation in Kids courseResilient despite childhood trauma experiencesA five-year, single-centre review of toxic epidermal necrolysis managementAll in the family: creating and implementing an inclusive provincial trauma registryLessons learned from a provincial trauma transfer systemThe NB Trauma Program: 5 years laterProvincial coordination of injury prevention: the New Brunswick (NB) experienceImproving access and uptake of trauma nursing core course (TNCC): a provincial approachULTRASIM: ultrasound in trauma simultation. Does the use of ultrasound during simulated trauma scenarios improve diagnostic abilities?Traumatic tale of 2 cities, part 1: Does being treated by different EMS affect outcomes in trauma patients destined for transport to level 1 trauma centres in Halifax and Saint John?Traumatic tale of 2 cities, part 2: Does being treated by different hospitals affect outcome in trauma patients destined for transport to Level 1trauma centres in Halifax and Saint John?Protective devices use in road traffic injuries in a developing countryFunctional and anatomical connectivity and communication impairments in moderate to severe traumatic brain injuryCaring and communicating in critical cases: Westlock trauma form, a resource for rural physiciansMonitoring of ocular nerve sheath in traumatic raised intracranial pressure (Moonstrip Study): a prospective blinded observational trialEstablishing an alcohol screening and brief intervention for trauma patients in a multicultural setting in the Middle East: challenges and opportunitiesThe poor compliance to seat belt use in Montréal: an 18 461 road user iPhone-based studyAn iPad-based data acquisition for core trauma registry data in 6 Tanzanian hospitals: 1 year and 13 462 patients later“The Triple-Q Algorithm”: a practical approach to the identification of liver topographyA pan-Canadian bicycle helmet use observational studyDoor to decompression: the new benchmark in trauma craniotomiesAre missed doses of pharmacological thromboprophylaxis a risk factor for thromboembolic complications?Complications following admission for traumatic brain injuryExcessive crystalloid infusion in the first 24 hours is not associated with increased complications or mortalitySBIRT: plant, tend, growReal time electronic injury surveillance in an African trauma centreSBIRT in concert: establishing a new initiativeReview of the current knowledge of the pathophysiology of acute traumatic coagulopathy: implications for current trauma resuscitation practicesFactors associated with primary fascial closure rates in patients undergoing damage control laparotomyFree intraperitoneal fluid on CT abdomen in blunt trauma: Is hospital admission necessary?The need for speed — the time cost of off-site helipadsEndovascular management of penetrating Zone III retroperitoneal injuries in selective patients: a case reportMeasured resting energy expenditure in patients with open abdomens: preliminary data of a prospective pilot studyTraumatic inferior gluteal artery pseudoaneurysm: case report and review of literaturePancreatico duodenectomy, SMA, SMV repair and delayed reconstruction following blunt abdominal trauma. A case report with discussion of trauma whipple and complex pancreatico duodenal injuriesA retrospective evaluation of the effect of the Trauma Team Training program in TanzaniaDoes procalcitonin measurement predict clinical outcomes in critically ill/injured adults managed with the open abdomen technique?In trauma, conventional ROTEM and TEG results are not interchangeable but are similar in clinical applicabilitySevere trauma in the province of New Brunswick: a descriptive epidemiological studyPartnering for success — a road safety strategy for London and regionEvaluation of a patient safety initiative of rapid removal of backboards in the emergency departmentActive negative pressure peritoneal therapy and C-reactive protein levels after abbreviated laparotomy for abdominal trauma or intra-abdominal sepsisA comparison of outcomes: Direct admissions vs. interhospital transfers April 2009–March 2014YEE HA or YEE OUCH! A 5-year review of large animal-related incidentsEarly goal-directed therapy for prevention of hypothermia-related transfusion, morbidity and mortality in severely injured trauma patientsImproving care of adolescent trauma patients admitted to adult trauma centres by fostering collaboration between adult and pediatric partnersExpediting operational damage control laparotomy closure: iTClam v. suturing during damage control surgical simulation trainingAre conventional coagulation tests inadequate in the assessment of acute traumatic coagulopathy?Predictors of long-term outcomes in patients admitted to emergency general surgery services: a systematic review of literatureUse of the iTClamp versus standard suturing techniques for securing chest tubes: A randomized cadaver studyiTClamp application for control of simulated massive upper extremity arterial hemorrhage by tactical policeAssessing performance in the trauma roomThe deadly need for methadone/opiate educationTrends in the management of major abdominal vascular injuries: 2000–2014Addressing high school seniors’ risky behaviours through a hospital-based and peer teaching outreach programScreening for risk of post-traumatic stress disorder after injury in acutely injured children: a systematic reviewThe impact of trauma centre designation levels on surgical delay, mortality and complications: a multicentre cohort studyHow many acutely injured children report subsequent stress symptoms?The frequency of coagulopathy and its significance in an emergency neurotrauma facilityPsychosocial care for injured children: The views of 2500 emergency department physicians and nurses from around the worldDevelopment of the Trauma Electronic Document (TED)Development of trauma team activation criteria for an urban trauma centreBrains and brawn: evaluation of a sports skills and concussion awareness campRegional trauma networks: a tale of 2 pilotsContinuous data quality improvement in a provincial trauma registryDoes the Rural Trauma Team Development Course shorten transfer time?Epidemiology of trauma in Puerto RicoCT scans facilitate early discharge of trauma patientsFeasibility of data collection in a conflict zone to assess the impact on emergency health care deliveryConsent for Emergency Research (CONfER): a national survey of Canadian research ethics board practicesMaking handover safer for our trauma patients through the lens of trauma team leadersChallenges and opportunities to improve trauma transitions of care from emergency to intensive care nursingPhysical disorder following major injury: a population-based studyToward an inclusive trauma system: regional trauma system development in OntarioTraumatic brain injury in British Columbia: current incidence, injury patterns and risk factorsAcute cytokine and chemokine profiles in brain-injured patients: relationship to sympathetic activation and outcomeMultidisciplinary trauma simulation training in a tertiary care centreNon-operative management of blunt splenic injuries: routine radiologic follow-up may reduce the time of activity restrictionModified triple layer peritoneal-aponeurotic transposition: a new strategy to close the open abdomenMesenchymal stem cells locate and differentiate to the trauma site in a blunt rat liver trauma model: preliminary resultsThree indications for the “open abdomen”, anatomical, logistical and physiological: How are they different?Development of an urban trauma centre using lean methodologyThe impact of standardized care in 191 patients with chest tube thoracostomyComplex abdominal wall reconstruction: recommendations from the Canadian Abdominal Wall Reconstruction GroupCompensatory behaviours and cognitions in persons with history of traumaDevelopment of the Kenyatta National Hospital — University of Alberta Orthopedic Trauma Assessment Tool: phase 1 resultsRisk-taking behaviour negatively affects outcome in burn patients. Can J Surg 2015. [DOI: 10.1503/cjs.003415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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The use of cognitive interviews to revise the Quality of Trauma Care Patient-Reported Experience Measure (QTAC-PREM). Qual Life Res 2015; 24:1911-9. [PMID: 25589232 DOI: 10.1007/s11136-015-0919-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE The "Quality of Trauma Care Patient-Reported Experience Measure" is the first measure of patient experiences with overall injury care. The objective of this study was to use cognitive interviews to inform revision of the measure into a parsimonious set of items that function as intended, in preparation for multicenter testing. METHODS Concurrent and retrospective cognitive interviews with injured patients (n = 17) and family members (n = 13) using semi-structured interview guides. Responses were analyzed using thematic analysis. RESULTS Six broad themes were identified and guided revisions: (1) participants did not have the information to answer items (n = 9); (2) items were ambiguous or were inconsistently interpreted (n = 13); (3) items did not measure the intended constructs (n = 6); (4) items included assumptions about healthcare processes (n = 4); (5) items measured non-priority aspects of injury care (n = 8); and (6) items were redundant (n = 5). Two issues resulted in key conceptual and content changes: participants' difficulty to evaluate pre-hospital, emergency department, and intensive care unit services due to recall issues and the challenge to evaluate the effectiveness and equity of care. In total, 39 items were deleted, 28 new items developed, and the final instrument included 63 items. CONCLUSIONS Our results informed changes to item content, format, and response options. This study highlights key issues to consider when incorporating patient/family perspectives into quality measurement, most notably, that few participants can assess the quality of care in the pre-hospital and emergency department phases of care and that novel methods are needed to evaluate the effectiveness and equity of care.
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The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: the RAPTOR (Resuscitation with Angiography Percutaneous Treatments and Operative Resuscitations). Injury 2014; 45:1413-21. [PMID: 24560091 DOI: 10.1016/j.injury.2014.01.021] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 12/25/2013] [Accepted: 01/18/2014] [Indexed: 02/02/2023]
Abstract
Traumatic injury is the leading cause of potentially preventable lost years of life in the Western world and exsanguination is the most potentially preventable cause of post-traumatic death. With mature trauma systems and experienced trauma centres, extra-abdominal sites, such as the pelvis, constitute the most frequent anatomic site of exsanguination. Haemorrhage control for such bleeding often requires surgical adjuncts most notably interventional radiology (IR). With the usual paradigm of surgery conducted within an operating room and IR procedures within distant angiography suites, responsible clinicians are faced with making difficult decisions regarding where to transport the most physiologically unstable patients for haemorrhage control. If such a critical patient is transported to the wrong suite, they may die unnecessarily despite having potentially salvageable injuries. Thus, it seems only logical that the resuscitative operating room of the future would have IR capabilities making it the obvious geographic destination for critically unstable patients, especially those who are exsanguinating. Our trauma programme recently had the opportunity to conceive, design, build, and operationalise a purpose-designed hybrid trauma operating room, designated as the resuscitation with angiographic percutaneous techniques and operative resuscitation (RAPTOR) suite, which we believe to be the first such resource designed primarily to serve the exsanguinating trauma patient. The project was initiated after consultations between the trauma programme and private philanthropists regarding the greatest potential impacts on regional trauma care. The initial capital construction costs were thus privately generated but coincided with a new hospital wing construction allowing the RAPTOR to be purpose-designed for the exsanguinating patient. Many trauma programmes around the world are now starting to navigate the complex process of building new facilities, or else retrofitting existing ones, to address the need for single-site flexible haemorrhage control. This manuscript therefore describes the many considerations in the design and refinement of the physical build, equipment selection, human factors evaluation of new combined treatment paradigms, and the final introduction of a RAPTOR protocol in order that others may learn from our initial efforts.
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The Advanced Trauma Operative Management course—a two student to one faculty model. J Surg Res 2013; 184:551-5. [DOI: 10.1016/j.jss.2013.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 02/28/2013] [Accepted: 03/07/2013] [Indexed: 11/28/2022]
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Trauma Association of Canada (TAC) Annual Scientific Meeting. The Westin Whistler Resort & Spa, Whistler, BC, Thursday, Apr. 11 to Saturday, Apr. 13, 2013Testing the reliability of tools for pediatric trauma teamwork evaluation in a North American high-resource simulation settingThe association of etomidate with mortality in trauma patientsDefinition of isolated hip fractures as an exclusion criterion in trauma centre performance evaluations: a systematic reviewEstimation of acute care hospitalization costs for trauma hospital performance evaluation: a systematic reviewHospital length of stay following admission for traumatic injury in Canada: a multicentre cohort studyPredictors of hospital length of stay following traumatic injury: a multicentre cohort studyInfluence of the heterogeneity in definitions of an isolated hip fracture used as an exclusion criterion in trauma centre performance evaluations: a multicentre cohort studyPediatric trauma, advocacy skills and medical studentsCompliance with the prescribed packed red blood cell, fresh frozen plasma and platelet ratio for the trauma transfusion pathway at a level 1 trauma centreEarly fixed-wing aircraft activation for major trauma in remote areasDevelopment of a national, multi-disciplinary trauma crisis resource management curriculum: results from the pilot courseThe management of blunt hepatic trauma in the age of angioembolization: a single centre experienceEarly predictors of in-hospital mortality in adult trauma patientsThe impact of open tibial fracture on health service utilization in the year preceding and following injuryA systematic review and meta-analysis of the efficacy of red blood cell transfusion in the trauma populationSources of support for paramedics managing work-related stress in a Canadian EMS service responding to multisystem trauma patientsAnalysis of prehospital treatment of pain in the multisystem trauma patient at a community level 2 trauma centreIncreased mortality associated with placement of central lines during trauma resuscitationChronic pain after serious injury — identifying high risk patientsEpidemiology of in-hospital trauma deaths in a Brazilian university teaching hospitalIncreased suicidality following major trauma: a population-based studyDevelopment of a population-wide record linkage system to support trauma researchInduction of hmgb1 by increased gut permeability mediates acute lung injury in a hemorrhagic shock and resuscitation mouse modelPatients who sustain gunshot pelvic fractures are at increased risk for deep abscess formation: aggravated by rectal injuryAre we transfusing more with conservative management of isolated blunt splenic injury? A retrospective studyMotorcycle clothesline injury prevention: Experimental test of a protective deviceA prospective analysis of compliance with a massive transfusion protocol - activation alone is not enoughAn evaluation of diagnostic modalities in penetrating injuries to the cardiac box: Is there a role for routine echocardiography in the setting of negative pericardial FAST?Achievement of pediatric national quality indicators — an institutional report cardProcess mapping trauma care in 2 regional health authorities in British Columbia: a tool to assist trauma sys tem design and evaluationPatient safety checklist for emergency intubation: a systematic reviewA standardized flow sheet improves pediatric trauma documentationMassive transfusion in pediatric trauma: a 5-year retrospective reviewIs more better: Does a more intensive physiotherapy program result in accelerated recovery for trauma patients?Trauma care: not just for surgeons. Initial impact of implementing a dedicated multidisciplinary trauma team on severely injured patientsThe role of postmortem autopsy in modern trauma care: Do we still need them?Prototype cervical spine traction device for reduction stabilization and transport of nondistraction type cervical spine injuriesGoing beyond organ preservation: a 12-year review of the beneficial effects of a nonoperative management algorithm for splenic traumaAssessing the construct validity of a global disability measure in adult trauma registry patientsThe mactrauma TTL assessment tool: developing a novel tool for assessing performance of trauma traineesA quality improvement approach to developing a standardized reporting format of ct findings in blunt splenic injuriesOutcomes in geriatric trauma: what really mattersFresh whole blood is not better than component therapy (FFP:RBC) in hemorrhagic shock: a thromboelastometric study in a small animal modelFactors affecting mortality of chest trauma patients: a prospective studyLong-term pain prevalence and health related quality of life outcomes for patients enrolled in a ketamine versus morphine for prehospital traumatic pain randomized controlled trialDescribing pain following trauma: predictors of persistent pain and pain prevalenceManagement strategies for hemorrhage due to pelvic trauma: a survey of Canadian general surgeonsMajor trauma follow-up clinic: Patient perception of recovery following severe traumaLost opportunities to enhance trauma practice: culture of interprofessional education and sharing among emergency staffPrehospital airway management in major trauma and traumatic brain injury by critical care paramedicsImproving patient selection for angiography and identifying risk of rebleeding after angioembolization in the nonoperative management of high grade splenic injuriesFactors predicting the need for angioembolization in solid organ injuryProthrombin complex concentrates use in traumatic brain injury patients on oral anticoagulants is effective despite underutilizationThe right treatment at the right time in the right place: early results and associations from the introduction of an all-inclusive provincial trauma care systemA multicentre study of patient experiences with acute and postacute injury carePopulation burden of major trauma: Has introduction of an organized trauma system made a difference?Long-term functional and return to work outcomes following blunt major trauma in Victoria, AustraliaSurgical dilemma in major burns victim: heterotopic ossification of the tempromandibular jointWhich radiological modality to choose in a unique penetrating neck injury: a differing opinionThe Advanced Trauma Life Support (ATLS) program in CanadaThe Rural Trauma Team Development Course (RTTDC) in Pakistan: Is there a role?Novel deployment of BC mobile medical unit for coverage of BMX world cup sporting eventIncidence and prevalence of intra-abdominal hypertension and abdominal compartment syndrome in critically ill adults: a systematic review and meta-analysisRisk factors for intra-abdominal hypertension and abdominal compartment syndrome in critically ill or injured adults: a systematic review and meta-analysisA comparison of quality improvement practices at adult and pediatric trauma centresInternational trauma centre survey to evaluate content validity, usability and feasibility of quality indicatorsLong-term functional recovery following decompressive craniectomy for severe traumatic brain injuryMorbidity and mortality associated with free falls from a height among teenage patients: a 5-year review from a level 1 trauma centreA comparison of adverse events between trauma patients and general surgery patients in a level 1 trauma centreProcoagulation, anticoagulation and fibrinolysis in severely bleeding trauma patients: a laboratorial characterization of the early trauma coagulopathyThe use of mobile technology to facilitate surveillance and improve injury outcome in sport and physical activityIntegrated knowledge translation for injury quality improvement: a partnership between researchers and knowledge usersThe impact of a prevention project in trauma with young and their learningIntraosseus vascular access in adult trauma patients: a systematic reviewThematic analysis of patient reported experiences with acute and post-acute injury careAn evaluation of a world health organization trauma care checklist quality improvement pilot programProspective validation of the modified pediatric trauma triage toolThe 16-year evolution of a Canadian level 1 trauma centre: growing up, growing out, and the impact of a booming economyA 20-year review of trauma related literature: What have we done and where are we going?Management of traumatic flail chest: a systematic review of the literatureOperative versus nonoperative management of flail chestEmergency department performance of a clinically indicated and technically successful emergency department thoracotomy and pericardiotomy with minimal equipment in a New Zealand institution without specialized surgical backupBritish Columbia’s mobile medical unit — an emergency health care support resourceRoutine versus ad hoc screening for acute stress: Who would benefit and what are the opportunities for trauma care?A geographical analysis of the Early Development Instrument (EDI) and childhood injuryDevelopment of a pediatric spinal cord injury nursing course“Kids die in driveways” — an injury prevention campaignEpidemiology of traumatic spine injuries in childrenA collaborative approach to reducing injuries in New Brunswick: acute care and injury preventionImpact of changes to a provincial field trauma triage tool in New BrunswickEnsuring quality of field trauma triage in New BrunswickBenefits of a provincial trauma transfer referral system: beyond the numbersThe field trauma triage landscape in New BrunswickImpact of the Rural Trauma Team Development Course (RTTDC) on trauma transfer intervals in a provincial, inclusive trauma systemTrauma and stress: a critical dynamics study of burnout in trauma centre healthcare professionalsUltrasound-guided pediatric forearm fracture reduction with sedation in the emergency departmentBlock first, opiates later? The use of the fascia iliaca block for patients with hip fractures in the emergency department: a systematic reviewRural trauma systems — demographic and survival analysis of remote traumas transferred from northern QuebecSimulation in trauma ultrasound trainingIncidence of clinically significant intra-abdominal injuries in stable blunt trauma patientsWake up: head injury management around the clockDamage control laparotomy for combat casualties in forward surgical facilitiesDetection of soft tissue foreign bodies by nurse practitioner performed ultrasoundAntihypertensive medications and walking devices are associated with falls from standingThe transfer process: perspectives of transferring physiciansDevelopment of a rodent model for the study of abdominal compartment syndromeClinical efficacy of routine repeat head computed tomography in pediatric traumatic brain injuryEarly warning scores (EWS) in trauma: assessing the “effectiveness” of interventions by a rural ground transport service in the interior of British ColumbiaAccuracy of trauma patient transfer documentation in BCPostoperative echocardiogram after penetrating cardiac injuries: a retrospective studyLoss to follow-up in trauma studies comparing operative methods: a systematic reviewWhat matters where and to whom: a survey of experts on the Canadian pediatric trauma systemA quality initiative to enhance pain management for trauma patients: baseline attitudes of practitionersComparison of rotational thromboelastometry (ROTEM) values in massive and nonmassive transfusion patientsMild traumatic brain injury defined by GCS: Is it really mild?The CMAC videolaryngosocpe is superior to the glidescope for the intubation of trauma patients: a prospective analysisInjury patterns and outcome of urban versus suburban major traumaA cost-effective, readily accessible technique for progressive abdominal closureEvolution and impact of the use of pan-CT scan in a tertiary urban trauma centre: a 4-year auditAdditional and repeated CT scan in interfacilities trauma transfers: room for standardizationPediatric trauma in situ simulation facilitates identification and resolution of system issuesHospital code orange plan: there’s an app for thatDiaphragmatic rupture from blunt trauma: an NTDB studyEarly closure of open abdomen using component separation techniqueSurgical fixation versus nonoperative management of flail chest: a meta-analysisIntegration of intraoperative angiography as part of damage control surgery in major traumaMass casualty preparedness of regional trauma systems: recommendations for an evaluative frameworkDiagnostic peritoneal aspirate: An obsolete diagnostic modality?Blunt hollow viscus injury: the frequency and consequences of delayed diagnosis in the era of selective nonoperative managementEnding “double jeopardy:” the diagnostic impact of cardiac ultrasound and chest radiography on operative sequencing in penetrating thoracoabdominal traumaAre trauma patients with hyperfibrinolysis diagnosed by rotem salvageable?The risk of cardiac injury after penetrating thoracic trauma: Which is the better predictor, hemodynamic status or pericardial window?The online Concussion Awareness Training Toolkit for health practitioners (CATT): a new resource for recognizing, treating, and managing concussionThe prevention of concussion and brain injury in child and youth team sportsRandomized controlled trial of an early rehabilitation intervention to improve return to work Rates following road traumaPhone call follow-upPericardiocentesis in trauma: a systematic review. Can J Surg 2013. [DOI: 10.1503/cjs.005813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Effectiveness of A 2:1-Student to Faculty Model for Teaching the Advanced Trauma Operative Management (ATOM) Course. J Surg Res 2013. [DOI: 10.1016/j.jss.2012.10.878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Trauma Association of Canada Annual Scientific Meeting abstractsErythroopoietin resuscitated with normal saline, Ringer’s lactate and 7.5% hypertonic saline reduces small intestine injury in a hemorrhagic shock and resuscitation rat model.Analgesia in the management of pediatric trauma in the resuscitative phase: the role of the trauma centre.Multidisciplinary trauma team care in Kandahar, Afghanistan: current injury patterns and care practices.Does computed tomography for penetrating renal injury reduce renal exploration? An 8-year review at a Canadian level 1 trauma centre.The other side of pediatric trauma: violence and intent injury.Upregulation of activated protein C leads to factor V deficiency in early trauma coagulopathy.A provincial integrated model of improved care for patients following hip fracture.Sports concussion: an Olympic boxing model comparing sex with biomechanics and traumatic brain injury.A multifaceted quality improvement strategy to optimize monitoring and management of delirium in trauma patients: results of a clinician survey.Risk factors for severe all-terrain vehicle injuries in Alberta.Evaluating potential spatial access to trauma centre care by severely injured patients.Incidence of brain injury in facial fractures.Surgical outcomes and the acute care surgery service.The acute care general surgery population and prognostic factors for morbidity and mortality.Disaster preparedness of trauma.What would you like to know and how can we help you? Assessing the needs of regional trauma centres.Posttraumatic stress disorder screening for trauma patients at a level 1 trauma centre.Physical and finite element model reconstruction of a subdural hematoma event.Abdominal wall reconstruction in the trauma patient with an open abdomen.Development and pilot testing of a survey to measure patient and family experiences with injury care.Occult shock in trauma: What are Canadian traumatologists missing?Timeliness in obtaining emergent percutaneous procedures for the severely injured patient: How long is too long?97% of massive transfusion protocol activations do not include a complete hemorrhage panel.Trauma systems in Canada: What system components facilitate access to definitive care?The role of trauma team leaders in missed injuries: Does specialty matter?The adverse consequences of dabigatran among trauma and acute surgical patients.A descriptive study of bicycle helmet use in Montréal.Factor XIII, desmopressin and permissive hypotension enhance clot formation compared with normotensive resuscitation: uncontrolled hemorrhagic shock model.Negative pressure wound therapy for critically ill adults with open abdominal wounds: a systematic review.The “weekend warrior:” Fact or fiction for major trauma?Canadian injury preventon curriculum: a means to promote injury prevention.Penetrating splenic trauma: Safe for nonoperative management?The pediatric advanced trauma life support course: a national initiative.The effectiveness of a psycho-educational program among outpatients with burns or complex trauma.Trauma centre performance indicators for nonfatal outcomes: a scoping review.The evaluation of short track speed skating helmet performance.Complication rates as a trauma care performance indicator: a systematic review.Unplanned readmission following admission for traumatic injury: When, where and why?Reconstructions of concussive impacts in ice hockey.How does head CT correlate with ICP monitoring and impact monitoring discontinuation in trauma patients with a Marshall CT score of I–II?Impact of massive transfusion protocol and exclusion of plasma products from female donors on outcome of trauma patients in Calgary region of Alberta Health Services.Primary impact arthrodesis for a neglected open Weber B ankle fracture dislocation.Impact of depression on neuropsychological functioning in electrical injury patients.Predicting the need for tracheostomy in patients with cervical spinal cord injury.Predicting crumping during computed tomography imaging using base deficit.Feasibility of using telehomecare technology to support patients with an acquired brain injury and family care-givers.Program changes impact the outcomes of severely injured patients.Do trauma performance indicators accurately reflect changes in a maturing trauma program?One-stop falls prevention information for clinicians: a multidisciplinary interactive algorithm for the prevention of falls in older adults.Use of focused assessment with sonography for trauma (FAST) for combat casualties in forward facilities.Alberta All-terrain Vehicle Working Group: a call to action.Observations and potential role for the rural trauma team development course (RTTDC) in India.An electronic strategy to facilitate information-sharing among trauma team leaders.Development of quality indicators of trauma care by a consensus panel.An evaluation of a proactive geriatric trauma consultation service.Celebrity injury-related deaths: Is a gangster rapper really gangsta?Prevention of delirium in trauma patients: Are we giving thiamine prophylaxis a fair chance?Intra-abdominal injury in patients who sustain more than one gunshot wound to the abdomen: Should non-operative management be used?Retrospective review of blunt thoracic aortic injury management according to current treatment recommendations.Telemedicine for trauma resuscitation: developing a regional system to improve access to expert trauma care in Ontario.Comparing trauma quality indicator data between a pediatric and an adult trauma hospital.Using local injury data to influence injury prevention priorities.Systems saving lives: a structured review of pediatric trauma systems.What do students think of the St. Michael’s Hospital ThinkFirst Injury Prevention Strategy for Youth?An evidence-based method for targeting a shaken baby syndrome prevention media campaign.The virtual mentor: cost-effective, nurse-practitioner performed, telementored lung sonography with remote physician guidance.Quality indicators used by teaching versus nonteaching international trauma centres.Compliance to advanced trauma life support protocols in adult trauma patients in the acute setting.Closing the quality improvement loop: a collaborative approach.National Trauma Registry: “collecting” it all in New Brunswick.Does delay to initial reduction attempt affect success rates for anterior shoulder dislocation (pilot study)?Use of multidisciplinary, multi-site morbidity and mortality rounds in a provincial trauma system.Caring about trauma care: public awareness, knowledge and perceptions.Assessing the quality of admission dictation at a level 1 trauma centre.Trauma trends in older adults: a decade in review.Blunt splenic injury in patients with hereditary spherocytosis: a population-based analysis.Analysis of trauma team activation in severe head injury: an institutional experience.ROTEM results correlate with fresh frozen plasma transfusion in trauma patients.10-year trend of assault in Alberta.10-year trend in alcohol use in major trauma in Alberta.10-year trend in major trauma injury related to motorcycles compared with all-terrain vehicles in Alberta.Referral to a community program for youth injured by violence: a feasibility study.New impaired driving laws impact on the trauma population at level 1 and 3 trauma centres in British Columbia, Canada.A validation study of the mobile medical unit/polyclinic team training for the Vancouver 2010 Winter Games.Inferior vena cava filter use in major trauma: the Sunny-brook experience, 2000–2011.Relevance of cellular microparticles in trauma-induced coagulopathy: a systemic review.Improving quality through trauma centre collaboratives.Predictors of acute stress response in adult polytrauma patients following injury.Patterns of outdoor recreational injury in northern British Columbia.Risk factors for loss-to-follow up among trauma patients include functional, socio-economic, and geographic determinants: Would mandating opt-out consent strategies minimize these risks?Med-evacs and mortality rates for trauma from Inukjuak, Nunavik, Quebec.Review of open abdomens in McGill University Health Centre.Are surgical interventions for trauma associated with the development of posttraumatic retained hemothorax and empyema?A major step in understanding the mechanisms of traumatic coagulopathy: the possible role of thrombin activatable fibrinolysis inhibitor.Access to trauma centre care for patients with major trauma.Repeat head computed tomography in anticoagulated traumatic brain injury patients: still warranted.Improving trauma system governance. Can J Surg 2012. [DOI: 10.1503/cjs.006312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Severe hypothermic arrest with direct admission to OR for CPB. Injury 2011; 42:544-5. [PMID: 21419410 DOI: 10.1016/j.injury.2011.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 02/21/2011] [Indexed: 02/02/2023]
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Use of computed tomography for cervical spine clearance in trauma patients. J Am Coll Surg 2010; 210:1008-11. [PMID: 20510811 DOI: 10.1016/j.jamcollsurg.2010.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Accepted: 03/15/2010] [Indexed: 10/19/2022]
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SOFA is superior to MOD score for the determination of non-neurologic organ dysfunction in patients with severe traumatic brain injury: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R115. [PMID: 16882348 PMCID: PMC1750966 DOI: 10.1186/cc5007] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2006] [Revised: 07/19/2006] [Accepted: 08/01/2006] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To compare the discriminative ability of the SOFA and MOD scoring systems with respect to hospital mortality and unfavorable neurologic outcome in patients with severe traumatic brain injury admitted to intensive care. METHODS We performed a prospective cohort study at Foothills Medical Centre, the sole adult tertiary care trauma center servicing southern Alberta (population approximately 1.3 million) All patients >or=16 years of age and older with severe traumatic brain injury (sTBI) and intensive care unit length of stay > 48 hours between May 1, 2000 and April 31, 2003 were included. Non-neurologic organ dysfunction was measured by the SOFA and MODS scoring systems. Comparison of the SOFA and MOD score determination of organ dysfunction for each non-neurological organ system was examined by calculating the proportion of patients with SOFA and MOD component score defined organ failure. Consistent with previous literature, organ system failure was defined as a component score >or=3. RESULTS The odds of death and unfavorable neurologic outcome in patients with SOFA defined cardiovascular failure were 14.7 times (95% CI: 5.9-36.3) and 7.6 times (95% CI 3.5-16.3) respectively, that of those without cardiovascular failure. The development of SOFA defined cardiovascular failure was a reasonable discriminator of hospital mortality and unfavorable neurologic outcome (AuROC=0.75 and 0.73, respectively). The odds of death and unfavorable neurologic outcome in patients with MOD defined cardiovascular failure were 2.6 times (95% CI: 1.24-5.26) and 4.1 times (95% CI 1.3-12.4) respectively, that of those without cardiovascular failure. The development of MOD defined cardiovascular failure was a poor discriminator of hospital mortality and unfavorable neurologic outcome (AuROC=0.57 and 0.59 respectively). Both SOFA and MOD defined respiratory failure were not statistically associated with hospital mortality. CONCLUSIONS In patients with brain injury, the SOFA scoring system has superior discriminative ability and stronger association with outcome compared to the MOD scoring system with respect to hospital mortality and unfavorable neurologic outcome.
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Abstract
BACKGROUND Aboriginal Canadians are considered to be at increased risk of major trauma. However, population-based studies characterizing the distribution, determinants and outcomes of major trauma in this group are lacking. We sought to measure the impact of ethnicity, as reflected by Aboriginal status, on the incidence of severe trauma and to broadly define the epidemiologic characteristics of severe trauma among status Aboriginal Canadians in a large health region. METHODS This population-based, observational study involves all adults (people > or = 16 years) resident in the Calgary Health Region between Apr. 1, 1999, and Mar. 31, 2002. Stratification of the population into status Aboriginal Canadians and the reference population was performed by Alberta Health and Wellness using an alternate premium arrangement field within the personal health care number. Injury incidence was determined by identifying all injuries with severity scores of 12 or greater in the Alberta Trauma Registry, regional corporate data and the Office of the Medical Examiner. RESULTS Aboriginal Canadians were at much higher risk than the reference population in the Calgary Health Region of sustaining severe trauma (257.2 v. 68.8 per 100,000; relative risk [RR] 3.7, 95% confidence interval [CI] 3.0-4.6). Aboriginal Canadians were found to be at significantly increased risk of injuries resulting from motor vehicle crashes (RR 4.8, 95% CI 3.5-6.5), assault (RR 11.1, 95% CI 6.2-18.6) and traumatic suicide (RR 3.1, 95% CI 1.4-6.1). A trend toward higher median injury severity scores was observed among Aboriginal Canadians (21 v. 18, p = 0.09). Although the case-fatality rate among Aboriginal Canadians was less than half that in the reference population (14/93 [15%] v. 531/1686 [31%], p < 0.0001), population mortality was almost 2 times greater (RR = 1.8, 95% CI 1.0-3.0, p = 0.046). INTERPRETATION Severe trauma disproportionately affects Aboriginal Canadians.
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The hand-held ultrasound examination for penetrating abdominal trauma. Am J Surg 2004; 187:660-5. [PMID: 15135687 DOI: 10.1016/j.amjsurg.2004.02.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2003] [Revised: 02/07/2004] [Indexed: 11/15/2022]
Abstract
BACKGROUND An evaluation of hand-held ultrasonography (US) in the assessment of penetrating torso trauma has not yet been reported. METHODS A 2.4 kg hand-held ultrasound device was used to examine penetrating trauma victims in an exam designated as the Hand-Held Focused Assessment with Sonography for Trauma (HHFAST). Results were compared with other US examinations including formal FAST (FFAST), computed tomography, diagnostic peritoneal lavage, operative and autopsy findings, and serial examination. Performance considered both the detection of fluid and injuries requiring intervention. RESULTS The HHFAST was excellent for detecting free intraperitoneal fluid, which had 100% specificity for peritoneal penetration, but was only moderately sensitive for injuries requiring therapy. CONCLUSIONS Hand-held sonography can quickly detect intraperitoneal fluid, which has good test performance in determining the presence of an intra-abdominal injury. Negative FAST examinations after penetrating trauma should be followed up with another diagnostic modality.
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Abstract
OBJECTIVE Provincial air ambulance transports of injured patients were quality reviewed prospectively to determine utilization and appropriateness of care. METHODS All trauma air ambulance transports over a 2-month span were reviewed prospectively. Revised Trauma Score, Injury Severity Score, probability of survival, prehospital time, distance of transport, procedures performed, and outcome were determined. Quality control questions were asked of the sending and receiving physicians. RESULTS The majority of air ambulance transports reviewed (N = 97) were indicated for mechanism and severity of injury. Economics and requirement for advanced medical care were indications in only 15%. Physicians tended to perform more advanced procedures, likely related to higher patient Injury Severity Score (23 vs. 15, p = NS). Four problems with air ambulance access were identified. The overtriage rate was 5%. Inappropriate patient care was documented in six (6%) cases; a physician was present for only one of these. CONCLUSIONS A low overtriage rate was documented, raising concerns that the undertriage rate may be too high. Injured patients air transported without physician accompaniment more often received inappropriate care, suggesting that physician accompaniment is beneficial.
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A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am J Surg 1994; 167:485-9. [PMID: 8185032 DOI: 10.1016/0002-9610(94)90240-2] [Citation(s) in RCA: 148] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
To examine the effectiveness of hyperbaric oxygen (HBO) therapy in the treatment of major truncal necrotizing infections, a retrospective (1980 to 1992) analysis of the medical records of 30 patients treated with HBO therapy and 24 patients treated without HBO therapy was undertaken. The two groups were similar; however, there was a selection bias towards more frequent clostridial infections in a younger population in the HBO group. There was no difference in length of hospital stay, intensive care unit (ICU) stay, or duration of antibiotic therapy between groups. The mortality rates were 9/30 (30%) in the HBO group versus 10/24 (42%) (nonsignificant difference) in the non-HBO group. The total number of operations was greater in the HBO-treated group. This study failed to show that the use of HBO in the treatment of major truncal necrotizing infections statistically reduced mortality or the number of débridements. We believe, however, that the apparent selection bias and the trend towards increased survival in the HBO-treated group (12%) justifies the continued use of and research with HBO therapy.
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A prospective randomized trial of routine postoperative nasogastric decompression in patients with bowel anastomosis. Can J Surg 1992; 35:629-32. [PMID: 1458389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Until relatively recently, the nasogastric (NG) tube has been used routinely for decompression in the patient with small- or large-bowel anastomosis. To determine if routine postoperative NG decompression benefited such patients, 102 patients were randomized prospectively to either NG decompression or no-NG tube. Excluded were patients with chronic bowel obstruction, peritonitis, gross fecal contamination or spillage, and previous abdominal or pelvic irradiation. There were 52 patients in the no-NG group and 50 in the NG group. Patients in the no-NG group had earlier bowel sounds, return of flatus, oral intake and first bowel movement. Four patients (8%) in the no-NG group, compared with one patient (2%) in the NG group, required subsequent decompression. Length of hospital stay was significantly (p < 0.001) shorter in the no-NG group. There were no significant differences in the presence of atelectasis, postoperative fever, wound infections and anastomotic leaks between the two groups. The authors conclude that routine nasogastric decompression is not warranted after elective surgery involving small- or large-bowel anastomosis.
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Abstract
Three cases are described in which carcinoid tumors arose in previously established inflammatory bowel disease: two were in the ileum in cases of Crohn's disease, and one was in the rectum in a case of ulcerative colitis. Review of this association in the literature suggests that it may be more than fortuitous.
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