Use of Lean methodology to improve operating room efficiency in hospitals across the Kingdom of Saudi Arabia.

OBJECTIVE: The objective of this study was to assess whether an intervention on process efficiency using the Lean methodology leads to improved utilization of the operating room (OR), as measured by key performance metrics of OR efficiency. DESIGN: A quasi-experimental design was used to test the impact of the intervention by comparing pre-intervention and post-intervention data on five key performance indicators. SETTING: The ORs of 12 hospitals were selected across regions of the Kingdom of Saudi Arabia (KSA). PARTICIPANTS: The participants were patients treated at these hospitals during the study period. INTERVENTION(S): The intervention comprised the following: (i) creation of visual dashboards that enable starting the first case on time; (ii) use of computerized surgical list management; (iii) optimization of time allocation; (iv) development of an operating model with policies and procedures for the pre-anesthesia clinic; and (iv) creation of a governance structure with policies and procedures for day surgeries. MAIN OUTCOME MEASURE(S): The following were the main outcome measures: on-time start for the first case, room turnover times, percent of overrun cases, average weekly procedure volume and OR utilization. RESULTS: The hospital exhibited statistically significant improvements in the following performance metrics: on-time start for the first case, room turnover times and percent of overrun cases. A statistically significant difference in OR utilization or average weekly procedure volumes was not detected. CONCLUSIONS: The implementation of a Lean-based intervention targeting process efficiency applied in ORs across various KSA hospitals resulted in encouraging results on some metrics at some sites, suggesting that the approach has the potential to produce significant benefit in the future. Copyright © 2016 John Wiley & Sons, Ltd.

The state of health in the Arab world, 1990-2010: an analysis of the burden of diseases, injuries, and risk factors.

BACKGROUND: The Arab world has a set of historical, geopolitical, social, cultural, and economic characteristics and has been involved in several wars that have affected the burden of disease. Moreover, financial and human resources vary widely across the region. We aimed to examine the burden of diseases and injuries in the Arab world for 1990, 2005, and 2010 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010). METHODS: We divided the 22 countries of the Arab League into three categories according to their gross national income: low-income countries (LICs; Comoros, Djibouti, Mauritania, Yemen, and Somalia), middle-income countries (MICs; Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, occupied Palestinian territory, Sudan, Syria, and Tunisia), and high-income countries (HICs; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). For the whole Arab world, each income group, and each individual country, we estimated causes of death, disability-adjusted life years (DALYs), DALY-attributable risk factors, years of life lived with disability (YLDs), years of life lost due to premature mortality (YLLs), and life expectancy by age and sex for 1990, 2005, and 2010. FINDINGS: Ischaemic heart disease was the top cause of death in the Arab world in 2010 (contributing to 14·3% of deaths), replacing lower respiratory infections, which were the leading cause of death in 1990 (11·0%). Lower respiratory infections contributed to the highest proportion of DALYs overall (6·0%), and in female indivduals (6·1%), but ischaemic heart disease was the leading cause of DALYs in male individuals (6·0%). DALYs from non-communicable diseases--especially ischaemic heart disease, mental disorders such as depression and anxiety, musculoskeletal disorders including low back pain and neck pain, diabetes, and cirrhosis--increased since 1990. Major depressive disorder was ranked first as a cause of YLDs in 1990, 2005, and 2010, and lower respiratory infections remained the leading cause of YLLs in 2010 (9·2%). The burden from HIV/AIDS also increased substantially, specifically in LICs and MICs, and road injuries continued to rank highly as a cause of death and DALYs, especially in HICs. Deaths due to suboptimal breastfeeding declined from sixth place in 1990 to tenth place in 2010, and childhood underweight declined from fifth to 11th place. INTERPRETATION: Since 1990, premature death and disability caused by communicable, newborn, nutritional, and maternal disorders (with the exception of HIV/AIDS) has decreased in the Arab world--although these disorders do still persist in LICs--whereas the burden of non-communicable diseases and injuries has increased. The changes in the burden of disease will challenge already stretched human and financial resources because many Arab countries are now dealing with both non-communicable and infectious diseases. A road map for health in the Arab world is urgently needed. FUNDING: Bill & Melinda Gates Foundation.

Constructing a question bank based on script concordance approach as a novel assessment methodology in surgical education.

BACKGROUND: Script Concordance Test (SCT) is a new assessment tool that reliably assesses clinical reasoning skills. Previous descriptions of developing SCT-question banks were merely subjective. This study addresses two gaps in the literature: 1) conducting the first phase of a multistep validation process of SCT in Plastic Surgery, and 2) providing an objective methodology to construct a question bank based on SCT. METHODS: After developing a test blueprint, 52 test items were written. Five validation questions were developed and a validation survey was established online. Seven reviewers were asked to answer this survey. They were recruited from two countries, Saudi Arabia and Canada, to improve the test's external validity. Their ratings were transformed into percentages. Analysis was performed to compare reviewers' ratings by looking at correlations, ranges, means, medians, and overall scores. RESULTS: Scores of reviewers' ratings were between 76% and 95% (mean 86% ± 5). We found poor correlations between reviewers (Pearson's: +0.38 to -0.22). Ratings of individual validation questions ranged between 0 and 4 (on a scale 1-5). Means and medians of these ranges were computed for each test item (mean: 0.8 to 2.4; median: 1 to 3). A subset of test items comprising 27 items was generated based on a set of inclusion and exclusion criteria. CONCLUSION: This study proposes an objective methodology for validation of SCT-question bank. Analysis of validation survey is done from all angles, i.e., reviewers, validation questions, and test items. Finally, a subset of test items is generated based on a set of criteria.

Seasonal variation of hypertrophic pyloric stenosis: a population-based study.

INTRODUCTION: Seasonal variation in the incidence of hypertrophic pyloric stenosis (HPS) has been long debated. The goal of this study was to determine if seasonal variation exists in the incidence of pyloric stenosis. METHODS: A population-based cohort consisted of all infants in the province of Ontario, Canada with HPS from 1993 to 2000. The incidence of HPS per season was adjusted by birth rate and expressed as number of pyloromyotomies per 100,000 infants less than 12 months of age. One-way analysis of variance was used to compare HPS incidence between seasons. Further time series and spectral analysis were performed to examine for seasonal variation. RESULTS: There were 1,777 infants included in the population-based cohort. June was the month with the highest rate of HPS. The highest rate of pyloromyotomy occurred in the summer 14.92 and the lowest in the winter 10.73, this difference was statistically significant (p = 0.01). Spectral analysis showed that June was the month with the highest rate and February had the lowest rates p = 0.0014. CONCLUSION: Hypertrophic pyloric stenosis more commonly presents in the summer. Seasonal variation suggests a possible etiological role for environmental factors.

Food Taste, Dietary Consumption, and Food Preference Perception of Changes Following Bariatric Surgery in the Saudi Population: A Cross-Sectional Study.

BACKGROUND: Bariatric surgery is known as the most effective treatment resulting in long-term weight loss for obesity. However, behavioral changes, including food preference, food allergies, and consumption, between groups of patients who underwent bariatric surgery in comparison with people who did not have bariatric surgery have not been fully discussed in the literature. OBJECTIVE: The aim of this article is to describe patient-reported changes of perception related to food preferences, consumption, and food allergies in participants who underwent bariatric surgery and to compare their food consumption with participants who did not have bariatric surgery in Saudi Arabia. METHODOLOGY: This study is a secondary analysis of the Sharik Diet and Health National Survey (SDHNS) conducted in July 2021. Quota sampling was utilized to generate balanced distributions of participants by age and gender across all administrative regions of Saudi Arabia. Data collection included sociodemographic information (age, gender, and educational level), as well as food habits and the consumption of various food categories. RESULTS: Of the 6267 potential participants contacted in 2021 from the 13 administrative regions of Saudi Arabia, 5228 successfully completed the interview, with a response rate of 83.4%. Gender was distributed equally among the total participants in the sample. The prevalence of bariatric surgeries in Saudi Arabia was estimated at around 4.1% of the total sample. More than 36% of people who had bariatric surgery experienced food taste changes, and around 15% reported a decrease in allergic reactions to food. Moreover, 68.1% had food preference changes, either starting to favor a new food or no longer favoring one. There was a significant association between consuming more red meat, chicken, and energy drinks and a decreased consumption of grains and rice among those who had the bariatric surgery compared with those who did not. CONCLUSIONS: This study found that more than two-thirds of people who had bariatric surgery self-reported food taste and food preference changes. More studies should be performed on the Saudi population, including clinical follow-up, to better understand these changes.

Reporting of Differences in Taste Between Branded and Unbranded Cigarettes by Smokers Blinded to Cigarette Branding: Within-Person, Randomized Crossover Study.

BACKGROUND: Saudi Arabia implemented a plain tobacco packaging regulation, one of the World Health Organization's recommended initiatives to help reduce smoking rates, in August 2019. A few weeks after implementation, a large number of smokers complained via various media channels, especially social media (eg, Twitter), that an extreme change in cigarette taste had occurred, frequency of coughing had increased, and for some, shortness of breath had led to hospitalization. OBJECTIVE: The main objective is to determine whether smokers blinded to cigarette branding report differences in taste between branded and unbranded cigarettes. The secondary objective is to observe the frequency of immediate cough or shortness of breath. METHODS: This study employed a within-person, randomized crossover design that recruited current smokers 18 years and older who were cleared upon physical assessment before the experiment. Participants received 6 sequences of different random exposures (3 puffs) to 3 plain-packaged cigarettes (2 from their favorite brand and 1 from another brand as a control) and 3 branded cigarettes (2 from the favorite brand and 1 from another brand as a control). Participants wore virtual reality goggles accompanied by special software to alter visual reality and gloves to alter the touch sensation. RESULTS: This study recruited 18 participants, measured at 6 time points, to produce 108 experiments. Participants were not able to identify the correct type of cigarettes (plain or branded, estimate of fixed effect=-0.01, P=.79). Moreover, there were no differences in the ability of the participants to identify their favorite brand (t107=-0.63, mean 0.47, P=.53). In terms of immediate coughing, out of the 108 experiments, 1 episode of short coughing was observed, which was attributed to the branded cigarette, not the plain-packaged cigarette. CONCLUSIONS: After controlling the visual and touch sensations, participants were not able to differentiate between branded and plain-packaged cigarettes in terms of taste or inducing immediate shortness of breath or cough. Interestingly, participants were not able to identify their favorite brand.

Robot-assisted pediatric surgery: how far can we go?

BACKGROUND: The purpose of this study was to assess the safety and feasibility of performing robot-assisted pediatric surgery using the da Vinci Surgical System in a variety of surgical procedures. METHODS: A retrospective review of 144 robot-assisted pediatric surgical procedures performed in our institution between June 2004 and December 2007 was done. The procedures included the following: 39 fundoplications; 34 cholecystectomies; 25 gastric bandings; 13 splenectomies; 4 anorectal pull-through operations for imperforate anus; 4 nephrectomies; 4 appendectomies; 4 sympathectomies; 3 choledochal cyst excisions with hepaticojejunostomies; 3 inguinal hernia repairs; two each of the following: liver cyst excision, repair of congenital diaphragmatic hernia, Heller's myotomy, and ovarian cyst excision; and one each of the following: duodeno-duodenostomy, adrenalectomy, and hysterectomy. RESULTS: A total of 134 procedures were successfully completed without conversion; 7 additional cases were converted to open surgery, and 3 were converted to laparoscopic surgery. There were no system failures (e.g., setup joint, arm, or camera malfunction; power error; monocular or binocular loss; metal fatigue or break of surgeon's console hand piece; software incompatibility). There was one esophageal perforation and two cases of transient dysphagia following Nissen fundoplication. The mean patient age was 8.9 years, and the mean patient weight was 57 kg. CONCLUSIONS: Robot-assisted surgery appears to be safe and feasible for a number of pediatric surgical procedures. Further system improvement and randomized studies are required to evaluate the benefits, if any, and the long-term outcomes of robotic surgery.

Impact of wait time on outcome for inguinal hernia repair in infants.

BACKGROUND: Prolonged surgical wait times are a problem in many health care systems. We used data from two pediatric surgical centers, one Canadian and one American, in order to determine if increased wait times are related to rates of incarceration and adverse outcomes. METHODS: Data were collected for children under the age of 2 who presented with an inguinal hernia to either the emergency department or clinic in the two hospitals in 2002 and 2003. RESULTS: Infants in the Canadian center were older at presentation and were more likely to present to the emergency department. Wait time for hernia repair was longer in the Canadian than the American hospital (99 +/- 103 vs. 27 +/- 53 days, P < 0.001). The incidence of incarceration was higher in the Canadian hospital, and infants in the Canadian center were more likely to have episodes of recurrent incarceration. Emergency department usage was greater in the Canadian hospital both at the time of diagnosis as well as during the waiting period for surgery. DISCUSSION: Prolonged wait time for inguinal hernia repair in infants is associated with a higher rate of incarceration as well as greater usage of emergency department resources. These data are important for those surgeons working in systems with limited resources in which strategies to shorten wait times are necessary.

Risk of incarceration of inguinal hernia among infants and young children awaiting elective surgery.

BACKGROUND: We determined the rate of incarceration of inguinal hernia among infants and young children waiting for elective surgery and examined the relation to wait times. We also explored the relation between wait times and the use of emergency department services before surgery. METHODS: We used linked data from administrative databases to identify infants and children less than 2 years of age who underwent surgical repair of an inguinal hernia between Apr. 1, 2002, and Mr. 31, 2004. We determined the rate of hernia incarceration during the wait for surgery and stratified the risk by patient age and sex. We used logistic regression analysis to examine factors associated with hernia incarceration and wait times. RESULTS: A total of 1065 infants and children less than 2 years old underwent surgical repair of an inguinal hernia during the study period. The median wait time was 35 days (interquartile range 17-77 days). Within 30 days after diagnosis, 126 (11.8%) of the patients had at least 1 emergency department visit; 23.8% of them presented with hernia incarceration. The overall rate of hernia incarceration was 11.9%. The rate was 5.2% with a wait time of up to 14 days (median time from diagnosis to first emergency department visit), as compared with 10.1% with a wait time of up to 35 days (median wait time to surgery) (p < 0.001). Factors associated with an increased risk of incarcerated hernia were age less than 1 year (odds ratio [OR] 2.07, 95% confidence interval [CI] 1.32-3.23), female sex (OR 1.75, 95% CI 1.04-2.93) and emergency department visits (1 visit, OR 2.73, 95% 1.65-4.50; > or = 2 visits, OR 3.77, 95% CI 1.89-7.43). Children less than 1 year old who waited longer than 14 days had a significant 2-fold risk of incarcerated hernia (OR 1.92, 95% CI 1.11-3.32). INTERPRETATION: A wait time for surgery of more than 14 days was associated with a doubling of the risk of hernia incarceration among infants and young children with inguinal hernia. Our data support a recommendation that inguinal hernias in this patient population be repaired within 14 days after diagnosis.

Level of evidence in minimal access pediatric surgery.

INTRODUCTION: The use of minimal access techniques is rapidly expanding in pediatric surgery. Our aim was to answer two questions: (1) What is the current quality of evidence for minimal access pediatric surgery (MAPS)? and (2) Has the evidence for MAPS improved with respect to focus and methodology over a 12-year period (1995-2006)? METHODS: A systematic review was performed. Data collected included: study characteristics, methods, and outcomes recorded. Approval by a research ethics board (REB) was recorded, where applicable, and articles were assessed for the reporting of learning curves and study limitations. Studies were divided into two eras according to publication date. Data were compared by using correlation, chi-squares, and univariate analyses. RESULTS: Four hundred and ten studies met the inclusion criteria. Of those, 260 (63.4%) were published in the late era. Only 1.46% of studies were level 1, whereas level 4 evidence was predominant (71.46%). The two eras were comparable with regard to country of origin, single-institution studies, length of follow-up, and quality of outcomes reporting. More studies reported REB approval (P = 0.0001) and clearly documented limitation of study design (P = 0.03) in the late era. CONCLUSIONS: There has been a significant increase in the number of articles dealing with MAPS. Recent studies were more likely to report limitations of study design and REB approval, but overall, there was no increase in level of evidence in the MAPS literature over the past 12 years. Although more research is being published, more attention needs to be paid to producing higher quality evidence.

Applicability of adult guidelines for withholding or terminating resuscitation for prehospital traumatic cardiopulmonary arrest in pediatrics.

PURPOSE: The aim of this study is to assess the applicability to a pediatric population of adult guidelines for withholding or terminating traumatic cardiopulmonary resuscitation (CPR). METHOD: Using a trauma registry database and patient data from May 2001 to February 2011, a retrospective cohort study was conducted for all trauma patients less than 18 years of age who arrived at the emergency department (ED) with no pulse at King Abdulaziz Medical City in Riyadh. The clinical criteria of the adult guidelines were applied to the study population; these criteria include an absence of pulse, apnea, unorganized electrocardiogram and fixed pupils (all observed at the scene). Then the outcomes of the studied patients were interpreted based on these guidelines; this analysis highlighted the relationship between the outcomes and the four clinical criteria of the adult guidelines. RESULTS: During the study period, 104 patients arrived at the ED with no pulse. CPR was initiated for only 44 of these patients. Unfortunately, every patient in this group died within 24 hours of ED arrival. Out of these 104 patients, 92 met the four clinical criteria of the adult guidelines, 11 met only three criteria, and one met only two criteria. CONCLUSION: The clinical criteria of the previously published adult guidelines for terminating or withholding resuscitation correctly predicted 100% of the patient mortality when all criteria were met.

Physician job satisfaction in Saudi Arabia: insights from a tertiary hospital survey.

BACKGROUND AND OBJECTIVES: Job satisfaction refers to the extent to which people like or dislike their job. Job satisfaction varies across professions. Few studies have explored this issue among physicians in Saudi Arabia. The objective of this study is to determine the level and factors associated with job satisfaction among Saudi and non-Saudi physicians. METHODS: In this cross-sectional study conducted in a major tertiary hospital in Riyadh, a 5-point Likert scale structured questionnaire was used to collect data on a wide range of socio-demographic, practice environment characteristics and level and consequences of job satisfaction from practicing physicians (consultants or residents) across different medical specialties. Logistic regression models were fitted to determine factors associated with job satisfaction. RESULTS: Of 344 participants, 300 (87.2%) were Saudis, 252 (73%) males, 255 (74%) married, 188 (54.7%) consultants and age [median (IQR)] was 32 (27-42.7) years. Overall, 104 (30%) respondents were dissatisfied with their jobs. Intensive care physicians were the most dissatisfied physicians (50%). In a multiple logistic regression model, income satisfaction (odds ratio [OR]=0.448 95% CI 0.278-0.723, P < .001) was the only factor independently associated with dissatisfaction. CONCLUSION: Factors adversely associated with physicians job satisfaction identified in this study should be addressed in governmental strategic planning aimed at improving the healthcare system and patient care.

Congenital Morgagni's hernia: a national multicenter study.

BACKGROUND: Congenital Morgagni's hernia (CMH) is rare and represents less than 5% of all congenital diaphragmatic hernias. This is a national review of our experience with CMH outlining clinical presentation, methods of diagnosis, associated anomalies, treatment, and outcome. PATIENTS AND METHODS: The medical records of all patients with the diagnosis of CMH treated at four pediatric surgery units in Saudi Arabia were retrospectively reviewed for age at diagnosis, sex, presenting symptoms, associated anomalies, diagnosis, operative findings, treatment, and outcome. RESULTS: During a 20-year period (January 1990-December 2010), 53 infants and children with CMH were treated. There were 38 males and 15 females. Their age at diagnosis ranged from 1 month to 9 years (mean 22.2 months). Forty-three (81%) presented with recurrent chest infection. Twenty-two (44.5%) had right CMH, 15 (28.3%) had left-sided hernia and 16 (30.2%) had bilateral hernia. In 7, the diagnosis of bilaterality was made at the time of surgery. Associated anomalies were seen in 38 (71.7%). Twenty-one (39.6%) had congenital heart disease, 8 (15%) had malrotation, and 15 (28.3%) had Down syndrome. All were operated on. Twenty-nine (54.7%) underwent repair via an open approach. The remaining 24 (45.3%) underwent repair using minimal invasive surgery, laparoscopic-assisted hernia repair (19 patients) or totally laparoscopic approach (5 patients). At the time of surgery, the hernia sac content included the colon in 33 (62.3%), part of the left lobe of the liver in 13 (24.5%), the small intestines in 11 (20.75%), the omentum in 5 (9.4%), and the stomach in 4 (7.5%). In 12 (22.6%), the hernia sac was empty. When compared to the open repair, the laparoscopic-assisted approach was associated with a shorter operative time, an earlier commencement of feeds, less requirement for postoperative analgesia, a shorter hospital stay, and better cosmetic appearance. There was no mortality. On follow-up, 2 (7%) of the open surgical group developed recurrence. CONCLUSIONS: CMH is rare and in the pediatric age group commonly presents with recurrent chest infection and has a high incidence of associated anomalies, commonly congenital heart disease and Down syndrome. We advocate a laparoscopic-assisted approach to repair CMH. This is a simple technique that produces a sound repair, and when compared with the open approach it takes less operative time, requires less analgesia, allows earlier commencement of feeds, is associated with a shorter hospital stay, and has a better cosmetic outcome.

Thoracoscopic repair of neonatal congenital diaphragmatic hernia (CDH): outcomes after a systematic quality improvement process.

BACKGROUND: Higher recurrence rates have been reported for thoracoscopic repair (TR) of neonatal congenital diaphragmatic hernia (CDH) compared to open repair. Our centre initiated changes in surgical management following a quality review in order to improve outcome. METHODS: A retrospective review of TR patients from 2000 to 2011 at a single institution was performed. A review was done in 2007, and changes were implemented to decrease recurrence rates. These included use of pledgets, an extracorporeal corner stitch, liberal prosthetic patch use, lower insufflation pressures, and TR was limited to two experienced surgeons. Outcome data before and after this quality improvement process were compared. Non-TR patients from the same time period served as controls. Data are quoted as median (range) and non-parametric tests used to compare. P<0.05 was regarded as significant. RESULTS: There were 23 neonatal TR patients with median follow-up of 3.6 (range 0.4-7) years. Median age at repair was 2 (range 0-21) days. There were 5 patch repairs (22%), all after 2008. There were 9 recurrences (39%) at a median time of 162 days after TR, compared to 13 (10%) recurrences in the control cohort. For primary TR, there was a trend towards a decreased recurrence rate from 50% prior to 2008 to 25% after 2008 (P=0.26). CONCLUSIONS: Systematic quality review was modestly effective in decreasing the recurrence rate for neonatal TR, but further outcome data are required.

Physician well-being: prevalence of burnout and associated risk factors in a tertiary hospital, Riyadh, Saudi Arabia.

BACKGROUND AND OBJECTIVES: This study is to determine level and factors associated with burnout among physicians in a tertiary hospital in Saudi Arabia. DESIGN AND SETTINGS: This is a cross-sectional study, conducted at the King Fahad National Guard Hospital at in King Abdulaziz Medical City between October 2010 and November 2010. METHODS: The Maslach Burnout Inventory questionnaire was used to measure burnout. Socio-demographic-, specialty-, and work-related characteristics were added to explore factors associated with burnout. RESULTS: The study included 348 participants; 252 (72%) were males, 189 (54%) were consultants, and 159 (46%) were residents. The mean (SD) age was 35 (9.8) years. The burnout prevalence was 243/348 (70%); 136 (56%) of the 243 were residents and 107 (44%) were consultants. Age, female gender, marital status, number of years in practice, sleep deprivation, presence of back pain, and a negative effect of practice on family life were associated with burnout in the univariate logistic regression analysis. The factors independently associated with burnout in the final multivariate model were as follows: suffering from back pain (odds ratio [OR]=2.1, 95%CI 1.2-3.8, P=.01), sleep deprivation (OR=2.2, 95%CI 1.2-3.8, P=.009), being a resident physician/surgeon (OR=4.9, 95%CI 1.7-14.2, P=.004), and negative effect of practice on family life (OR=2.1, 95%CI 1.1-3.9, P=.02). CONCLUSION: In this study, the prevalence of burnout was found to be higher than estimates documented in most other studies. Reported risk factors should be addressed to decrease the prevalence and consequences of burnout.

Epidemiology of traumatic head injury in children and adolescents in a major trauma center in Saudi Arabia: implications for injury prevention.

BACKGROUND AND OBJECTIVES: Injury to the head is the most common affected body part in pediatric trauma and could be associated with deleterious consequences. It presents a challenge for developing countries since many injuries are preventable and there are few epidemiological data to support injury prevention programs. The current study aimed to determine demographic characteristics, etiology and outcome of head injury in the pediatric population and compare findings to international figures. DESIGN AND SETTINGS: Retrospective review of consecutive cases registered in major trauma center database, Riyadh, from 2001 to 2009. PATIENTS AND METHODS: The database registry was limited to hospitalized patients following injury. Any head injury in a patient ≤18 years was included. RESULTS: Of 3796 patients identified, 1219 patients (32.1%) suffered head injury (mean age 8.6 years; males 78.4%). Children under 12 years comprised 66.3%. Motor vehicle crash (MVC) was the commonest cause (34.2%), followed by pedestrian injury (30.3%) and falls (28.4%). When stratified by age, falls (45.6%) were the most common etiology under 6 years while MVC was the leading cause in high school students (74.4%). The latter group had the lowest mean (SD) Glascow coma scale scores ( 8.58 [4.7]), highest mean injury severity scale scores (23.4 [21]), highest rate of craniotomy (7%) and highest mortality (20%). CONCLUSION: One third of pediatric trauma requiring hospital admission suffered head injury. Preschoolers and elementary school students were mostly affected. The striking incidence of pedestrian and fall injuries call for organized national prevention programs. Additionally, more attention should be directed to reduce MVC among high school students given their comparative high rate of severe injuries and deaths following trauma.

Causes and patterns of adult traumatic head injuries in Saudi Arabia: implications for injury prevention.

BACKGROUND AND OBJECTIVES: Data on the epidemiology of traumatic head injuries (THI) is essential for any organized prevention program. Such data are few in the developing world. Our primary goal was to study the causes, descriptive features, and outcomes of THI in adults in Saudi Arabia. DESIGN AND SETTINGS: The present study is a retrospective review. METHODS: This retrospective review included all consecutive cases of adults with THI ( > 18 years) who were admitted to a major trauma centre in Riyadh, Saudi Arabia, from May 2001 to July 2010. Patients were identified through a trauma database, which includes cases that required hospital admission or died in the emergency department. RESULTS: A total of 1870 patients met the inclusion criteria with a mean age of 32.6 years and a male predominance (91.2%). Most injuries were secondary to motor vehicle collisions (MVC; 69.4%). Pedestrian injuries were second (16.8%) and had 40% risk of mortality (odds ratio 0.62, 95% CI 0.48-0.8). Most patients (56.7%) had a severe THI (Glasgow coma score, GCS < 8). The overall mortality rate was 30%. Mortality was significantly associated with older age (P=.0001), lower GCS (P=.0001), and a higher injury severity score (ISS; P=.0001). CONCLUSION: The most common causes of hospital admission following injury were MVC and pedestrian injuries. Both were also the most common causes for injury-related deaths. Safety on the roads should be the primary target for any organized injury prevention programs to be successful.

Does obesity impact the pattern and outcome of trauma in children?

PURPOSE/BACKGROUND: Childhood obesity is pandemic condition. The effect of obesity on trauma outcomes in children has been relatively understudied. We conducted this study to ascertain the effects of obesity on the hospital outcome of injured children. METHODS: A retrospective cohort study of patients aged 2 to 18 years admitted to the King Abdul Aziz Medical City between May 2001 and May 2009 was conducted. Patients were categorized as lean (body mass index <95th percentile) and obese (body mass index ≥ 95th percentile). Groups were compared regarding admission demographics, mechanism of injury, pattern of injury, length of stay, intensive care unit admission, ventilation duration, types of procedures performed, injury severity score, and mortality. RESULT: Nine hundred thirty-three patients were included, of those 55 (5.89%) children were obese. The obese children were older than nonobese (P = .001) and had a higher injury severity score (P = .001) and a lower pediatric trauma score (P = .00), heart rate (P = .0081), and respiratory rate (P = .000). There were no differences between groups with regard to sex, mechanism of injury, and surgical procedures. Obese children were more likely to have rib fractures (P = .02) and pelvic injuries (P = .033). There was no significant association between mortality and obesity (P = .42). CONCLUSION: Obesity does not seem to impact the severity of injury, mortality rate, types of injury, and procedure outcomes in children. Obese patients are more likely to have rib and pelvic injuries.

Toward an objective assessment of technical skills: a national survey of surgical program directors in Saudi Arabia.

BACKGROUND: After almost a decade of implementing competency-based programs in postgraduate training programs, the assessment of technical skills remains more subjective than objective. National data on the assessment of technical skills during surgical training are lacking. We conducted this study to document the assessment tools for technical skills currently used in different surgical specialties, their relationship with remediation, the recommended tools from the program directors' perspective, and program directors' attitudes toward the available objective tools to assess technical skills. METHODS: This study was a cross-sectional survey of surgical program directors (PDs). The survey was initially developed using a focus group and was then sent to 116 PDs. The survey contains demographic information about the program, the objective assessment tools used, and the reason for not using assessment tools. The last section discusses the recommended tools to be used from the PDs' perspective and the PDs' attitude and motivation to apply these tools in each program. The associations between the responses to the assessment questions and remediation were statistically evaluated. RESULTS: Seventy-one (61%) participants responded. Of the respondents, 59% mentioned using only nonstandardized, subjective, direct observation for technical skills assessment. Sixty percent use only summative evaluation, whereas 15% perform only formative evaluations of their residents, and the remaining 22% conduct both summative and formative evaluations of their residents' technical skills. Operative portfolios are kept by 53% of programs. The percentage of programs with mechanisms for remediation is 29% (19 of 65). CONCLUSION: The survey showed that surgical training programs use different tools to assess surgical skills competency. Having a clear remediation mechanism was highly associated with reporting remediation, which reflects the capability to detect struggling residents. Surgical training leadership should invest more in standardizing the assessment of surgical skills.

An innovative method of pediatric chest wall reconstruction using Surgisis and swinging rib technique.

PURPOSE: Herein, we describe a new surgical approach for chest wall reconstruction using a native supporting rib and Surgisis. METHODS: A retrospective review of 3 cases from 2 tertiary pediatric health care centers presenting with chest wall defects in the neonatal period was performed. Perioperative data were collected. RESULTS: Two chest wall deformities were diagnosed at birth (Poland syndrome and cleft sternum). One patient was diagnosed prenatally with a mediastinal mass. The first infant had absent ribs 2 through 9. He underwent chest wall reconstruction at 4 weeks of life because of difficulty weaning from ventilation related to paradoxical breathing. The hamartoma of the second asymptomatic patient was removed at 6 weeks. The third patient's V-shaped sternal defect encompassed through the upper two thirds of the sternum and was repaired at 6 months of age with intraoperative transesophageal echocardiogram monitoring. In all cases, Surgisis (collagen matrix) was used as an onlay patch. In 2 cases, a swinging rib acted supportive. Neither patient had intraoperative complications. CONCLUSION: Surgisis is useful in pediatric chest wall reconstruction, particularly in combination with swinging ribs. The capacity for adaptation to the child's growth of this approach is crucial. Short-term safety is shown, but long-term assessment is required.