The right treatment at the right time in the right place: a population-based, before-and-after study of outcomes associated with implementation of an all-inclusive trauma system in a large Canadian province.

OBJECTIVE: To evaluate the implementation of an all-inclusive philosophy of trauma care in a large Canadian province. BACKGROUND: Challenges to regionalized trauma care may occur where transport distances to level I trauma centers are substantial and few level I centers exist. In 2008, we modified our predominantly regionalized model to an all-inclusive one with the hopes of increasing the role of level III trauma centers. METHODS: We conducted a population-based, before-and-after study of patient admission and transfer practices and outcomes associated with implementation of an all-inclusive provincial trauma system using multivariable Poisson and linear regression and Cox proportional hazard models. RESULTS: In total, 21,772 major trauma patients were included. Implementation of the all-inclusive model of trauma care was associated with a decline in transfers directly to level I trauma centers [risk ratio (RR) = 0.91; 95% confidence interval (CI): 0.88-0.94; P < 0.001] and an increase in transfers from level III to level I centers (RR = 1.10; 95% CI: 1.00-1.21; P = 0.04). These changes in trauma care occurred in conjunction with a 12% reduction in the hazard of mortality (hazard ratio = 0.88; 95% CI: 0.84-0.98; P = 0.003) and a decrease in mean trauma patient hospital length of stay by 1 day (95% CI: 1.02-1.11; P = 0.02) after adjustment for differences in case mix. CONCLUSIONS: In this study, introduction of an all-inclusive provincial trauma system was associated with an increased number of injured patients cared for in their local systems and improved trauma patient mortality and hospital length of stay.

Delayed recovery associated with persistent serum concentrations after clozapine overdose.

Experience with managing overdoses of the atypical antipsychotic agent, clozapine, has been limited. A 20-year-old woman, who presented 6 h after ingesting 3500 mg of clozapine, had an unexpectedly prolonged duration of tachycardia and somnolence. Successful recovery followed management with supportive measures for several days in the intensive care unit. However, the duration of symptoms greatly exceeded that predicted by the published 12-h half-life of clozapine and was associated with an unexplained persistence of serum clozapine concentrations. Recovery with normalization of autonomic function occurred only after serum clozapine began to decline again after a 4-day plateau, as revealed by serum monitoring. Similar observations have been reported in two other cases. In overdose, clozapine may not behave as predicted by its published pharmacokinetics. Persistent serum drug concentrations may prolong the period of intensive care, suggesting that aggressive measures to remove clozapine from the gut at the time of overdose may be warranted.

The risk of cardiovascular disease in adults who have had childhood nephrotic syndrome.

While increased risk of cardiovascular disease (CVD) in patients with hyperlipidemia, chronic kidney disease (CKD), or end-stage renal disease (ESRD) is well documented, transient hyperlipidemia or intermittent renal disease as a consequence of relapsing nephrotic syndrome (NS) has not been studied. To investigate this enigma, 62 patients, between 25 and 53 years of age, who had steroid-responsive/dependent NS during childhood, were identified from the records of the Division of Pediatric Nephrology at Yale School of Medicine. Forty patients were located and contacted to ascertain symptoms or occurrences of CVD via a telephone interview. At the time of follow-up, 23-46 years after cessation of NS, none of these patients had ESRD or CKD. Three patients had experienced a myocardial infarction (MI): a 32-year-old male with a family history of CVD; a 41-year-old male with a history of heavy smoking, hypertension, diabetes mellitus, and elevated cholesterol; a 31-year-old male after a cocaine overdose. The occurrence of events (8%) and mortality from CVD (none) in this cohort of patients is comparable to patients of a similar age in the general population and is lower than that of patients of the same age who are on dialysis. The data suggest that relapsing NS during childhood does not place patients at increased risk for CVD mortality or morbidity compared with the general population. Consequently, it would appear that factors related to persistent proteinuria or renal insufficiency, rather than transient proteinuria and renal disease, contribute to the CVD documented in patients with CKD or ESRD.