Introduction of hospital quality measures may lead to a temporary decrease in patient outcomes.

OBJECTIVES: To analyse the impact of hospital quality indicators on hip fracture mortality in Israel. STUDY DESIGN: A retrospective observational study. METHODS: Data were collected on all patients aged ≥65 years with an isolated hip fracture in the years 2010-2016 from the Israel's National Trauma Registry. These data were then cross checked with information on co-morbidities and medication intake from the Clalit medical fund. All successfully matched patients constituted the study population. The main outcome measures were in-hospital and 1-year mortality. Trend analysis of surgery on hip fractures within 48 h of hospitalisation (referred to as early hip fracture surgeries) and mortality was performed. The introduction of the proportion of early hip fracture surgeries as an official quality parameter in 2013 was considered an intervention. RESULTS: The proportion of early hip fracture surgeries continuously increased during the study period and, after the introduction of the quality measure, a significant increase in the uniformity of practice among hospitals was observed. The mortality trend was not related to the early surgeries trend, with a sharp upward spike detected in 2014, followed by a gradual return to previous levels in the subsequent years. The analysis has shown that when adjusting for demographic factors and co-morbidity, both in 2010-2013 and in 2015-2016, a clear benefit in survival existed for patients who were operated on within the first 48 h. In 2014, which was the first year of open publication of achieved quality measures reported in the media, no such benefit was found. CONCLUSIONS: Even when an improvement in a promoted practice is achieved, its positive impact on clinical outcomes may be delayed, possibly indicating the need for a learning period.

Should the management approach to the anterior abdominal stab wound be different in patients with self-inflicted abdominal injury?

BACKGROUND: Self-inflicted injury is a leading cause of death worldwide. It is hypothesized that due to instincts for self-preservation, the severity of abdominal injury would be decreased following suicidal self-stabbing in comparison to stab wounds from assault, and therefore a more conservative management might be considered. METHODS: All patients with isolated abdominal stab wound (SW) admitted to 19 Trauma Centers in Israel between the years 1997 and 2018 were included in the study. Patients with self-inflicted abdominal SW (Group I) were compared to victims with abdominal SW following assault (Group II). RESULTS: Group I included 9.4% (314/3324) of patients eligible for this study. Compared to Group II, Group I patients were older (median: 39 years, IQR 28,52 vs. 24 years, IQR 19,33; p<0.001), had more females (28.7% vs 4.9%, p <0.001), had longer length of hospitalization (median: 3 days vs. 2 days; p<0.001), underwent surgery more frequently (55.4% vs. 37.4%; p<0.001), and had higher mortality (2.9% vs. 0.7%; p=0.003). Possible covariates for mortality were examined and following logistic regression, self-inflicted injury remained associated with higher death rates compared to assault (OR 4.027, CI95% 1.380, 11.749; p=0.011). CONCLUSION: In this study, patients with isolated self-inflicted abdominal injuries had higher mortality and more frequently underwent abdominal surgery.

Time to surgery: Is it truly crucial in initially stable patients with penetrating injury?

BACKGROUND: Treatment recommendations for patients with penetrating abdominal injury are well established. Trauma victims with clear indications for surgery, should undergo immediate operative intervention without any delay or additional imaging. However, the optimal time for surgery remains unclear. There are some significant advantages in preoperative abdominal CT, including gathering essential information regarding a few difficult to reach anatomical areas, avoiding unnecessary explorations associated with increased morbidity and assessing the existence of extra-abdominal injuries that may have non-expectable impact on initial therapeutic plan. The aim of this study was to determine the impact of "time-to-surgery" on final medical outcomes in patients with penetrating abdominal trauma with normal blood pressure on admission. METHODS: A retrospective cohort study using the Israeli National Trauma Registry was conducted from 2000- 2018. This study included trauma patients with penetrating injuries and a systolic blood pressure of 90mmHg or above on admission. All patients included in the study were divided into three groups according to the time that lapsed from their admission to surgery: half an hour, an hour, and two hours. We assessed the outcome for each patient, including length of hospital stay, need for intensive care and mortality. Statistical analysis was performed using the Chi-square test, ANOVA test. A p-value of less than 0.05 was considered statistically significant. RESULTS: The study included 1,136 penetrating trauma patients. Among these, 78.0% (886) had sustained low-energy penetrating injury (SWPI) and 22.0% (250) had sustained high-energy penetrating injury (FAPI). Males accounted for 93.5% (1,062) of the patients. Mean age was 30.4. About 29% (327) of all the patients underwent surgery within 30 minutes from admission, 42% (475) within 30-60 min, and 29% (334) patients were operated within one to two hours. Patients who underwent surgery within 30 minutes, had worse ISS and GCS scores and were, therefore, more likely to have worse clinical outcomes. No other differences in outcomes were found in patients who were operated upon within 2 hours. CONCLUSIONS: Time to surgery within two hours from admission has no impact on final outcomes in trauma patients with penetrating injury and normal blood pressure on admission.

Policies for managing emergency medical services in mass casualty incidents.

INTRODUCTION: Diverse decision-making is needed in managing mass casualty incidents (MCIs), by emergency medical services (EMS). The aim of the study was to review consensus among international experts concerning policies of EMS management during MCIs. METHODS: Applicability of 21 EMS policies was tested through a 2-cycle modified e-Delphi process, in which 38 multi-disciplinary experts from 10 countries participated. Threshold for approving proposed solutions was defined as consensus of >80%. Policies that did not achieve the targeted consensus were reviewed to detect variability according to respondents' origin country. RESULTS: 16 policies were endorsed in the first cycle including collaboration between ambulance service providers; implementing a unified mode of operation; preparing criteria for ground versus aerial evacuation; and, developing support systems for caregivers exposed to violence. An additional policy which proposed that senior EMS officers should not necessarily act as on-site MCI commanders was endorsed in the second cycle. Demographic breakdown of views concerning non-consensual policies revealed differences according to countries of origin. Assigning ambulances to off-duty team members was highly endorsed by experts from Israel and South Africa and strongly rejected by European respondents. Avoiding entry to risk areas until declared safe was endorsed by European, Asian and Oceanic experts, but rejected by Israeli, South African and North American experts. CONCLUSIONS: Despite uniqueness of countries and EMS agencies, solutions to most dilemmas were applicable to all organizations, regardless of location or affiliation. Cultural diversity was found concerning readiness to implement military-civilian collaboration in MCIs and a rigid separation between work-leisure responsibilities.

Therapeutic strategies to correct proteostasis-imbalance in chronic obstructive lung diseases.

Proteostasis is a critical cellular homeostasis mechanism that regulates the concentration of all cellular proteins by controlling protein- synthesis, processing and degradation. This includes protein-conformation, binding interactions and sub-cellular localization. Environmental, genetic or age-related pathogenetic factors can modulate the proteostasis (proteostasis-imbalance) through transcriptional, translational and post-translational changes that trigger the development of several complex diseases. Although these factors are known to be involved in pathogenesis of chronic obstructive pulmonary disease (COPD), the role of proteostasis mechanisms in COPD is scarcely investigated. As a proof of concept, our recent data reveals a novel role of proteostasis-imbalance in COPD pathogenesis. Briefly, cigarette- and biomass- smoke induced proteostasis-imbalance may aggravate chronic inflammatory-oxidative stress and/or protease-anti-protease imbalance resulting in pathogenesis of severe emphysema. In contrast, pathogenesis of other chronic lung diseases like ΔF508-cystic fibrosis (CF), α1-anti-trypsin-deficiency (α-1 ATD) and pulmonary fibrosis (PF) is regulated by other proteostatic mechanisms, involving the degradation of misfolded proteins (ΔF508-CFTR/α1-AT- Z variant) or regulating the concentration of signaling proteins (such as TGF-ß1) by the ubiquitin-proteasome system (UPS). The therapeutic strategies to correct proteostasis-imbalance in misfolded protein disorders such as ΔF508-CF have been relatively well studied and involve strategies that rescue functional CFTR protein to treat the underlying cause of the disease. While in the case of COPD-emphysema and/or PF, identification of novel proteostasis-regulators that can control inflammatory-oxidative stress and/or protease-anti-protease balance is warranted.