Establishing Consensus on Essential Resources for Musculoskeletal Trauma Care Worldwide: A Modified Delphi Study.

BACKGROUND: Despite evidence that formalized trauma systems enhance patient functional outcomes and decrease mortality rates, there remains a lack of such systems globally. Critical to trauma systems are the equipment, materials, and supplies needed to support care, which vary in availability regionally. The purpose of the present study was to identify essential resources for musculoskeletal trauma care across diverse resource settings worldwide. METHODS: The modified Delphi method was utilized, with 3 rounds of electronic surveys. Respondents consisted of 1 surgeon with expertise in musculoskeletal trauma per country. Participants were identified with use of the AO Trauma, AO Alliance, Orthopaedic Trauma Association, and European Society for Trauma and Emergency Surgery networks. Respondents rated resources on a Likert scale from 1 (most important) to 9 (least important). The "most essential" resources were classified as those rated ≤2 by ≥75% of the sampled group. RESULTS: One hundred and three of 111 invited surgeons completed the first survey and were included throughout the subsequent rounds (representing a 93% response rate). Most participants were fellowship-trained (78%) trauma and orthopaedic surgeons (90%) practicing in an academic setting (62%), and 46% had >20 years of experience. Respondents represented low-income and lower-middle-income countries (LMICs; 35%), upper-middle income countries (UMICs; 30%), and high-income countries (HICs; 35%). The initial survey identified 308 unique resources for pre-hospital, in-hospital, and post-hospital phases of care, of which 71 resources achieved consensus as the most essential. There was a significant difference (p < 0.0167) in ratings between income groups for 16 resources, all of which were related to general trauma care rather than musculoskeletal injury management. CONCLUSIONS: There was agreement on a core list of essential musculoskeletal trauma care resources by respondents from LMICs, UMICs, and HICs. All significant differences in resource ratings were related to general trauma management. This study represents a first step toward establishing international consensus and underscores the need to prioritize resources that are locally available. The information can be used to develop effective guidelines and policies, create best-practice treatment standards, and advocate for necessary resources worldwide. CLINICAL RELEVANCE: This study utilized the Delphi method representing expert opinion; however, this work did not examine patient management and therefore does not have a clinical Level of Evidence.

Current Status of Musculoskeletal Trauma Care Systems Worldwide.

BACKGROUND AND RATIONALE: Although general trauma care systems and their effects on mortality reduction have been studied, little is known of the current state of musculoskeletal trauma delivery globally, particularly in low-income (LI) and low middle-income (LMI) countries. The goal of this study is to assess and describe the development and availability of musculoskeletal trauma care delivery worldwide. MATERIALS & METHODS: A questionnaire was developed to evaluate different characteristics of general and musculoskeletal trauma care systems, including general aspects of systems, education, access to care and pre- and posthospital care. Surgical leaders involved with musculoskeletal trauma care were contacted to participate in the survey. RESULTS: Of the 170 surveys sent, 95 were returned for use for the study. Nearly 30 percent of surgeons reported a formalized and coordinated trauma system in their countries. Estimates for the number of surgeons providing musculoskeletal trauma per one million inhabitants varied from 2.6 in LI countries to 58.8 in high-income countries. Worldwide, 15% of those caring for musculoskeletal trauma are fellowship trained. The survey results indicate a lack of implemented musculoskeletal trauma care guidelines across countries, with even high-income countries reporting less than 50% availability in most categories. Seventy-nine percent of the populations from LI countries were estimated to have no form of health care insurance. Formalized emergency medical services were reportedly available in only 33% and 50% of LI and LMI countries, respectively. Surgeons from LI and LMI countries responded that improvements in the availability of equipment (100%), number and locations of trauma-designated hospitals (90%), and physician training programs (88%) were necessary in their countries. The survey also revealed a general lack of resources for postoperative and rehabilitation care, irrespective of the country's income level. CONCLUSION: This study addresses the current state of musculoskeletal trauma care delivery worldwide. These results indicate a greater need for trauma system development and support, from prehospital through posthospital care. Optimization of these systems can lead to better outcomes for patients after trauma. This study represents a critical first step toward better understanding the state of musculoskeletal trauma care in countries with different levels of resources, developing strategies to address deficiencies, and forming regional and international collaborations to develop musculoskeletal trauma care guidelines.

Influence of residual stenosis after percutaneous coronary intervention with stent implantation on development of restenosis and stent thrombosis.

The aim of this study was to assess the effects of residual stenosis after single-stent implantation on the rate of stent thrombosis, as well as restenosis within a 6-month follow-up period. Coronary angiograms of 2,157 patients with 2,523 lesions treated with a single stent were analyzed by quantitative coronary angiography before, immediately after stent implantation, and at a planned 6-month follow-up. Lesions were classified into 4 subgroups according to the degree of residual stenosis after stent implantation: group 1, gross oversizing <-15%; group 2, slight oversizing -15% to <0%; group 3, mild residual 0% to <15%; group 4, moderate residual 15% to <30%. Stent thrombosis rates were not significantly different among the 4 subgroups (group 1: 0 of 60 [0%]; group 2: 2 of 388 [0.5%]; group 3: 8 of 1,370 [0.6%]; group 4: 8 of 705 [1.1%]; p = NS for all). An adequate dosage of ticlopidine (250 mg twice daily) and aspirin (100 mg/day) led to a lower rate of stent thrombosis (6 of 2,189 cases) than inadequate dosages or missing therapy (12 of 343 cases). In 1,882 stenoses with angiographic follow-up (77.7%), gross oversizing of stents lead to a significantly higher increase of percent stenosis (p <0.001) associated with a higher restenosis rate (group 1: 34.7% vs groups 2, 3, and 4: 32.5%, 28.2%, and 29.6%, respectively). A multiple regression analysis was performed. Optimal results with regard to stent thrombosis and restenosis were achieved with mild residual stenoses between 0% and 15% after stent implantation. Oversizing of stents is no longer necessary with an adequate dosage of ticlopidine and aspirin.