Enhanced superconductivity and ferroelectric quantum criticality in plastically deformed strontium titanate.

The properties of quantum materials are commonly tuned using experimental variables such as pressure, magnetic field and doping. Here we explore a different approach using irreversible, plastic deformation of single crystals. We show that compressive plastic deformation induces low-dimensional superconductivity well above the superconducting transition temperature (Tc) of undeformed SrTiO3, with evidence of possible superconducting correlations at temperatures two orders of magnitude above the bulk Tc. The enhanced superconductivity is correlated with the appearance of self-organized dislocation structures, as revealed by diffuse neutron and X-ray scattering. We also observe deformation-induced signatures of quantum-critical ferroelectric fluctuations and inhomogeneous ferroelectric order using Raman scattering. Our results suggest that strain surrounding the self-organized dislocation structures induces local ferroelectricity and quantum-critical dynamics that strongly influence Tc, consistent with a theory of superconductivity enhanced by soft polar fluctuations. Our results demonstrate the potential of plastic deformation and dislocation engineering for the manipulation of electronic properties of quantum materials.

UBC Reticulum: a province-wide network promoting surgical excellence and continuous improvement of general surgery in British Columbia.

The University of British Columbia's (UBC) Division of General Surgery is a diverse group, including both academic and community surgeons. Since its launch in 2019, the UBC Reticulum website has been a transformative tool in engaging general surgeons, fellows, residents, students and researchers through its many features and user-created content, such as its messaging board, Netter, and Connect feature, which connects members based on their specialty, location, procedures and interests. Reticulum also serves as a valuable repository of educational resources and is instrumental in the division's goal of improving continuing medical education; the Reticulum mentorship grant program provides financial support for practising surgeons pursuing peer-mentorship projects. UBC Reticulum serves as a model for how to coordinate surgical education, research and quality improvement within diverse provincial divisions.

Uniaxial Strain Control of Bulk Ferromagnetism in Rare-Earth Titanates.

The perovskite rare-earth titanates are model Mott insulators with magnetic ground states that are very sensitive to structural distortions. These distortions couple strongly to the orbital degrees of freedom and, in principle, it should be possible to tune the superexchange and the magnetic transition with strain. We investigate the representative system (Y,La,Ca)TiO_{3}, which exhibits low crystallographic symmetry and no structural instabilities. From magnetic susceptibility measurements of the Curie temperature, we demonstrate direct, reversible, and continuous control of ferromagnetism by influencing the TiO_{6} octahedral tilts and rotations with uniaxial strain. The relative change in T_{C} as a function of strain is well described by ab initio calculations, which provides detailed understanding of the complex interactions among structural, orbital, and magnetic properties in rare-earth titanates. The demonstrated manipulation of octahedral distortions opens up far-reaching possibilities for investigations of electron-lattice coupling, competing ground states, and magnetic quantum phase transitions in a wide range of quantum materials.

Access to health care for people with stroke in South Africa: a qualitative study of community perspectives.

BACKGROUND: Incidence of stroke is increasing in sub-Saharan Africa. People who survive stroke experience disability and require long-term care. Health systems in South Africa (SA) are experiencing important challenges, and services in the public health system for people with stroke (PWS) are fragmented. We aimed to explore the perspectives and experiences of PWS related to stroke care services to inform health system strengthening measures. METHODS: In-depth interviews with 16 PWS in urban and rural areas in the Western and Eastern Cape Provinces of SA were conducted between August and October 2020. PWS were recruited through existing research networks, non-government organisations and organisations of persons with disabilities by snowball sampling. Interviews were transcribed, coded, and thematically analysed. We used the conceptual framework of access to health care as proposed by Levesque et al. to map and inform barriers to accessing health care from the user perspective. RESULTS: PWS recognised the need for health care when they experienced signs of acute stroke. Health literacy on determinants of stroke was low. Challenges to accessing stroke care include complex pathways to care, physical mobility related to stroke, long travel distances and limited transport options, waiting times and out of pocket expenses. The perceived quality of services was influenced by cultural beliefs, attitudinal barriers, and information challenges. Some PWS experienced excellent care and others particularly poor care. Positive staff attitude, perceived competence and trustworthiness went in hand with many technical and interpersonal deficits, such as long waiting times and poor staff attitude that resulted in poor satisfaction and reportedly poor outcomes for PWS. CONCLUSIONS: Strategic leadership, governance and better resources at multiple levels are required to address the unmet demands and needs for health care of PWS. Stroke care could be strengthened by service providers routinely providing information about prevention and symptoms of stroke, treatment, and services to patients and their social support network. The role of family members in continuity of care could be strengthened by raising awareness of existing resources and referral pathways, and facilitating connections within services.

Technical considerations in the management of penetrating cardiac injury.

Penetrating cardiac injuries require rapid diagnosis, efficient exposure and nuanced technical approaches, within a framework of highly coordinated and integrated multidisciplinary care. Acute care surgeons, with both strategic and technical expertise, are ideally positioned to address the potentially devastating consequences of these injuries. The aim of this narrative review is to offer a technical approach to the rapid evaluation, exposure, operative repair and postoperative care of penetrating cardiac injuries. A comprehensive review of the cardiac trauma literature, dating back to 1970, has provided a detailed toolbox of approaches to subxiphoid pericardial windows, resuscitative thoracotomy, median sternotomy, pericardiotomy, aortic clamping, cardiac hemorrhage control, cardiac repair, coronary artery injuries, pericardial closure, drain placement, chest wall closures, damage control thoracic procedures and immediate postoperative cardiac care, all based on fundamental physiological principles and anatomical considerations.

A framework for role allocation in education, research and leadership services in Canadian academic divisions of general surgery: a modified Delphi consensus.

BACKGROUND: Moving toward a funding standard similar to that for clinical services for roles essential to the functioning of education, research and leadership services within divisions of general surgery is necessary to strengthen divisional resilience. We aimed to identify roles and underlying tasks in these services central to sustainable functioning of Canadian academic divisions of general surgery. METHODS: Between June 2018 and October 2020, we used a 4-step modified Delphi method (online survey, face-to-face nominal group technique [n = 12], semistructured telephone interview [n = 8] and nominal group technique [n = 12]) to achieve national consensus from an expert panel of all 17 heads of academic divisions of general surgery in Canada on the roles and accompanying tasks essential to education, research and leadership services within an academic division of general surgery. We used 70% agreement to determine consensus. RESULTS: The expert panel agreed that a framework for role allocation in education, research and leadership services was relevant and necessary. Consensus was reached for 7 roles within the educational service, 3 roles within the research service and 5 roles within the leadership service. CONCLUSION: Our framework represents a national consensus that defines role standards for education, research and leadership services in Canadian academic divisions of general surgery. The framework can help divisions build resiliency, and enable sustained and deliberate advances in these services.

Transport Time and Mortality in Critically Ill Patients with Severe Traumatic Brain Injury.

PURPOSE: Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality in critically ill patients. Pre-hospital care and transportation time may impact their outcomes. METHODS: Using the British Columbia Trauma Registry, we included 2,860 adult (≥18 years) patients with severe TBI (abbreviated injury scale head score ≥4), who were admitted to an intensive care unit (ICU) in a centre with neurosurgical services from January 1, 2000 to March 31, 2013. We evaluated the impact of transportation time (time of injury to time of arrival at a neurosurgical trauma centre) on in-hospital mortality and discharge disposition, adjusting for age, sex, year of injury, injury severity score (ISS), revised trauma score at the scene, location of injury, socio-economic status and direct versus indirect transfer. RESULTS: Patients had a median age of 43 years (interquartile range [IQR] 26-59) and 676 (23.6%) were female. They had a median ISS of 33 (IQR 26-43). Median transportation time was 80 minutes (IQR 40-315). ICU and hospital length of stay were 6 days (IQR 2-12) and 20 days (IQR 7-42), respectively. Six hundred and ninety-six (24.3%) patients died in hospital. After adjustment, there was no significant impact of transportation time on in-hospital mortality (odds ratio 0.98, 95% confidence interval 0.95-1.01). There was also no significant effect on discharge disposition. CONCLUSIONS: No association was found between pre-hospital transportation time and in-hospital mortality in critically ill patients with severe TBI.

A Prospective Evaluation of the Utility of a Hybrid Operating Suite for Severely Injured Patients: Overstated or Underutilized?

OBJECTIVE: The primary objective of this study was to evaluate the utility, clinical impact, and work flow of a new trauma hybrid operating theater. SUMMARY BACKGROUND DATA: The potential utility and clinical benefit of hybrid operating theaters are increasingly postulated. Unfortunately, the clinical outcomes and efficiencies of these environments remain unclear. METHODS: All severely injured patients who were transferred to the hybrid suite for emergent intervention between 2013 and 2017 were compared to consecutive prehybrid patients. Standard statistical methodology was employed (P < 0.05 = significant). RESULTS: One hundred sixty-nine patients with severe injuries (mean ISS = 23; hemodynamic instability = 70%; hospital/ICU stay = 12 d; mortality = 14%) were transferred urgently to the hybrid suite. Most were young (38 yrs) males (84%) with blunt injuries (51%). Combined hybrid trauma procedures occurred in 18% of cases (surgery (82%) and angiography (11%) alone). Procedures within the hybrid suite included: laparotomy (57%), extremity (14%), thoracotomy/sternotomy (12%), angioembolization of the spleen/pelvis/liver/other (9%), neck (9%), craniotomy (4%), and aortic endostenting (6%). Compared with historical controls, use of the hybrid suite resulted in shorter arrival to intervention and total procedure times (P < 0.05). A clear benefit for survival was evident (42% vs. 22%). CONCLUSIONS: Availability of a hybrid environment for severely injured patients reduces time to intervention, total procedural duration, blood product transfusion and salvages a small subset of patients who would not otherwise survive. The cost associated with a hybrid suite remains prohibitive for many centers.

Repurposing of respiratory drug theophylline against Candida albicans: mechanistic insights unveil alterations in membrane properties and metabolic fitness.

AIMS: Drug repurposing is an attractive chemotherapeutic strategy that serves to make up for the inadequacy of current antifungal drugs. The present study aims to repurpose theophylline (THP) against Candida albicans. THP is a methylxanthine derived from cocoa beans and tea extracts, generally used as the first-line drug for asthma and other respiratory disorders. METHODS AND RESULTS: We investigated the antifungal activity of THP against C. albicans and non-albicans species. Mechanistic insights revealed that THP induces membrane damage. Enhanced ionic disturbances and depleted ergosterol levels with the concomitant rise in membrane fluidity due to elevated flippase activity confirmed the membrane damaging effect. THP impeded the metabolic adaptability of C. albicans by inhibiting malate synthase and isocitrate lyase enzymes of the glyoxylate cycle. In vivo efficacy of THP was depicted by increased survival of C. albicans infected Caenorhabditis elegans model. CONCLUSIONS: This study elucidates the antifungal potential of THP with mechanistic insights. SIGNIFICANCE AND IMPACT OF THE STUDY: This study unveils the antifungal potential of THP, a known respiratory drug that can be further utilized for a wider range of applications such as combating fungal infections. The effect of THP with the known antifungal drugs can be exploited in the combinatorial drug approach for treating candidiasis.

Optimal treatments for hepato-pancreato-biliary trauma in severely injured patients: a narrative scoping review.

SUMMARY: Hepato-pancreato-biliary (HPB) injuries can be extremely challenging to manage. This scoping review (8438 citations) offers a number of recommendations. If diagnosis and therapy are rapid, patients with major hepatic injuries who present in physiologic extremis have high survival rates despite prolonged hospital stays. Nonoperative management of major liver injuries, as diagnosed using computed tomography, is typically successful. Adjuncts (e.g., angioembolization, laparoscopic washouts, biliary stents) are essential in managing high-grade injuries. Injury to the extrahepatic biliary tree is rare. Cholecystectomy is indicated for all gallbladder trauma. Full-thickness common bile duct injuries require a hepaticojejunostomy, although damage control remains closed suction drainage. Injuries to the pancreatic head often involve concurrent trauma to regional vasculature. Damage control necessitates drainage after stopping hemorrhage. Injury to the left pancreas commonly requires a distal pancreatectomy. Outcomes for high-grade pancreatic and liver injuries are improved by involving an HPB team. Complications are multidisciplinary and should be managed without delay.

Patterns of complex emergency general surgery in Canada.

BACKGROUND: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada. METHODS: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality. RESULTS: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001). CONCLUSION: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.

CONTEXTE: La plupart des études sur les services de chirurgie générale d'urgence (CGU) s'intéressent seulement aux atteintes de l'appendice et de la vésicule biliaire. Pourtant, les chirurgiens du domaine traitent beaucoup d'autres problèmes complexes. L'objectif de l'étude était de décrire le travail chirurgical associé à ces problèmes dans l'ensemble du Canada. MÉTHODES: Notre étude de cohorte rétrospective multicentrique inclut les patients adultes (≥ 18 ans) qui ont subi en 2014 une opération non planifiée pour une atteinte qui ne touchait ni l'appendice ni la vésicule biliaire dans 1 des 7 centres sélectionnés, répartis un peu partout au pays. Nous avons recueilli les données suivantes : renseignements de base des patients, diagnostic, détails de l'intervention, nature des complications et durée d'hospitalisation. Puis nous avons dégagé les facteurs prédictifs de morbidité et de mortalité en appliquant un modèle de régression logistique. RÉSULTATS: L'échantillon totalisait 2595 patients, pour un âge médian de 60 ans (écart interquartile 46­73 ans). Les diagnostics principaux les plus courants étaient l'occlusion de l'intestin grêle (16 %), la hernie (15 %), la tumeur maligne (11 %) et les lésions périanales (9 %). Les interventions les plus fréquentes étaient la résection de l'intestin (30 %), la réparation d'une hernie (15 %), le débridement (11 %) et le débridement de tissus mous ou cutanés infectés (10 %). L'opération a eu lieu le soir ou la nuit (entre 17 h et 8 h) dans 47 % des cas. Le taux global de mortalité à l'hôpital était de 8 %. Des complications sont survenues chez 33 % des patients, dont les facteurs prédictifs indépendants étaient l'âge avancé (p = 0,001), un score ASA (de l'American Society of Anesthesiologists) élevé (p = 0,02) et le transfert à partir d'un autre centre (p = 0,001). CONCLUSION: Cette étude dresse le profil épidémiologique des interventions effectuées par les services de CGU du Canada en présence d'atteintes autres que celles de l'appendice et de la vésicule biliaire. Les chirurgiens du pays font beaucoup d'interventions générales urgentes, pour traiter des affections associées à un risque élevé de morbidité et de mortalité. Les résultats de l'étude guideront les prochaines recherches et serviront de points de référence en matière d'amélioration de la qualité.

A 30-day prospective audit of all inpatient complications following acute care surgery: How well do we really perform?

Background: Acute care surgery (ACS) and emergency general surgery (EGS) services must provide timely care and intervention for patients who have some of the most challenging needs. Patients treated by ACS services are often critically ill and have both substantial comorbidities and poor physiologic reserve. Despite the widespread implemention of ACS/EGS services across North America, the true postoperative morbidity rates remain largely unknown. Methods: In this prospective study, inpatients at 8 high-volume ACS/EGS centres in geographically diverse locations in Canada who underwent operative interventions were followed for 30 days or until they were discharged. Readmissions during the 30-day window were also captured. Preoperative, intraoperative and postoperative variables were tracked. Standard statistical methodology was employed. Results: A total of 601 ACS/EGS patients were followed for up to 30 inpatient or readmission days after their index emergent operation. Fifty-one percent of patients were female, and the median age was 51 years. They frequently had substantial medical comorbidities (42%) and morbid obesity (15%). The majority of procedures were minimally invasive (66% laparoscopic). Median length of stay was 3.3 days and the early readmission (< 30 d) rate was 6%. Six percent of patients were admitted to the critical care unit. The overall complication and mortality rates were 34% and 2%, respectively. Cholecystitis (31%), appendicitis (21%), bowel obstruction (18%), incarcerated hernia (12%), gastrointestinal hemorrhage (7%) and soft tissue infections (7%) were the most common diagnoses. The morbidity and mortality rates for open surgical procedures were 73% and 5%, respectively. Conclusion: Nontrauma ACS/EGS procedures are associated with a high postoperative morbidity rate. This study will serve as a prospective benchmark for postoperative complications among ACS/EGS patients and subsequent quality improvement across Canada.

Contexte: Les services de chirurgie dans les unités de soins actifs (CSA) et de chirurgie générale dans les services d'urgence (CGSU) doivent fournir rapidement des soins et des interventions à des patients dont les besoins sont parmi les plus complexes. En effet, les patients pris en charge par les services de CSA sont souvent gravement malades et présentent des comorbidités sur fond de faible réserve physiologique. Même si les services de CSA/CGSU se sont répandus en Amérique du Nord, les taux réels de morbidité postopératoire demeurent pour une bonne part inconnus. Méthodes: Dans cette étude prospective, on a suivi pendant 30 jours ou jusqu'à leur congé, les patients hospitalisés pour des interventions chirurgicales dans 8 centres de CSA/CGSU achalandés de divers endroits au Canada. On a également tenu compte des réadmissions dans les 30 jours. Les paramètres pré-, per- et postopératoires ont été enregistrés. Une méthodologie statistique standard a été appliquée. Résultats: En tout, 601 patients de CSA/CGSU ont ainsi été suivis pendant une durée allant jusqu'à 30 jours d'hospitalisation ou de réadmission après leur intervention urgente initiale. Cinquante et un pour cent étaient de sexe féminin et l'âge moyen était de 51 ans. Ces patients étaient nombreux à présenter des comorbidités de nature médicale substantielles (42 %) et une obésité morbide (15 %). La majorité des interventions ont été minimalement effractives (66 % laparoscopiques). La durée médiane des séjours a été de 3,3 jours et le taux de réadmission précoce (< 30 j) a été de 6 %. Six pour cent des patients ont été admis aux soins intensifs. Les taux globaux de complications et de mortalité ont été respectivement de 34 % et de 2 %. Cholécystite (31 %), appendicite (21 %), obstruction intestinale (18 %), hernie incarcérée (12 %), hémorragie digestive (7 %) et infections des tissus mous (7 %) comptent parmi les diagnostics les plus fréquents. Les taux de morbidité et de mortalité dans les cas de chirurgies ouvertes ont été respectivement de 73 % et 5 %. Conclusion: Les interventions de CSA/CGSU non liées à la traumatologie sont associées à un taux de morbidité postopératoire élevé. Cette étude fournira un ensemble de valeurs de références pour l'étude prospective des complications chez les patients pris en charge par les services de CSA/CGSU et l'amélioration subséquente des soins partout au Canada.

A Systematic Review of the Risks and Benefits of Venous Thromboembolism Prophylaxis in Traumatic Brain Injury.

BACKGROUND: Patients suffering from traumatic brain injury (TBI) are at increased risk of venous thromboembolism (VTE). However, initiation of pharmacological venous thromboprophylaxis (VTEp) may cause further intracranial hemorrhage. We reviewed the literature to determine the postinjury time interval at which VTEp can be administered without risk of TBI evolution and hematoma expansion. METHODS: MEDLINE and EMBASE databases were searched. Inclusion criteria were studies investigating timing and safety of VTEp in TBI patients not previously on oral anticoagulation. Two investigators extracted data and graded the papers' levels of evidence. Randomized controlled trials were assessed for bias according to the Cochrane Collaboration Tool and Cohort studies were evaluated for bias using the Newcastle-Ottawa Scale. We performed univariate meta-regression analysis in an attempt to identify a relationship between VTEp timing and hemorrhagic progression and assess study heterogeneity using an I 2 statistic. RESULTS: Twenty-one studies were included in the systematic review. Eighteen total studies demonstrated that VTEp postinjury in patients with stable head computed tomography scan does not lead to TBI progression. Fourteen studies demonstrated that VTEp administration 24 to 72 hours postinjury is safe in patients with stable injury. Four studies suggested that administering VTEp within 24 hours of injury in patients with stable TBI does not lead to progressive intracranial hemorrhage. Overall, meta-regression analysis demonstrated that there was no relationship between rate of hemorrhagic progression and VTEp timing. CONCLUSIONS: Literature suggests that administering VTEp 24 to 48 hours postinjury may be safe for patients with low-hemorrhagic-risk TBIs and stable injury on repeat imaging.

Multidisciplinary in-situ simulation to evaluate a rare but high-risk process at a level 1 trauma centre: the "Mega-Sim" approach

Summary: Multidisciplinary simulation has been used to successfully teach crisis resource management in operating room and emergency department settings. This article describes a "Mega-Sim" approach using an in-situ simulation that moves among multiple hospital departments to enhance multidisciplinary training and assess institutional response to a rare but high-risk event: trauma in a pregnant patient. It appears that a Mega-Sim can be used to identify systems issues, increase medical knowledge and improve perceptions of teamwork and communication within and among hospital departments.

A day in the life of emergency general surgery in Canada: a multicentre observational study.

BACKGROUND: Emergency general surgery (EGS) services are gaining popularity in Canada as systems-based approaches to surgical emergencies. Despite the high volume, acuity and complexity of the patient populations served by EGS services, little has been reported about the services' structure, processes, case mix or outcomes. This study begins a national surveillance effort to define and advance surgical quality in an important and diverse surgical population. METHODS: A national cross-sectional study of EGS services was conducted during a 24-hour period in January 2017 at 14 hospitals across 7 Canadian provinces recruited through the Canadian Association of General Surgeons Acute Care Committee. Patients admitted to the EGS service, new consultations and off-service patients being followed by the EGS service during the study period were included. Patient demographic information and data on operations, procedures and complications were collected. RESULTS: Twelve sites reported resident coverage. Most services did not include trauma. Ten sites had protected operating room time. Overall, 393 patient encounters occurred during the study period (195/386 [50.5%] operative and 191/386 [49.5%] nonoperative), with a mean of 3.8 operations per service. The patient population was complex, with 136 patients (34.6%) having more than 3 comorbidities. There was a wide case mix, including gallbladder disease (69 cases [17.8%]) and appendiceal disease (31 [8.0%]) as well as complex emergencies, such as obstruction (56 [14.5%]) and perforation (23 [5.9%]). CONCLUSION: The characteristics and case mix of these Canadian EGS services are heterogeneous, but all services are busy and provide comprehensive operative and nonoperative care to acutely ill patients with high levels of comorbidity.

CONTEXTE: Les services de chirurgie générale d'urgence (CGU) gagnent en popularité au Canada en tant qu'approches systémiques aux urgences chirurgicales. Malgré le volume élevé, le caractère urgent et la complexité des populations de patients desservies en CGU, peu de rapports ont porté sur la structure, les processus, les clientèles ou les résultats de ces services. La présente étude instaure une démarche de surveillance nationale qui servira à définir et à améliorer la qualité des chirurgies destinées à cette population importante et hétérogène. MÉTHODES: Une étude transversale nationale sur les services de CGU a été réalisée sur une période de 24 heures en janvier 2017 dans 14 hôpitaux de 7 provinces canadiennes recrutés par l'entremise du comité pour les soins aigus de l'Association canadienne des chirurgiens généraux. On y a inclus les patients admis dans les services de CGU, les nouvelles consultations et les patients de l'extérieur suivis par les services de CGU pendant la période de l'étude. On a recueilli les caractéristiques démographiques des patients et les données sur les interventions, les procédures et les complications. RÉSULTATS: Douze sites ont fait état de la couverture assurée par les résidents. La plupart des services ont exclu la traumatologie. Dix sites disposaient de temps protégé au bloc opératoire. En tout, 393 rencontres avec des patients ont eu lieu pendant la période de l'étude (195/386 [50,4 %] chirurgicales, 191/386 [49,5 %] non chirurgicales), avec une moyenne de 3,8 chirurgies par service. La population regroupait des cas complexes : 136 patients (34,6 %) présentaient plus de 3 comorbidités. La clientèle était diversifiée et comprenait des cas de maladie de la vésicule biliaire (69 cas [17,8 %]) et de l'appendice (31 [8,0 %]), de même que des situations d'urgence délicates, telle qu'obstruction (56 [14,5 %]) et perforation (23 [5,9 %]). CONCLUSION: Leurs caractéristiques et leurs clientèles sont hétérogènes, mais les services de CGU sont tous achalandés et ils offrent tous des soins chirurgicaux et non chirurgicaux complets à des patients gravement malades porteurs d'importantes comorbidités.

Does increased prehospital time lead to a "trial of life" effect for patients with blunt trauma?

BACKGROUND: Variance in prehospital time among severely injured blunt trauma patients is dependent upon numerous factors. Effects on subsequent mortality and trauma team activation (TTA) rates are also unclear. The primary aim of this study was to evaluate the relationship between prehospital time and mortality at level I trauma referral centers amongst critically blunt injured patients. MATERIALS AND METHODS: This multiinstitutional study from three geographically distinct level I trauma centers analyzed all severely blunt injured patients (Injury Severity Score [ISS] ≥12). The relationship between prehospital time and survival was evaluated. Secondary outcomes included the association between prehospital time and TTA. Standard statistical methodology was used (P < 0.05 = significance). RESULTS: Between January 1, 2011, and January 1, 2016, 5375 severely blunt injured patients (mean ISS = 25; mean length of stay = 16.3 d) were analyzed (center 1 = 3376; center 2 = 2401; and center 3 = 1104). As prehospital time interval increased, overall mortality decreased (0-30 min = 24.1%; 31-60 min = 14.7%; 61-90 min = 10.3%; 91-120 min = 10.4%; 121-150 min = 10.2%; P < 0.05). This pattern was especially strong for patients with an arrival measurement of hypotension, despite corrections for ISS (P < 0.05). TTA and patient outcomes were extremely variable across intervals and centers (P < 0.05). CONCLUSIONS: A trial of life effect is present for severely blunt injured patients who arrive with vital signs. Despite arrival measurements of hypotension, patients with prolonged prehospital times have a substantially lower risk of subsequent mortality. This concept should contribute to decision-making with regard to TTA.

Timing of cholecystectomy following endoscopic sphincterotomy: a population-based study.

BACKGROUND: Choledocholithiasis is commonly treated initially with endoscopic sphincterotomy, followed by cholecystectomy to definitively address the underlying problem of cholelithiasis. While the benefits of early cholecystectomy have been realized in other populations, the preferred timing for this subset of patients is less well established. We performed a large, population-based analysis to determine the frequency, benefits, and practice variance in regard to early cholecystectomy on a provincial level. METHODS: Patients undergoing endoscopic sphincterotomy followed by cholecystectomy in British Columbia, Canada, from January 2001 to December 2011 were identified using fee-code billing data. Multiple databases were linked to obtain information on demographics, admissions, procedures, mortality, and census geographic data. Regression analysis was performed for length of stay (LOS) and additional procedures. Outcome data were risk adjusted for age, gender, comorbidities, socioeconomic status, and year of procedure. Variability of early cholecystectomy crude rates across census areas was determined using a funnel plot. RESULTS: There were 4287 eligible patients. Of these, 1905 (44.4%) underwent early cholecystectomy, defined as surgery within 14 days of sphincterotomy. Median interval to cholecystectomy was 2 days for the early cholecystectomy group and 61 days for delayed. There was a significant difference in hospital LOS favoring early cholecystectomy for patients with documented gallstone disease (p < 0.05). Patients initially admitted to a surgical service were more likely to undergo early cholecystectomy (60 vs. 36%, p < 0.001). There was no difference between groups in terms of bile duct injury or mortality. There was wide variability in rates of early cholecystectomy among census areas (range 0-96%) and health regions (range 20-66%) which was not explained by population density or geography. CONCLUSION: Early cholecystectomy is the ideal approach to gallstone disease post-sphincterotomy. Despite this, a large amount of clinical variance exists in regard to timing of cholecystectomy which seems to be primarily institution dependent.