Status of trauma quality improvement programs in the Americas: a survey of trauma care providers.

INTRODUCTION: Global disparities in trauma care contribute to significant morbidity and mortality (M&M) in low- and middle-income countries. Implementation of quality improvement (QI) programs has been shown to be a cost-effective strategy to improve trauma care quality. In this study, we aim to characterize the trauma QI programs in a broad range of low- to high-income countries in the Americas to assess areas for targeted improvement in global trauma QI efforts. METHODS: We conducted a mixed methods survey of trauma care providers in North and South America distributed in-person at trauma care conferences and online via a secure survey platform. Responses were analyzed to observe differences across respondent country income categories. RESULTS: One hundred ninety-two surveys were collected, representing 21 different countries from three income strata (three lower-middle-, eleven upper-middle-, and eight high-income countries). Respondents were primarily physicians or physicians-in-training (85%). Eighty-nine percent of respondents worked at an institution where M&M conferences occurred. M&M conferences were significantly more frequent at higher income levels (P = 0.002), as was attending physician presence at M&M conferences (70% in high-income countries versus 43% in lower-middle-income countries). There were also significant differences in the structure, quality, and follow-up of M&M conferences in lower versus higher income countries. Sixty-three percent of respondents reported observing some kind of positive change at their institution due to M&M conferences. The survey also suggested significantly higher utilization of autopsy (P < 0.001) and electronic trauma registries (P = 0.01) at higher income levels. CONCLUSIONS: This survey demonstrated an encouraging pattern of widespread adoption of trauma QI programs in several countries in North and South America. However, there continue to be significant disparities in the structure and function of trauma QI efforts in low- and middle-income countries in the Americas. There are several potential areas for development and improvement of trauma care systems, including standardization of case selection and follow-up for M&M conferences and increased use of medical literature to improve evidence-based care.

Long-Term Exposure to Nitrogen Dioxide and Ozone and Respiratory Health in Children.

RATIONALE: Further evaluation of the impact of long-term exposure to the gaseous air pollutants nitrogen dioxide (NO2) and ozone (O3) on child lung function, and of NO2 or O3 on eosinophilic airway inflammation, is needed. OBJECTIVE: To determine whether NO2 and O3 are associated with lung function and FeNO in children. METHODS: We measured lung function (FEV1 and FVC) at mid-childhood (mean age 7.9 years, n=703), early teens (13.2 years, n=976), and mid-teen (17.6 years, n=624) study visits, and fractional exhaled nitric oxide (FeNO) at the early and mid-teen study visits in Project Viva, a cohort of mother-child pairs in the Boston, MA area. Long-term exposure to NO2 and O3 was estimated at home address using geospatial models. We examined associations of home address NO2 and O3 exposure and proximity to roadway with lung function and FeNO using linear regression models, adjusting for age, sex, height, weight, season, relative humidity, temperature, parental smoking, and measures of socioeconomic status. We examined for effect modification of the mid-teen associations by blood eosinophil level, physical activity, aeroallergen sensitization, and parental atopy. RESULTS: Median exposure to NO2 was 33.1 ppb (interquartile range [IQR] 10.4 ppb) and to O3 was 35.3 ppb (IQR 3.4) in the first year of life. Exposure to NO2 was associated with lower FEV1 and FVC across all age groups and exposure time intervals: e.g. an IQR increment of NO2 exposure from birth through the early teen visit was associated with 189.9 mL lower FEV1 (95% CI -273.3, -106.5) at the mid-teen visit. Lifetime NO2 exposure at was associated with higher FeNO at the early teen visit: e.g. 16.2% higher FeNO [95% CI 7.1-26.4%) per IQR of lifetime NO2 through the early teen visit. O3 exposure was not associated with lung function or FeNO. Aeroallergen sensitization (measured in a subset of participants) modified associations of NO2 and O3 with FeNO. CONCLUSIONS: Exposure to NO2 was associated with lower lung function and higher FeNO among generally healthy children and teenagers. As NO2 exposure levels were within the annual EPA standard, these findings suggest a need to reduce exposure to this pollutant to optimize child respiratory health.

Personal air pollution exposure and metals in the nasal epithelial lining fluid of COPD patients.

Sampling of the nasal epithelial lining fluid is a potential method to assess exposure to air pollution within the respiratory tract among high risk populations. We investigated associations of short- and long-term particulate matter exposure (PM) and pollution-related metals in the nasal fluid of people with chronic obstructive pulmonary disease (COPD). This study included 20 participants with moderate-to-severe COPD from a larger study who measured long-term personal exposure to PM2.5 using portable air monitors and short-term PM2.5 and black carbon (BC) using in-home samplers for the seven days preceding nasal fluid collection. Nasal fluid was sampled from both nares by nasosorption, and inductively coupled plasma mass spectrometry was used to determine the concentration of metals with major airborne sources. Correlations of selected elements (Fe, Ba, Ni, Pb, V, Zn, Cu) were determined within the nasal fluid. Associations between personal long-term PM2.5 and seven day home PM2.5 and BC exposure and nasal fluid metal concentrations were determined by linear regression. Within nasal fluid samples, concentrations of vanadium and nickel (r = 0.8) and lead and zinc (r = 0.7) were correlated. Seven day and long-term PM2.5 exposure were both associated with higher levels of copper, lead, and vanadium in the nasal fluid. BC exposure was associated with higher levels of nickel in the nasal fluid. Levels of certain metals in the nasal fluid may serve as biomarkers of air pollution exposure in the upper respiratory tract.

Comparison of multiplexed protein analysis platforms for the detection of biomarkers in the nasal epithelial lining fluid of healthy subjects.

BACKGROUND: Multiplexed protein analysis platforms are a novel and efficient way to characterize biomarkers in a variety of biological samples. Few studies have compared protein quantitation and reproducibility of results across platforms. We utilize a novel nasosorption technique to collect nasal epithelial lining fluid (NELF) from healthy subjects, and compare the detection of proteins in NELF across three commonly used platforms. METHODS: NELF was collected from both nares of twenty healthy subjects using an absorbent fibrous matrix and analyzed using three different protein analysis platforms: Luminex, Meso Scale Discovery (MSD), and Olink. Twenty-three protein analytes were shared across two or more platforms, and correlations across platforms were assessed using Spearman correlations. RESULTS: Among the twelve proteins represented on all three platforms, IL1⍺ and IL6 were very highly correlated (Spearman correlation coefficient [r] ≥ 0.9); CCL3, CCL4, and MCP1 were highly correlated (r ≥ 0.7); and IFNÉ£, IL8, and TNF⍺ were moderately correlated (r ≥ 0.5). Four proteins (IL2, IL4, IL10, IL13) were poorly correlated across at least two platform comparisons (r < 0.5); for two of these proteins (IL10 and IL13), the majority of observations were below the limits of detection for Olink and Luminex. DISCUSSION: Multiplexed protein analysis platforms are a promising method for analyzing nasal samples for biomarkers of interest in respiratory health research. For most proteins evaluated, there was good correlation across platforms, although results were less consistent for low abundance proteins. Of the three platforms tested, MSD had the highest sensitivity for analyte detection.

Hospital-level Variation in the Quality of Benign Inpatient Urologic Surgery.

OBJECTIVE: To examine hospital-level variation in outcomes following benign urologic surgeries given that hospital-level variation in surgical outcomes can portend quality and appropriateness of care concerns and identify quality improvement opportunities in perioperative care. MATERIALS AND METHODS: Using the Washington State Comprehensive Hospital Abstract Reporting System, we identified patients who underwent transurethral resection of the prostate (TURP), percutaneous nephrostolithotomy (PCNL), and pyeloplasty from 2003 to 2008. We classified prolonged postoperative length of stay (LOS) as that exceeding the 75th percentile, and we measured the rate of Agency for Healthcare Quality Patient Safety Indicators, readmissions, and death. We calculated hospital-specific observed-to-expected event rates using random effects multilevel multivariable models adjusted for age and comorbidity. RESULTS: We identified 6699 TURP patients at 54 hospitals, 2541 PCNL patients at 45 hospitals, and 584 pyeloplasty patients at 36 hospitals. Complication rates were highest after PCNL (22.9% prolonged LOS vs 17.3% for TURP and 13.9% for pyeloplasty, P < .001; 3.4% 90-day mortality vs 0.6% for TURP and 0% for pyeloplasty). Hospital-level variation was most substantial for LOS after TURP and pyeloplasty (8.1% and 14.3% of variance in prolonged LOS, respectively). CONCLUSION: Hospital-level variation is common after benign inpatient urologic surgeries and may relate to difference in perioperative provider practice patterns. The morbidity of PCNL in this study was higher than expected and merits further investigation.