Showing papers by "Russell L. Gruen published in 2012"

Advances and future directions for management of trauma patients with musculoskeletal injuries

Abstract: Musculoskeletal injuries are the most common reason for operative procedures in severely injured patients and are major determinants of functional outcomes. In this paper, we summarise advances and future directions for management of multiply injured patients with major musculoskeletal trauma. Improved understanding of fracture healing has created new possibilities for management of particularly challenging problems, such as delayed union and non union of fractures and large bone defects. Optimum timing of major orthopaedic interventions is guided by increased knowledge about the immune response after injury. Individual treatment should be guided by trading off the benefits of early definitive skeletal stabilisation, and the potentially life-threatening risks of systemic complications such as fat embolism, acute lung injury, and multiple organ failure. New methods for measurement of fracture healing and function and quality of life outcomes pave the way for landmark trials that will guide the future management of musculoskeletal injuries.

Hospital discharge criteria following colorectal surgery:a systematic review

Abstract: Aim The aim of this study was to identify and synthesize the hospital discharge criteria that have been used in the colorectal surgery literature. Methods A systematic literature search was conducted using eight bibliographic databases. Searches were limited to English language journal articles published between January 1996 and October 2009. Primary research applying hospital discharge criteria following colorectal surgery was included. Study selection was made independently by two reviewers. Discharge criteria were extracted from each included study. Results The 156 studies identified by the search strategy described 70 different sets of criteria to indicate readiness for discharge. The majority of studies applied a combination of three or four criteria; those most frequently cited were tolerance of oral intake (80%), return of bowel function (70%), adequate pain control (44%) and adequate mobility (35%). End-points employed to determine the achievement of criteria were generally poorly defined. Conclusion A variety of hospital discharge criteria were applied in the colorectal surgery literature. Development of standardized criteria will allow more accurate comparison of results between studies assessing hospital length of stay or other discharge-related outcome measures.

Aggressive fresh frozen plasma (FFP) with massive blood transfusion in the absence of acute traumatic coagulopathy

Abstract: Introduction A high ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC) is currently recognised as the standard of care in some centres during massive transfusion post trauma. The aim of this study was to test whether the presumption of benefit held true for severely injured patients who received a massive transfusion, but did not present with acute traumatic coagulopathy. Patients and methods Data collected in The Alfred Trauma Registry over a 6 year period were reviewed. Included patients were sub-grouped by a high FFP:PRBC ratio (≥1:2) in the first 4 h and compared to patients receiving a lower ratio. Outcomes studied were associations with mortality, hours in the intensive care unit and hours of mechanical ventilation. Results Of 4164 eligible patients, 374 received a massive transfusion and 179 (49.7%) patients who did not have coagulopathy were included for analysis. There were 66 patients who received a high ratio of FFP:PRBC, and were similar in demographics and presentation to 113 patients who received a lower ratio. There was no significant difference in mortality between the two groups (p = 0.80), and the FFP:PRBC ratio was not significantly associated with mortality, ICU length of stay or mechanically ventilated hours. Conclusions A small proportion of major trauma patients received a massive blood transfusion in the absence of acute traumatic coagulopathy. Aggressive FFP transfusion in this group of patients was not associated with significantly improved outcomes. FFP transfusion carries inherent risks with substantial costs and the population most likely to benefit from a high FFP:PRBC ratio needs to be clearly defined.

Legal disputes over informed consent for cosmetic procedures: A descriptive study of negligence claims and complaints in Australia

Abstract: BACKGROUND: Plastic surgeons and other doctors who perform cosmetic procedures face relatively high risks of malpractice claims and complaints. In particular, alleged problems with the consent process abound in this area, but little is known about the clinical circumstances of these cases. METHOD: We reviewed 481 malpractice claims and serious health care complaints resolved in Australia between 2002 and 2008 that alleged failures in the informed consent process for cosmetic and other procedures. We identified all "cases" involving cosmetic procedures and reviewed them in-depth. We calculated their frequency, and described the treatments, allegations, and outcomes involved. RESULTS: A total of 16% (77/481) of the legal disputes over informed consent involved cosmetic procedures. In 70% (54/77) of these cases, patients alleged that the doctor failed to disclose risks of a particular complication, in 39% patients claimed that potential lack of benefit was not explained, and in 26% patients allegations centred on the process by which consent was sought. Five treatment types-liposuction, breast augmentation, face/neck lifts, eye/brow lifts, and rhinoplasty/septoplasty-featured in 70% (54/77) of the cases. Scarring (30/77) and the need for reoperation (18/77) were among the most prevalent adverse health outcomes at issue. CONCLUSION: A mix of factors "supercharges" the informed consent process for cosmetic procedures. Doctors who deliver these procedures should take special care to canvas the risks and possible outcomes that matter most to patients.

Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study.

Abstract: Background Quality Improvement (QI) programs have been shown to be a valuable tool to strengthen care of severely injured patients, but little is known about them in low and middle income countries (LMIC). We sought to explore opportunities to improve trauma QI activities in LMIC, focusing on the Asia–Pacific region.

How to define 'best practice' for use in Knowledge Translation research: a practical, stepped and interactive process.

Abstract: Objectives Defining ‘best practice’ is one of the first and crucial steps in any Knowledge Translation (KT) research project. Without a sound understanding of what exactly should happen in practice, it is impossible to measure the extent of existing gaps between ‘desired’ and ‘actual’ care, set implementation goals, and monitor performance. The aim of this paper is to present a practical, stepped and interactive process to develop best practice recommendations that are actionable, locally applicable and in line with the best available research-based evidence, with a view to adapt these into process measures (quality indicators) for KT research purposes. Methods Our process encompasses the following steps: (1) identify current, high-quality clinical practice guidelines (CPGs) and extract recommendations; (2) select strong recommendations in key clinical management areas; (3) update evidence and create evidence overviews; (4) discuss evidence and produce agreed ‘evidence statements’; (5) discuss the relevance of the evidence with local stakeholders; and (6) develop locally applicable actionable best practice recommendations, suitable for use as the basis of quality indicators. Conclusions Actionable definitions of local best practice are a prerequisite for doing KT research. As substantial resources go into rigorously synthesizing evidence and developing CPGs, it is important to make best use of such available resources. We developed a process for efficiently developing locally applicable actionable best practice recommendations from existing high-quality CPGs that are in line with current research evidence.

Interventions for reducing wrong-site surgery and invasive procedures

Abstract: Wrong-site surgery is a rare but serious event that can have substantial consequences for patients and healthcare providers. It occurs when a surgical or invasive procedure is undertaken on the wrong body part, wrong patient or the wrong procedure is performed. A number of interventions to reduce surgical error have been proposed over recent years, but few specifically report of incidence of wrong-site surgery. This review identified one interrupted-time-series (ITS) study, which evaluated a targeted educational intervention aimed at reducing the incidence of wrong-site procedures. The intervention included examination of wrong-site tooth extraction as well as an explanation of relevant clinical guidelines. It was found to reduce the incidence of wrong-site surgery in this context.

Trauma center quality improvement programs in the United States, Canada, and Australasia.

Abstract: Objective:To compare quality improvement (QI) programs of trauma centers in 4 high-income countries.Background:Injury is a leading cause of morbidity and mortality in countries around the world, but patient outcomes vary among countries with similar systems of trauma care.Methods:We surveyed medical

An overview of published research about the acute care and rehabilitation of traumatic brain injured and spinal cord injured patients

Abstract: Knowledge of the breadth, nature, and volume of traumatic brain injury (TBI) and spinal cord injury (SCI) research can aid in research planning. This study aimed to provide an overview of existing TBI and SCI research to inform identification of knowledge translation (KT), systematic review (SR), and primary research opportunities. Topics and relevant articles from three large neurotrauma evidence resources were synthesized: the Global Evidence Mapping (GEM) Initiative (129 topics and 1644 articles), the Acquired Brain Injury Evidence-Based Review (ERABI; 152 topics and 732 articles), and the Spinal Cord Injury Rehabilitation Evidence (SCIRE) Project (297 topics and 1650 articles). A de-duplicated dataset of SRs, randomized controlled trials (RCTs), and other studies identified by these projects was created. In all, 145 topics were identified (66 TBI and 79 SCI), yielding 3466 research articles (1256 TBI and 2210 SCI). Topics with KT potential included cognitive therapies for TBI and prevention/management of urinary tract problems post-SCI, which accounted for 17% and 18%, respectively, of the TBI and SCI yield. Topics that may require SR included management of raised intracranial pressure in TBI, and ventilation and intermittent positive pressure interventions following SCI. Topics for which primary research may be needed included pharmacological therapies for neurological recovery post-TBI, and management of sleep-disordered breathing post-SCI. There was a larger volume of non-intervention (epidemiological) studies in SCI than in TBI. This comprehensive overview of TBI and SCI research can aid funding agencies, researchers, clinicians, and other stakeholders in prioritizing and planning TBI and SCI research.

Administer tranexamic acid early to injured patients at risk of substantial bleeding

Abstract: #### Key points Haemorrhage is the principal cause of 30-40% of all trauma deaths, and half of these occur before admission to hospital.1 Many bleeding patients develop coagulopathy, making control of haemorrhage more difficult. In some patients this coagulopathy develops early2 and seems to be associated with excessive fibrinolysis and breakdown of clots.3 Current protocols for massive transfusions of blood products (variably defined as >10 red cell units or >50% blood volume in 24 hours, or >5 units in four hours) to patients with haemorrhagic shock prescribe plasma and cryoprecipitate to replace lost, consumed, diluted, or dysfunctional clotting factors, but these do not specifically treat fibrinolysis. There is now compelling evidence that tranexamic acid (1 g loading dose plus 1 g over eight hours), a relatively safe and inexpensive antifibrinolytic, should be administered within three hours of injury in patients at risk of severe bleeding. Tranexamic acid was discovered in the 1950s and has been used during surgery to minimise blood loss. A systematic review evaluated 126 randomised controlled trials in elective surgery and three in emergency surgery (total of 10 488 patients) that had been conducted between 1972 and 2011. This showed that tranexamic acid reduced blood transfusions by a third (risk ratio 0.62, 95% confidence interval 0.58 to 0.65),4 an effect that persisted when only trials with adequate allocation concealment were considered (0.68, 0.62 to 0.74). In these higher quality trials the effect on mortality was uncertain (0.67, 0.33 to 1.34), as was …

Legal Disputes over Duties to Disclose Treatment Risks to Patients: A Review of Negligence Claims and Complaints in Australia

Abstract: David Studdert and colleagues identified disputes over informed consent among malpractice claims and serious health care complaints in Australia and provide an analysis of disagreements between patients and doctors over whether particular clinical risks should have been disclosed before treatment.

Improving the care of people with traumatic brain injury through the Neurotrauma Evidence Translation (NET) program: protocol for a program of research

Abstract: The Neurotrauma Evidence Translation (NET) program was funded in 2009 to increase the uptake of research evidence in the clinical care of patients who have sustained traumatic brain injury. This paper reports the rationale and plan for this five-year knowledge translation research program. The overarching aims of the program are threefold: to improve outcomes for people with traumatic brain injury; to create a network of neurotrauma clinicians and researchers with expertise in knowledge translation and evidence-based practice; and to contribute knowledge to the field of knowledge translation research. The program comprises a series of interlinked projects spanning varying clinical environments and disciplines relevant to neurotrauma, anchored within four themes representing core knowledge translation activities: reviewing research evidence; understanding practice; developing and testing interventions for practice change; and building capacity for knowledge translation in neurotrauma. The program uses a range of different methods and study designs, including: an evidence fellowship program; conduct of and training in systematic reviews; mixed method study designs to describe and understand factors that influence current practices (e.g., semi-structured interviews and surveys); theory-based methods to develop targeted interventions aiming to change practice; a cluster randomised trial to test the effectiveness of a targeted theory-informed intervention; stakeholder involvement activities; and knowledge translation events such as consensus conferences.

Inception of an Australian spine trauma registry: the minimum dataset.

Abstract: Background The establishment of a spine trauma registry collecting both spine column and spinal cord data should improve the evidential basis for clinical decisions. This is a report on the pilot of a spine trauma registry including development of a minimum dataset. Methods A minimum dataset consisting of 56 data items was created using the modified Delphi technique. A pilot study was performed on 104 consecutive spine trauma patients recruited by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Data analysis and collection methodology were reviewed to determine its feasibility. Results Minimum dataset collection aided by a dataset dictionary was uncomplicated (average of 5 minutes per patient). Data analysis revealed three significant findings: (1) a peak in the 40 to 60 years age group; (2) premorbid functional independence in the majority of patients; and (3) significant proportion being on antiplatelet or anticoagulation medications. Of the 141 traumatic spine fractures, the thoracolumbar segment was the most frequent site of injury. Most were neurologically intact (89%). Our study group had satisfactory 6-month patient-reported outcomes. Conclusion The minimum dataset had high completion rates, was practical and feasible to collect. This pilot study is the basis for the development of a spine trauma registry at the Level 1 trauma center.

Australian health policy makers' priorities for research synthesis: A survey

Abstract: Objectives. Health policy making is complex, but can be informed by evidence of what works, including systematic reviews. We aimed to inform the work of the Cochrane Effective Practice and Organisation of Care (EPOC) Group by identifying systematic review topics relevant to Australian health policy makers and exploring whether existing Cochrane reviews address these topics. Methods. We interviewed 30 senior policy makers from State and Territory Government Departments of Health to identify topics considered important for systematic reviews within the scope of health services research, including professional, financial, organisational and regulatory interventions to improve professional practice and the organisation of services. We then looked for existing Cochrane reviews relevant to these topics. Results. Eighty-five priority topics were identified by policy makers, including advanced practice roles, care for Indigenous Australians, care for chronic disease, coordinating across jurisdictions, admission avoidance, and eHealth. Sixty published Cochrane reviews address these issues, and 34 additional reviews are in progress. Thirty-four topics are yet to be addressed. Conclusions. This survey has identified questions for which Australian policy makers have indicated a need for systematic reviews. Further, it has confirmed that existing reviews do address issues of importance to policy makers, with the potential to inform policy processes. What is known about the topic? Evidence-informed policy making is a complex process, requiring integration of relevant evidence in the context of multiple influences, inputs and priorities. Communication between policy makers and researchers is likely to increase the availability of relevant research evidence for policy, and improve its uptake into action. The Cochrane Effective Practice and Organisation of Care Group produces systematic reviews in areas intersecting with key policy responsibilities, including professional, financial, organisational and regulatory interventions designed to improve health professional practice and the organisation of healthcare services, and seeks to engage with policy makers to identify their research priorities. What does this paper add? This study surveyed Australian health policy makers from each of the Australian State and Territory Government Departments of Health, and identified 85 policy questions for which they considered systematic reviews of the evidence would be useful. Relevant to these topics, 60 existing published Cochrane systematic reviews were identified, as well as 34 reviews in progress, and 34 topics not yet addressed. The study also identified those published reviews that could not reach definitive conclusions, indicating that more primary research is required. What are the implications for practitioners? For researchers, areas of need for new systematic reviews have been identified. For policy makers, a suite of relevant systematic reviews have been identified that may be of use in policy processes.

Authors' reply: Surgical wisdom (Br J Surg 2012; 99: 3–5)

Abstract: Sir We have read the invited commentary to our article1 by Dr Flum. He is an authority in the field and we greatly appreciate his views. The sources of inaccuracy he raises, including patients lost to follow-up or uncertainty regarding the proportion of emergency operations, are indeed very real difficulties inherent in any study of this sort. We deal with these in the discussion, but nevertheless we believe that the study has produced new data despite these limitations. Dr Flum mentions that only recurrences requiring admission to hospital were included. One of the most important aspects of the study was that all patients were diagnosed according to the most objective criteria possible in clinical practice. Thus we defined acute diverticulitis (AD) by clinical and radiological criteria; recurrence as a new episode of AD was diagnosed according to the same definition and had to occur at least 2 months after complete resolution of the index episode. Patients with radiological evidence of acute diverticulitis were rarely treated as outpatients. Some patients treated with antibiotics for abdominal pain and fever in an outpatient setting without instrumental examination confirming the diagnosis of AD were simply classified as having persistence or recurrence of symptoms. It is of course the case that a multicentre study of diverticular disease as presented in our study is extremely difficult to carry out. Confounding factors include the accuracy of data recording, uniformity of adherence to the protocol, and variation in the clinical severity of the illness, length of follow-up and many other variables. Any future study will always be faced with the same practical difficulties to a greater or lesser extent. Despite these difficulties, we are, nevertheless, strongly of the view that the data presented represent an advance on previous studies. Admittedly, the results do not give a complete picture but they add to present knowledge beyond what was available before. G. A. Binda1, A. Serventi2 and D. F. Altomare3 1Department of General Surgery, Galliera Hospital, 16128 Genoa, 2Department of General Surgery, San Giacomo Hospital, 15067 Novi Ligure and 3Department of Emergency and Organ Transplantation, University of Bari, 70121 Bari, Italy (e-mail: gian.andrea.binda@galliera.it) DOI: 10.1002/bjs.8768

Suction versus no suction for chest drain management

Abstract: This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: In any age group or pathology requiring an intrathoracic chest drain does the addition of suction improve clinical outcomes? In draining the pleural space using underwater seal, one‐way valve (or any other type of drain identified from the search) is the use of suction compared to without suction safer or more effective at evacuating either air, blood, fluid or pus? In draining the mediastinal space using underwater seal, one‐way valve (or any other type of drain identified from the search) is the use of suction compared to without suction safer and more effective from evacuating air, blood and fluids? If suction is found to be beneficial when applied to chest drains (pleural and or mediastinal), what are the optimum pressures that should be used for adults, children and neonates?

Tranexamic acid effects in trauma patients with significant hemorrhage.

Abstract: The term evidence-based medicine was first coined by Sackett and colleagues as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”The key to practicing evidence-based medicine is applying the best current knowledge to decisions in individual patients. Medical knowledge is continually and rapidly expanding, and it is impossible for an individual clinician to read all the medical literature. For clinicians to practice evidence-based medicine, they must have the skills to read and interpret the medical literature so that they can determine the validity, reliability, credibility, and utility of individual articles. These skills are known as critical appraisal skills. Generally, critical appraisal requires that the clinician have some knowledge of biostatistics, clinical epidemiology, decision analysis, and economics as well as clinical knowledge. The Canadian Association of General Surgeons (CAGS) and the American College of Surgeons (ACS) jointly sponsor a program titled “Evidence-Based Reviews in Surgery” (EBRS), supported by an educational grant from Ethicon Inc and Ethicon Endo Surgery Inc. The primary objective of this initiative is to help practicing surgeons improve their critical appraisal skills. During the academic year, 8 clinical articles are chosen for review and discussion. They are selected not only for their clinical relevance to general surgeons, but also because they cover a spectrum of issues important to surgeons; for example, causation or risk factors for disease, natural history or prognosis of disease, how

Self-reported health outcomes of delayed union and nonunion of femoral and tibial shaft fractures

Abstract: Delayed union and non-union are complications of fracture healing associated with pain and with functional and psychosocial disability. This study compares the effect on self-reported health outcomes of delayed union or non-union of femoral and tibial shaft fractures treated at two major metropolitan trauma centres in Victoria. Patients admitted to the Royal Melbourne Hospital and The Alfred with extra- articular femoral and tibial shaft fractures during 2003-2004 and 2005-2006, and followed up by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR) were included. Hospital medical records were reviewed to identify the outcome of each fracture. Fracture healing was assessed by the need for unplanned revision surgery for delayed union or nonunion, and clinical and radiological evidence of union. Prospectively-gathered VOTOR health outcome measurements included the Short Form 12-Item Health Survey (SF-12), and return to work and pain status at 6 and 12 months post injury. Of the 520 patients, 260 femoral and 282 tibial shaft fractures were included. In total, 285 fractures progressed to union, 138 fractures developed delayed union or non-union and 119 fractures had an unknown outcome. Factors that were significantly different between the union and delayed union or non-union groups included: fund source, mechanism of injury, other injuries, wound and Gustilo type, and fixation method. On linear regression modelling, an inverse relationship was demonstrated between delayed union or nonunion and the Physical and Mental Component Summary scores of the SF-12. This was statistically significant at both 6 and 12 months post injury unadjusted and adjusted for age, gender and other injuries. On logistic regression modelling, patients with delayed union or non-union showed unadjusted and adjusted risk ratios of 0.85 and 0.82, respectively at 6 months, and 0.82 and 0.76, respectively at 12 months to return to work. Similarly, patients with delayed union or nonunion had unadjusted and adjusted risk ratios of 1.09 and 1.11, respectively at 6 months, and 1.33 and 1.37, respectively at 12 months to have pain. Both were statistically significant at 12 months post injury unadjusted and adjusted for age, gender and other injuries. Patients with delayed union or non-union of femoral and tibial shaft fractures have poorer physical and mental health at 6 and 12 months post injury. In addition, they are less likely to have returned to work and more likely to still have pain at 12 months post injury.

Trauma Surgery 2 Haemorrhage control in severely injured patients

Abstract: Most surgeons have adopted damage control surgery for severely injured patients, in which the initial operation is abbreviated after control of bleeding and contamination to allow ongoing resuscitation in the intensive-care unit. Developments in early resuscitation that emphasise rapid control of bleeding, restrictive volume replacement, and prevention or early management of coagulopathy are making defi nitive surgery during the fi rst operation possible for many patients. Improved topical haemostatic agents and interventional radiology are becoming increasingly useful adjuncts to surgical control of bleeding. Better understanding of trauma-induced coagulopathy is paving the way for the replacement of blind, unguided protocols for blood component therapy with systemic treatments targeting specifi c defi ciencies in coagulation. Similarly, treatments targeting dysregulated infl ammatory responses to severe injury are under investigation. As point-of-care diagnostics become more suited to emergency environments, timely targeted intervention for haemorrhage control will result in better patient outcomes and reduced demand for blood products. Our Series paper describes how our understanding of the roles of the microcirculation, infl ammation, and coagulation has shaped new and emerging treatment strategies.

Trauma Surgery 1 Early management of severe traumatic brain injury

Abstract: Severe traumatic brain injury remains a major health-care problem worldwide. Although major progress has been made in understanding of the pathophysiology of this injury, this has not yet led to substantial improvements in outcome. In this report, we address present knowledge and its limitations, research innovations, and clinical implications. Improved outcomes for patients with severe traumatic brain injury could result from progress in pharmacological and other treatments, neural repair and regeneration, optimisation of surgical indications and techniques, and combination and individually targeted treatments. Expanded classifi cation of traumatic brain injury and innovations in research design will underpin these advances. We are optimistic that further gains in outcome for patients with severe traumatic brain injury will be achieved in the next decade.