A comparison of the management of blunt splenic injury in children and young people—A New South Wales,population-based,retrospective study

The importance and safety of non-operative management (NOM) of Blunt Splenic Injury (BSI) has been established in children and adults over recent decades. However, studies have shown higher operation rates in adults. There is international evidence that when children are managed in adult centres, operation rates are higher while adolescents in paediatric centres, are operated on in line with paediatric guidelines. This difference between children and young adults, and the factors responsible, have not been examined in New South Wales (NSW).ObjectiveTo use NSW hospital and mortality data to compare the characteristics of BSI in patients aged 0–16 to those aged 17–25, and determine factors related to operative management (OM) and splenic salvage in each group.MethodsPatients age 0–25 between July 2000 and December 2011, with a diagnosis of BSI, were identified in the NSW Admitted Patient Data Collection, and linked to deaths data from Registry of Births Deaths and Marriages and Bureau of Statistics. Operation rate was compared between the two groups. Univariable analysis was used to determine factors associated with OM. Multivariable logistic regression with stepwise elimination was then performed to determine likelihood of OM according to age group, adjusting for potential confounders.Results1986 cases were identified, with 422 (21.2%) managed operatively – 101/907 children (11.1%) and321/1079 (29.7%)young adults(p < 0.001). Of these, 59 (58%) children underwent splenectomy compared with 233 (73%) young adults (p < 0.001). OM increased significantly after the age of 12 (p = 0.03), and the percentage almost tripled in the teenage years, coinciding with a higher proportion admitted to adult centres. OM doubled again in young adults(p < 0.001), all of whom were managed away from paediatric centres. On multivariable analysis, factors significantly associated with operation included age over 16 (OR 2.82, 95%CI 2.10-3.81), splenic injury severity, associated thoracic, liver, pancreatic and hollow viscus injury, and blood transfusion.ConclusionWhile Paediatric Surgeons have wholeheartedly adopted non-operative management, away from paediatric centres, it is possible children and young people in NSW are undergoing operation unnecessarily. Further evaluation of the surgeon attitudes and institutional factors involved in the management of injured children and young people within the broad NSW trauma system is required.     

Intracranial pressure monitoring in severe traumatic brain injuries: a closer look at level 1 trauma centers in the United States

IntroductionThe Brain Trauma Foundation (BTF) recently updated recommendations for intracranial pressure (ICP) monitoring in severe traumatic brain injury (TBI). The effect of ICP monitoring on outcomes is controversial, and compliance with BTF guidelines is variable. The purpose of this study was to assess both compliance and outcomes at level I trauma centers.Materials and methodsThe American College of Surgeons Trauma Quality Improvement Program database was queried for all patients admitted to level I trauma centers with isolated blunt severe TBI (AIS > 3, GCS < 9) who met criteria for ICP monitoring. Patients who had severe extracranial injuries, craniectomy, or death in the first 24 h were excluded. Comparison between groups with and without ICP monitoring was made, analyzing demographics, comorbidities, mechanism of injury, head Abbreviated Injury Scale (AIS), vital signs on admission, head CT scan findings. Outcomes included in-hospital mortality, mechanical ventilation days, intensive care unit (ICU) length of stay, hospital length of stay, systemic complications, and functional independence at discharge. Multivariable analysis was used to identify independent risk factors for each of the outcomes.ResultsOverall, 4880 patients were included. ICP monitoring was used in 529 patients (10.8%). Stepwise logistic regression analysis identified ICP monitor placement as an independent risk factor for mortality (OR 1.63; 95% CI 1.28–2.07; p < 0.001), mechanical ventilation (OR 5.74 95% CI 4.42–7.46; p < 0.001), ICU length of stay (OR 4.03; 95% CI 2.94–5.52; p < 0.001), systemic complications (OR 2.78; 95% CI 2.29–3.37; p < 0.001), and decreased functional independence at discharge (OR 1.71 95% CI 1.29–2.26; p < 0.001). Subgroup analysis of patients with head AIS 3, 4, and 5 confirmed that ICP monitors remained an independent risk factor for mortality in both head AIS 4 and 5.ConclusionsCompliance with BTF guidelines for ICP monitoring is low, even at level I trauma centers. In this study, ICP monitoring was associated with poor outcomes, and was found to be an independent risk factor for mortality. Further studies are needed to determine the optimal role of ICP monitoring in the management of severe TBI.     

Factors associated with receiving anti-osteoporosis treatment among older persons with minimal trauma hip fracture presenting to an acute orthogeriatric service

Background/AimThe aim of this study was to investigate factors that were associated with receiving anti-osteoporosis treatment (AOT) among patients with minimal trauma hip fracture admitted to an Australian tertiary trauma centre under the Acute Orthogeriatric Service (AOS) over a 6 month period.DesignObservational study using prospectively collected data.MethodsDemographic and clinical characteristics of 211 patients were extracted from the local hip fracture registry and electronic medical records. The outcome measure was receipt of AOT before separation from the AOS. Binary logistic regression was used to identify factors independently associated with treatment.Results91 (45%) patients received AOT, including 51 (25.2%) treatment-naive patients. Factors significantly associated with receiving treatment included higher serum vitamin D level (OR 1.44, 95% CI 1.23–1.70, p < 0.001) and trochanteric vs. cervical fracture (OR 2.67, 95% CI 1.30–5.49, p = 0.007). Living in a residential aged care facility (RACF) prior to the index fracture (OR 0.2, 95% CI 0.08–0.54, p = 0.001) and higher American Society of Anaesthesiologists (ASA) physical status score (OR 0.5, 95% CI 0.25–0.98, p = 0.04) significantly lowered the likelihood of treatment. Age, gender, cognitive impairment, premorbid walking ability, previous fragility fracture and renal impairment did not correlate with treatment.ConclusionA significant proportion (55%) of hip fracture patients did not receive AOT in hospital. The probability of receiving treatment appears to be significantly associated with serum vitamin D level, fracture type, place of residence and comorbidity burden.     

Trauma surgery by general surgeons: Still an option for proximal femoral fractures?

IntroductionSurgery for proximal femoral fractures in the Netherlands is performed by trauma surgeons, general surgeons and orthopaedic surgeons. The aim of this study was to assess whether there is a difference in outcome for patients with proximal femoral fractures operated by trauma surgeons versus general surgeons. Secondly, the relation between hospital and surgeon volume and postoperative complications was explored.MethodsPatients of 18 years and older were included if operated for a proximal femoral fracture by a trauma surgeon or a general surgeon in two academic, eight teaching and two non-teaching hospitals in the Netherlands from January 2010 until December 2013. The combined endpoint was defined as reoperation or surgical site infection. Multivariate analysis was used to adjust for patient and fracture characteristics and hospital and surgeon volume. Categories for hospital volume were >170/year (high volume), 96–170/year (medium volume) and <96/year (low volume).ResultsIn 4552 included patients 2382 (52.3%) had surgery by a trauma surgeon. Postoperative complications occurred in 276 (11.6%) patients operated by a trauma surgeon and in 258 (11.9%) operated by a general surgeon (p = 0.751). When considering confounders in a multivariate analysis, surgery by trauma surgeons was associated with less postoperative complications (OR 0.746; 95%CI 0.580–0.958; p = 0.022). Surgery in high volume hospitals was also associated with less complications (OR 0.997; 95%CI 0.995–0.999; p = 0.012). Surgeon volume was not associated with complications (OR 1.008; 95%CI 0.997–1.018; p = 0.175).ConclusionSurgery by trauma surgeons and high hospital volume are associated with less reoperations and surgical site infections for patients with proximal femoral fractures.     

Fibrinogen is an independent predictor of mortality in major trauma patients: A five-year statewide cohort study

IntroductionFibrinogen may be reduced following traumatic injury due to loss from haemorrhage, increased consumption and reduced synthesis. In the absence of clinical trials, guidelines for fibrinogen replacement are based on expert opinion and vary internationally. We aimed to determine prevalence and predictors of low fibrinogen on admission in major trauma patients and investigate association of fibrinogen levels with patient outcomes.Patients and methodsData on all major trauma patients (January 2007–July 2011) identified through a prospective statewide trauma registry in Victoria, Australia were linked with laboratory and transfusion data. Major trauma included any of the following: death after injury, injury severity score (ISS) >15, admission to intensive care unit requiring mechanical ventilation, or urgent surgery for intrathoracic, intracranial, intra-abdominal procedures or fixation of pelvic or spinal fractures. Associations between initial fibrinogen level and in-hospital mortality were analysed using multiple logistic regression.ResultsOf 4773 patients identified, 114 (2.4%) had fibrinogen less than 1 g/L, 283 (5.9%) 1.0–1.5 g/L, 617 (12.9%) 1.6–1.9 g/L, 3024 (63.4%) 2–4 g/L and 735 (15%) >4 g/L. Median fibrinogen was 2.6 g/L (interquartile range 2.1–3.4). After adjusting for age, gender, ISS, injury type, pH, temperature, Glasgow Coma Score (GCS), initial international normalised ratio and platelet count, the lowest fibrinogen categories, compared with normal range, were associated with increased in-hospital mortality (adjusted odds ratio [OR] for less than 1 g/L 3.28 [95% CI 1.71–6.28, p < 0.01], 1–1.5 g/L adjusted OR 2.08 [95% CI 1.36–3.16, p < 0.01] and 1.6–1.9 g/L adjusted OR 1.39 [95% CI 0.97–2.00, p = 0.08]). Predictors of initial fibrinogen <1.5 g/L were younger age, lower GCS, systolic blood pressure <90 mmHg, chest decompression, penetrating injury, ISS >25 and lower pH and temperature.ConclusionsInitial fibrinogen levels less than the normal range are independently associated with higher in-hospital mortality in major trauma patients. Future studies are warranted to investigate whether earlier and/or greater fibrinogen replacement improves clinical outcomes.     

Incidence and risk factors of acute kidney injury in the Japanese trauma population: A prospective cohort study

IntroductionPrevious studies have reported the prevalence and risk factors of acute kidney injury (AKI) in relatively young trauma patients. The aims of this study were to identify the prevalence and risk factors of AKI among older Japanese trauma patients.MethodsWe conducted a prospective observational study in the 8-bed intensive care unit (ICU) of a Japanese tertiary-care hospital. Participants comprised trauma patients aged 18 years or older admitted to the ICU. Our primary outcome was the incidence of AKI within 10 days of admission, according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria.ResultsAmong 333 patients, 66 (19.8%) developed AKI (Stage 1, n = 54; Stages 2, n = 5; and Stage 3, n = 7). Multivariate logistic regression analysis revealed that the incidence of AKI was associated with increased age (odds ratio (OR), 1.38; 95% confidence interval (CI), 1.15–1.65), male sex (OR, 2.06; 95%CI, 1.04–4.07), greater amount of red blood cell transfusions (OR, 1.61; 95%CI, 1.04–1.17), and presence of underlying chronic kidney disease (CKD) (OR, 3.97; 95%CI, 1.78-8.83). Length of stay in the ICU was significantly longer in patients with AKI (6 days) than in those without (3 days; p < 0.001). Patients ≥65 years old were more likely to develop AKI (26.2% vs 11.6%; p < 0.001). No significant differences in ICU stay (median, 4 vs 4 days; p = 0.70), hospital stay (median, 24 vs 21 days; p = 0.45), or 28-day mortality (2.1% vs 1.4%; p = 0.19) were evident between age groups.ConclusionsApproximately 20% of trauma patients developed AKI, and the elderly were more likely to develop AKI. Older age, male, greater units of red blood cell transfusions, and underlying CKD were associated with incidence of AKI.     

Prediction of intra-hospital mortality after severe trauma: which pre-hospital score is the most accurate?

PurposeComputing trauma scores in the field allows immediate severity assessment for appropriate triage. Two pre-hospital scores can be useful in this context: the Triage-Revised Trauma Score (T-RTS) and the Mechanism, Glasgow, Age and arterial Pressure (MGAP) score. The Trauma Revised Injury Severity Score (TRISS), not applicable in the pre-hospital setting, is the reference score to predict in-hospital mortality after severe trauma. The aim of this study was to compare T-RTS, MGAP and TRISS in a cohort of consecutive patients admitted in the Trauma system of the Northern French Alps(TRENAU).Materials and methodsFrom 2009 to 2011, 3260 patients with suspected severe trauma according to the Vittel criteria were included in the TRENAU registry. All data necessary to compute T-RTS, MGAP and TRISS were collected in patients admitted to one level-I, two level-II and ten level-III trauma centers. The primary endpoint was death from any cause during hospital stay. Discriminative power of each score to predict mortality was measured using receiver operating curve (ROC) analysis. To test the relevancy of each score for triage, we also tested their sensitivity at usual cut-offs. We expected a sensitivity higher than 95% to limit undertriage.ResultsThe TRISS score showed the highest area under the ROC curve (0.95 [CI 95% 0.94–0.97], p < 0.01). Pre-hospital MGAP score had significantly higher AUC compared to T-RTS (0.93 [CI 95% 0.91–0.95] vs 0.86 [CI 95% 0.83–0.89], respectively, p < 0.01). MGAP score < 23 had a sensitivity of 88% to detect mortality. Sensitivities of T-RTS < 12 and TRISS < 0.91 were 79% and 87%, respectively.Discussion/conclusionPre-hospital calculation of the MGAP score appeared superior to T-RTS score in predicting intra-hospital mortality in a cohort of trauma patients. Although TRISS had the highest AUC, this score can only be available after hospital admission. These findings suggest that the MGAP score could be of interest in the pre-hospital setting to assess patients’ severity. However, its lack of sensitivity indicates that MGAP should not replace the decision scheme to direct the most severe patients to level-I trauma center.     

Association between common risk factors and molecular subtypes in breast cancer patients

BackgroundBreast cancer is the most commonly diagnosed cancer in women worldwide and characterized its by molecular and clinical heterogeneity. Gene expression profiling studies have classified breast cancers into five subtypes: luminal A, luminal B, HER-2 overexpressing, basal-like, and normal breast-like. Although clinical differences between subtypes have been well described in the literature, etiologic heterogeneity have not been fully studied. The aim of this study was to assess the associations between several hormonal and nonhormonal risk factors and molecular subtypes of breast cancer.MethodsThis cross-sectional study consisted of 1884 invasive breast cancer cases. Variables studied included family history, age at first full-term pregnancy, number of children, duration of lactation, menstruation history, menopausal status, blood type, smoking, obesity, oral contraceptive use, hormone replacement therapy and in vitro fertilization. The odds ratios (OR) and 95% confidence intervals (CI) were estimated using multivariate logistic regression analysis.ResultsThousand two-hundred and forty nine patients had luminal A, 234 had luminal B, 169 had HER-2 overexpressing and 232 had triple negative breast cancer. The age of ≥40 years was found to be a risk factor for luminal A (OR 1.41 95% CI 1.15–1.74; p = 0.001) and HER-2 overexpressing subtype (OR: 1.51, 95% CI: 1.01–2.25; p = 0.04). Women who were nulliparous (OR 1.48, 95% CI 1.03–2.13; p = 0.03) or who had their first full-term pregnancy at age 30 years or older (OR 1.25 95% CI 0.83–1.88; p = 0.04) were at increased risk of luminal breast cancer, whereas women with more than two children had a decreased risk (OR 0.68, 95% CI 0.47–0.97; p = 0.03). Breast-feeding was also a protective factor for luminal subtype (OR 0.74, 95% CI 0.53–1.04; p = 0.04) when compared to non-luminal breast cancer. We found increased risks for postmenopausal women with HER-2 overexpressing (OR 2.20, 95% CI 0.93–5.17; p = 0.04) and luminal A (OR 1.87, 95% CI 0.93–3.90, p = 0.02) breast cancers, who used hormone replacement therapy for 5 years or more. Overweight and obesity significantly increased the risk of triple negative subtype (OR 1.89 95% CI 1.06–3.37; p = 0.04 and OR 1.90 95% CI 1.00–3.61; p = 0.03), on the contrary, decreased the risk of luminal breast cancer (OR 0.63 95% CI 0.43–0.95; p = 0.02 and OR 0.50 95% CI 0.32–0.76; p = 0.002, respectively) in premenopausal women. There were no significant differences between risk of breast cancer subtypes and early menarche, late menopause, family history, postmenopausal obesity, oral contraseptive use, smoking, in vitro fertilization, blood groups and use of hands.ConclusionsReproductive and hormonal characteristics (breastfeeding, parity, age at first full-term birth, hormone replacement therapy) were associated with luminal subtype, compared to non-luminal breast cancer, as consistent with previous studies. Obesity and overweight increased the risk of triple negative subtype, particularly in premenopausal women. Older age and use of hormone replacement therapy were related to the risk of HER-2 overexpressing breast cancer. Our data suggest a significant heterogeneity in association of traditional breast cancer risk factors and tumor subtypes.     

Estado nutricional preoperatorio valorado mediante la herramienta CONUT y su relación con la aparición de complicaciones mayores postoperatorias

IntroductionMalnutrition is a risk factor for the appearance of major postoperative complications; therefore, early identification and perioperative optimization of surgical patients may improve postoperative outcomes. The objective of our study was to determine the prevalence of moderate or high under nutrition alerts in patients undergoing major non-cardiac surgery, and their relationship with the appearance of major postoperative complications. Nutritional status was calculated using the CONUT tool.Material and methodsA retrospective observational study in 190 patients who underwent major non-cardiac surgery over two consecutive years. Preoperative nutritional status was calculated using CONUT, and the patients’ medical records were reviewed to determine their epidemiological characteristics and major complications.ResultsThe under nutrition alert was moderate in 17% of patients, and high in 10%. A high under nutrition alert was an independent risk factor for treatment with vasoactive drugs (OR 3.58; 95% CI 1.18-10.89; p = .025), respiratory support (OR 7.63; 95% CI 1.25-46.43; p = .027), renal support (OR 23.29; 95% CI 2.0-271.08; p = .012), prolonged hospital stay (coef. 20.16; 95% CI 2.10-38.22; p = .029) and higher in-hospital mortality (OR 7.15; 95% CI 1.31-39.02; p = .023).ConclusionsIn total, 10% of patients who underwent major non-cardiac surgery presented serious preoperative deterioration in their nutritional status. A high under nutrition alert was an independent risk factor for the appearance of major postoperative complications.     

Early predictors for massive transfusion in older adult severe trauma patients

BackgroundMany scoring systems for the early prediction of the need for massive transfusion (MT) have been reported; in most of these, vital signs are regarded as important. However, the validity of these scoring systems in older patients remains unclear because older trauma patients often present with normal vital signs. In this study, we investigated the effectiveness of previously described scoring systems, as well as risk factors that can provide early prediction of the need for MT in older severe trauma patients.MethodsWe prospectively collected data from a cohort of severe trauma patients (ISS ≥16 and age ≥16 years) admitted from January 2007 to March 2015. Trauma Associated Severe Hemorrhage (TASH), Assessment of Blood Consumption (ABC), and Prince of Wales Hospital (PWH) scores were compared between a younger and an older group. Furthermore, the predictors associated with MT in older severe trauma patients were assessed using multivariable logistic regression analyses.ResultsThe area under the curve (AUC) was significantly smaller for older group than for younger group for all three scoring systems (p < 0.05). The most important risk factors to predict the need for MT were related to anatomical factors including FAST results (odds ratio (OR): 5.58, 95% confidence interval (CI): 2.10–14.99), unstable pelvic fracture (OR: 21.56, 95% CI: 6.05–90.78), and long bone open fracture of the lower limbs (OR: 12.21, 95% CI: 4.04–39.09), along with pre-injury anticoagulant agent use (OR: 5.22, 95% CI: 1.30–19.61), antiplatelet agent use (OR: 3.81, 95% CI: 1.57–9.04), lactate levels (OR: 1.20, 95% CI: 1.04–1.39) and shock index (OR: 2.67, 95% CI: 1.05–6.84). Traditional vital signs were not early risk factors.ConclusionWe suggest that MT in older trauma patients should be considered on the basis of anatomical factors, pre-injury anticoagulant or antiplatelet agent use, lactate level and SI even if traditional vital signs are normal.     

A United Kingdom perspective on the relationship between body mass index (BMI) and bone health: A cross sectional analysis of data from the Nottingham Fracture Liaison Service

ObjectivesThis study examines the relationship between high BMI, a diagnosis of osteoporosis and low trauma fractures.MethodThis is a cross sectional analysis using data collected from the Nottingham Fracture Liaison Service. A total of 4288 participants with a low trauma fracture from 1 January 2007 to 31 August 2012 were analysed. Logistic regression adjusted for potential confounders was used investigate osteoporosis and BMI. Fracture types were compared between those who were obese and non-obese.ResultsA total of 30% (1285) were obese. Prevalence of osteoporosis was 13.4%, 24.9%, and 40.4% in the obese, overweight and normal category respectively. Being obese has an odds ratio of 0.23 (95% CI 0.19–0.28, p < 0.01) of having osteoporosis compared to a normal BMI category. When variable BMI cut offs were used (BMI 25, 30 and 35) to calculate the positive predictive value of patients not having osteoporosis, it was 80.5%, 86.3% and 88.3%. Examining fracture types, obese patients when compared with the non-obese category, were more likely to fracture their ankle (OR 1.48, p < 0.01) and upper arm (OR 1.48, p < 0.001), but were less likely to fracture their wrist (OR 0.65, p < 0.001). In the elderly (> 70 years), obesity no longer influenced ankle or wrist fractures but there is an increased risk of upper arm fractures (OR 1.46, p = 0.005).ConclusionHigher BMD in obesity is not protective against fractures as there are a significant number of fractures in this group which may be due to body habitus, mechanism of injury and the effect of adiposity on bone. A low trauma osteoporotic fracture will need to be redefined in light of these findings.     

Increased morbidity associated with weekend paediatric road traffic injuries: 10-year analysis of trauma registry data

BackgroundRoad traffic injuries (RTIs) are a significant cause of paediatric morbidity and mortality worldwide, with a disproportionate number of these injuries occurring in low- and middle-income countries (LMICs). Adult data from LMICs suggest that weekends are particularly high-risk for RTIs, but whether children are at increased risk of RTI on weekends has not previously been investigated in any setting. This study sought to assess patterns in paediatric RTI presentations using hospital-based trauma surveillance data in Cape Town, South Africa.MethodsData was analysed from Childsafe South Africa's prospectively collected trauma registry for injured children below 13 years of age presenting to a tertiary paediatric referral Trauma Department between 2004 and 2013.ResultsDuring the 10-year study period, a total of 71,180 patients presented with traumatic injuries, of which 8,815 (12.4%) resulted from RTIs. RTI patients had a mean age of 5.2 ± 3.6 years, and were predominantly males and pedestrians. RTIs were more common on weekends than weekdays (2.98 vs. 2.19 patients/day, p < 0.001), representing a greater proportion of daily all-cause trauma (15.5% vs. 11.2%, p < 0.001). Moreover, weekend RTI patients sustained more severe injuries than on weekdays, and compared to weekend all-cause trauma patients (injury score 1.66 vs. 1.46 and 1.43, both p < 0.001). RTI patients were more likely to require admission to both the trauma ward (1.14 vs. 0.79 patients/day, p < 0.001) and the PICU (0.10 vs. 0.07 patients/day, p < 0.05) on weekends than on weekdays. Weekend RTI patients most frequently required admission to the trauma ward (p < 0.001) and the PICU (p < 0.05) during the last annual quarter.ConclusionsIn a LMIC-setting, paediatric RTI patients are more frequently brought to medical attention, sustain more severe injuries and more frequently require hospital admission during the weekend. Weekends during the last annual quarter were particularly high-risk for paediatric RTIs. These findings highlight the importance of trauma surveillance data to inform targeted community prevention strategies for improving child road safety.     

Trends in 1029 trauma deaths at a level 1 trauma center: Impact of a bleeding control bundle of care

BackgroundOver the last decade the age of trauma patients and injury mortality has increased. At the same time, many centers have implemented multiple interventions focused on improved hemorrhage control, effectively resulting in a bleeding control bundle of care. The objective of our study was to analyze the temporal distribution of trauma-related deaths, the factors that characterize that distribution and how those factors have changed over time at our urban level 1 trauma center.MethodsRecords at an urban Level 1 trauma center were reviewed. Two time periods (2005–2006 and 2012–2013) were included in the analysis. Mortality rates were directly adjusted for age, gender and mechanism of injury. The Mann-Whitney and chi square tests were used to compare variables between periods, with significance set at 0.05.Results7080 patients (498 deaths) were examined in 2005–2006, while 8767 patients (531 deaths) were reviewed in 2012–2013. The median age increased 6 years, with a similar increase in those who died. In patients that died, no differences by gender, race or ethnicity were observed. Fall-related deaths are now the leading cause of death. Traumatic brain injury (TBI) and hemorrhage accounted for >91% of all deaths. TBI (61%) and multiple organ failure or sepsis (6.2%) deaths were unchanged, while deaths associated with hemorrhage decreased from 36% to 25% (p < 0.01). Across time periods, 26% of all deaths occurred within one hour of hospital arrival, while 59% occurred within 24 h. Unadjusted mortality dropped from 7.0% to 6.1 (p = 0.01) and in-hospital mortality dropped from 6.0% to 5.0% (p < 0.01). Adjusted mortality dropped 24% from 7.6% (95% CI: 6.9–8.2) to 5.8% (95% CI: 5.3–6.3) and in-hospital mortality decreased 30% from 6.6% (95% CI: 6.0–7.2) to 4.7 (95% CI: 4.2–5.1).ConclusionsOver the same time frame of this study, increases in trauma death across the globe have been reported. This single-site study demonstrated a significant reduction in mortality, attributable to decreased hemorrhagic death. It is possible that efforts focused on hemorrhage control interventions (a bleeding control bundle) resulted in this reduction. These changing factors provide guidance on future prevention and intervention efforts.     

Efficacy and safety of sugammadex compared to neostigmine for reversal of neuromuscular blockade: a meta-analysis of randomized controlled trials

Background and objectiveSugammadex has been introduced for reversal of rocuronium (or vecuronium)–induced neuromuscular blockade (NMB). Although its efficacy has been established, data are conflicting whether it is safer than neostigmine traditionally used for reversing NMB.DesignMeta-analysis of data about effectiveness and safety of sugammadex compared to neostigmine for reversing NMB in adults was performed using the PRISMA methodology.SettingUniversity medical hospital.MethodsA comprehensive search was conducted using PubMed, Web of Science, and Cochrane Library electronic databases to identify English-language randomized controlled trials. Two reviewers independently selected the trials; extracted data on reversal times, incomplete reversals of NMB, and adverse events (AEs); and assessed the trials' methodological quality and evidence level. Only AEs that were related to study drug by a blinded safety assessor were considered for meta-analysis.PatientsA total of 1384 patients from 13 articles were included in this meta-analysis.Main resultsCompared to neostigmine, sugammadex was faster in reversing NMB (P < .0001) and more likely to be associated with higher train-of-four ratio values at extubation (mean difference, 0.18; 95% confidence interval [CI], 0.14-0.22; P < .0001) and lower risk of postoperative residual curarization after extubation (odds ratio [OR], 0.05; 95% CI, 0.01-0.43; P = .0068). Compared to neostigmine, sugammadex was associated with a significantly lower likelihood of global AEs (OR, 0.47; 95% CI, 0.34-0.66; P < .0001), respiratory AEs (OR, 0.36; 95% CI, 0.14-0.95; P = .0386), cardiovascular AEs (OR, 0.23; 95% CI, 0.08-0.61; P = .0036), and postoperative weakness (OR, 0.45; 95% CI, 0.21-0.97; P = .0409). Sugammadex and neostigmine were associated with a similar likelihood of postoperative nausea and vomiting (OR, 1.23; 95% CI, 0.70-2.15; P = .4719), pain (OR, 1.06; 95% CI, 0.15-7.36; P = .9559), neurologic AEs (OR, 1.47; 95% CI, 0.52-4.17; P = .4699), general AEs (OR, 0.75; 95% CI, 0.47-1.21; P = .2448), and changes in laboratory tests' values (OR, 0.57; 95% CI, 0.18-1.78; P = .3368).ConclusionsResults from this meta-analysis suggest that sugammadex is superior to neostigmine, as it reverses NMB faster and more reliably, with a lower risk of AEs.     

Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care

BackgroundModern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC).MethodsFor this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed.ResultsThe USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p < 0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17–29] vs. 21 [17–26], p < 0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61–1.48, p = 0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2–11] vs. 2 [2–7] days, p = 0.006) but had a shorter hospital stay (median [IQR] 6 [3–13] vs. 8 [4–16] days, p < 0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p < 0.0001), and had a higher readmission rate (8% vs. 4%, p = 0.01).ConclusionAlthough several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.     

Uninsured status may be more predictive of outcomes among the severely injured than minority race

AimWorse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers.MethodsWe performed a retrospective analysis of the 2010–2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18–64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care.ResultsThere were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29–1.98, p < 0.001) and black race (OR 1.24, 1.04–1.49, p = 0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36–0.51, p < 0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29–2.19, p < 0.001) and decreased post-hospital care (OR 0.45, 0.32–0.63, p < 0.001).ConclusionUninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.     

Avoiding delayed diagnosis of significant blunt bowel and mesenteric injuries: Can a scoring tool make the difference? A 7-year retrospective cohort study

IntroductionSignificant blunt bowel and mesenteric injuries (sBBMI) are frequently missed despite the widespread use of computed tomography (CT). Early treatment improves the outcome related to these injuries. The aim of this study was to assess the prevalence of sBBMI, the incidence of delayed diagnosis and to test the performance of the Bowel Injury Prediction Score (BIPS), determined by the white blood cell (WBC) count, presence or absence of abdominal tenderness and CT grade of mesenteric injury.Patients and methodsSingle-centre, registry-based retrospective cohort study, screening all consecutive trauma patients admitted to Lausanne University Hospital Trauma Centre from 2008 to 2015 after a road traffic accident. All patients with reliable information about the presence or absence of sBBMI who underwent abdominal CT and for whom calculation of the BIPS was possible were included for analysis. The incidence of delayed (>24 h after admission) diagnosis in the patient group with sBBMI was determined and the diagnostic performance of the BIPS for sBBMI was assessed.ResultsFor analysis, 766 patients with reliable information about the presence or absence of sBBMI were included. The prevalence of sBBMI was 3.1% (24/766). In 24% (5/21) of stable trauma patients undergoing CT, a diagnostic delay of more than 24 h occurred. Abdominal tenderness (p < 0.0001) and CT grade ≥4 (p < 0.0001) were associated with sBBMI, whereas CT grade 4 alone (p = 0.93) and WBC count ≥17 G/l (p = 0.30) were not. A BIPS ≥2 had a sensitivity of 89% (95% CI, 67–99), specificity of 89% (95% CI, 86–91), positive likelihood ratio of 8 (95% CI, 6.1–10), negative likelihood ratio of 0.12 (95% CI, 0.03–0.44), positive predictive value (PPV) of 19% (95% CI, 15–24) and negative predictive value (NPV) of 99.7% (95% CI, 98.7–99.9). CT alone identified 79% (15/19) and the BIPS 89% (17/19) of patients with sBBMI (p = 0.66).ConclusionsDiagnostic delays in patients with sBBMI are common (24%), despite the routine use of abdominal CT. Application of the BIPS on the present cohort would have led to a high number of non-therapeutic abdominal explorations without identifying significantly more sBBMI early than CT alone.     

Burn induced nervous system morbidity among burn and non-burn trauma patients compared with non-injured people

ObjectiveBurns cause acute damage to the peripheral nervous system with published reports identifying that neurological changes after injury remain for a prolonged period. To shed some light on potential mechanisms, we assessed injury etiology and patterns of nervous system morbidity after injury by comparing long-term hospital admissions data of burns patients and other non-burn trauma patients with uninjured people.MethodsLinked hospital and death data of a burn patient cohort (n = 30,997) in Western Australia during the period 1980–2012 were analysed along with two age and gender frequency matched comparison cohorts: non-burn trauma patients (n = 28,647) and; non-injured people (n = 123,399). The number of annual NS disease admissions and length of stay (LOS) were used as outcome measures. Multivariable negative binomial regression modelling was used to derive adjusted incidence rate ratios and 95% confidence intervals (IRR, 95% CI) and adjusted Cox regression models and hazard ratios (HR) were used to examine time to first nervous system admission after burn and incident admission rates.ResultsThe most common peripheral nervous system condition identified in each cohort (burn, non-burn trauma, uninjured) were episodic and paroxysmal disorders followed by nerve root and plexus disorders and polyneuropathies/peripheral NS conditions. Significantly elevated admission rates for NS conditions (IRR, 95% CI) were found for the burn (2.20, 1.86–2.61) and non-burn trauma (1.85, 1.51–2.27), compared to uninjured. Peripheral nervous system admission rates after injury (IRR, 95% CI) were significantly higher regardless of age at time of injury for the burn (<15years: 1.97, 1.49–2.61; 15–45: 2.70, 2.016–3.55; ≥45 year: 1.62, 1.33–1.97) and non-burn trauma cohorts (<15years: 1.91, 1.55–2.35; 15–45: 1.94, 1.51–2.49; ≥45 year: 1.42, 1.18–1.72), when compared to the uninjured. Significantly higher rates of incident NS hospitalisations were found for the burn cohort vs. uninjured cohort for a period of 15-years after discharge (0–5 years: HR, 95% CI: 1.97, 1.75–2.22; 5–15 years; HR, 95% CI: 1.44, 1.28–1.63). The non-burn trauma cohort had significantly higher incident nervous system admissions for 10 years after discharge (0–30 days: HR, 95% CI: 4.75, 2.44–9.23; 30 days to 1-year HR, 95% CI: 2.95, 2.34–3.74; 1–5 years; HR, 95% CI: 1.47, 1.26–1.70; 5–10 years; HR, 95% CI: 1.34, 1.13–1.58).ConclusionsResults suggest that injury patients are at increased risk of peripheral nervous system morbidity after discharge for a prolonged period of time. The time patterns associated with incident nervous system conditions suggest possible differences in underlying pathology and long-term patient care needs. Further research is needed to elucidate the underlying neuropathology.     

A retrospective cohort study of the relationship between quality indicator measurement and patient outcomes in adult trauma centers in the United States

BackgroundImproving care is a key strategy for reducing the burden of injuries, but it is unknown whether the use of quality indicators (QI) is associated with patient outcomes. We sought to evaluate the association between the use of QIs by trauma centers and outcomes in adult injury patients.MethodsWe identified consecutive adult patients (n = 223,015) admitted to 233 verified trauma centers January 1, 2007 to December 31, 2010 that contributed data to the National Trauma Data Bank and participated in a survey of QI practices. Generalized Linear Mixed Models were employed to evaluate the association between the intensity (number of QIs) and nature (report cards, internal and external benchmarking) of QI use and survival to hospital discharge, adjusting for patient and hospital characteristics.ResultsThere were no significant differences in the odds of survival to trauma center discharge according to the number of QIs measured (quartiles; odds ratio{OR} [95% confidence interval{CI}] 1.00 vs. 1.08 [0.90–1.31] vs. 1.00 [0.82–1.22] vs. 1.21 [0.99–1.49]), or whether centers used reports cards (OR 1.07, 95%CI 0.94–1.23), internal (OR 1.06, 95%CI 0.89–1.26) or external (OR 1.09, 95%CI 0.92–1.31) benchmarking. The duration (geometric mean) of mechanical ventilation (4.0 days), ICU stay (4.6 days), hospital stay (7.7 days) and proportion of patients with a complication (13.6%) did not significantly differ according to the intensity or nature of QI use.ConclusionsThe intensity and nature of the QIs used by trauma centers was not associated with outcomes of patient care. Alternative quality improvement strategies may be needed.