Accuracy of prehospital triage systems for mass casualty incidents in trauma register studies - A systematic review and meta-analysis of diagnostic test accuracy studies

BackgroundPrioritising patients in mass casualty incidents (MCI) can be extremely difficult. Therefore, triage systems are important in every emergency medical service. This study reviews the accuracy of primary triage systems for MCI in trauma register studies.MethodsWe registered a protocol at PROSPERO ID: CRD42018115438. We searched MEDLINE, EMBASE, Central, Web of Science, Scopus, Clinical Trials, Google Scholar, and reference lists for eligible studies. We included studies that both examined a primary triage system for MCI in trauma registers and provided sensitivity and specificity for critically injured vs non-critically injured as results. We excluded studies that used paediatric, chemical, biological, radiological or nuclear MCIs populations or triage systems. Finally, we calculated intra-study relative sensitivity, specificity and diagnostic odds ratio for each triage system.ResultsTriage Sieve (TS) significantly underperformed in relative diagnostic odds ratio (DOR) when compared to START and CareFlight (CF) (START vs TS: 19.85 vs 13.23 (p<0.0001)│CF vs TS: 23.72 vs 12.83 (p<0.0001)). There was no significant difference in DOR between TS and Military Sieve (MS) (p<0.710). Compared to START, MS and CF TS had significantly higher relative specificity (START vs TS: 93.6% vs 96.1% (p=0.047)│CF vs TS: 96% vs 95.3% (p=0.0006)│MS vs TS: 94% vs 88.3% (p=0.0002)) and lower relative sensitivity (START vs TS: 57.8% vs 34.8% (p<0.0001)│CF vs TS: 53.9% vs 34.7% (p<0.0001)│MS vs TS: 51.9% vs 35.2% p<0.0001)).CF had significantly better relative DOR than START (CF vs START: 23.56 vs 27.79 (p=0.043)). MS had significantly better relative sensitivity than CF and START (MS vs CF: 49.5% vs 38.7% (p<0.0001)│MS vs START: 49.4% vs 43.9% (p=0.01)). In contrast, CF had significantly better relative specificity than MS (MS vs CF: 91.3% vs 93.3% (p<0.0001)). The remaining comparisons did not yield any significant differences.ConclusionAs the included studies were at risk of bias and had heterogenic characteristics, our results should be interpreted with caution. Nonetheless, our results point towards inferior accuracy of Triage Sieve compared to START and CareFlight, and less firmly point towards superior accuracy of Military Sieve compared to START, CareFlight and Triage Sieve     

MRI对坏死股骨头关节软骨的评估

目的研究坏死股骨头关节软骨的MRI表现，以期用MRI表现反映关节软骨的受损程度。方法收集12例股骨头坏死（14髋）的股骨头直视观和对应的MRI表现及相应的X线片表现资料，比较三者在关节软骨的受累情况、软骨下分离及软骨下骨与骨分离的表现。结果相片中所有软骨均有受累，对应MRI中有11髋X线片没有表现。相片中有7髋表现为软骨下分离，对应MRI中有6髋、X线片为4髋。相片中有8髋表现为软骨下骨与骨分离，对应MRI中有8髋、X线片为3髋。结论虽然在软骨下骨与骨分离上有假阳性表现，MRI明显优于X线片，能更好反映关节软骨情况。但是对MRI的表现如何指导临床治疗还需进一步研究。     

Cassane-type diterpenes from Caesalpinia minax induce apoptosis in pituitary adenoma: structure–activity relationship,ER stress and Wnt/β-catenin pathways

Plant-derived natural products have been the highly significant sources of novel antitumor agents. The cassane-type diterpenes of genus Caesalpinia have been reported to bear antiproliferative activities toward different types of cancer cells. In this study, we evaluated the antineoplasmic activities of 16 natural origin cassane-type diterpenes isolated from the CHCl₃ extract of the seeds of C. minax in pituitary adenomas cells and identified caesalpin G (CAG) showed the strongest cytotoxicity. Moreover, we further investigated the structure–activity relationship and molecular mechanism of these derivatives systematically. The results confirmed the unsaturated lactone-type ring, hydroxyl at C-7, and alkenyl at C-11 or C-14 functionality as critical for anticancer activity in this family of natural products. In addition, the mechanism experiments also demonstrated unfolded protein response and ER stress and Wnt/β-catenin pathway were involved in the CAG-induced apoptosis.     

Biomechanical analysis of fractures in the mandibular neck (collum mandibulae)

After treatment of fractures in the neck of the mandible by means of immobilization of the dentition, often more or less severe manifestations of malocclusion remain. It was hypothesized that this is caused by an altered articulation in the jaw joint on the affected side. Furthermore, it was hypothesized that an anteriorly displaced condyle, as observed frequently as a side effect of the treatment, is caused by pull of the lateral pterygoid muscle, despite maxillomandibular fixation.Intervention experiments were performed in silico to test these hypotheses. With a biomechanical model of the human masticatory system alterations were applied mimicking a fractured mandibular neck and configurations that had been observed after healing.It was predicted that the altered articulation in the jaw joint caused asymmetrical jaw movements despite symmetrical muscle activation. The jaw was predicted to close with an open bite similar to clinical observations. The predicted laterodeviations, however, were not in accordance with clinical observations. Despite maxillo-mandibular fixation the lateral pterygoid muscle was able to pull the mandibular condyle out of its fossa in anterior direction. Consequently, despite some methodological limitations, in general the predictions corroborated the hypotheses.     

SPECT、SPECT-CT与MRI对新鲜骨质疏松性椎体压缩骨折的诊断价值

目的:比较分析单光子发射计算机断层摄影术(SPECT)、单光子发射计算机断层摄影术联合同机CT扫描图像融合技术(SPECT-CT)与磁共振成像(MRI)对新鲜骨质疏松性椎体压缩骨折(OVCF)的诊断价值.方法:对201 1年10月～2012年4月因OVCF就诊而又同时接受了胸腰椎MRI、SPECT及SPECT-CT检查的20例老年患者进行回顾性分析,其中女12例,男8例,年龄60～80岁,平均73.5岁,平均病程21d.根据MRI表现确定最终诊断,MRI上出现骨髓水肿像的椎体定义为新鲜骨折椎体,椎体形态有压缩改变但MRI信号无异常者定义为陈旧骨折.由2位核医学医师分别评估SPECT及SPECT-CT检查,记录出现核素浓集的椎体,并给出疾病诊断意见.采用Kappa检验对比MRI与SPECT-CT判断新鲜骨折及陈旧骨折的一致性以及定性诊断能力.参考MRI发现,采用卡方检验分析SPECT与SPECT-CT定位病椎能力的异同.结果:根据MRI或SPECT-CT,20例患者均确诊为新鲜OVCF,其中MRI发现32个椎体存在新鲜OVCF,SPECT-CT发现34个椎体存在新鲜OVCF;根据SPECT诊断新鲜OVCF 12例,疑似新鲜OVCF但难以与肿瘤、感染相鉴别8例,共发现34个椎体存在核素浓集.MRI发现新鲜OVCF 32个椎体、陈旧OVCF 10个椎体,SPECT-CT发现新鲜OVCF 34个椎体、陈旧OVCF 8个椎体,两者之问具有良好的一致性(Kappa=0.0577,P＜0.05).在对病椎定位的准确性上,以MRI定位的病椎节段为参考,SPECT与MRI定位相同24个椎体,SPECT-CT与MRI定位相同30个椎体,SPECT-CT定位准确性优于SPECT(P＜0.05).SPECT-CT检查还发现了MRI未能显示的骨骼病损,其中骶尾椎骨折1例,肋骨骨折2例,骶髂关节炎1例,胸锁关节良性病变1例.结论:SPECT-CT在OVCF的定位、定性诊断上与MRI的价值相似,其准确定位病椎的性能优于传统SPECT检查;SPECT-CT还可以发现一些MRI未能显示的合并骨骼病损.SPECT-CT是患者不能接受MRI时的可靠选择.     

非创伤性股骨头坏死骨髓水肿与疼痛分级及坏死分期相关性的研究

目的探讨非创伤性股骨头坏死（nontraurnatic ostconecrosis of femoral head，NONFH）骨髓水肿与疼痛分级、坏死分期的相关性，提高对骨髓水肿在NONFH中临床意义的认识。方法2004年10月-2006年10月收治的97例149髋NONFH患者进行回顾性分析。男68例，女29例；年龄19～62岁，平均38．8岁。病程20d～4年。患者骨髓水肿根据MRI表现分为0～2级；疼痛分级按主诉疼痛分级法分为无疼痛（0级）、轻度疼痛（1级）和中重度疼痛（2级）；坏死根据世界骨循环研究学会国际骨坏死分期标准分为Ⅰ～Ⅳ期。分析各级疼痛及各期骨髓水肿的发生率，并将骨髓水肿分别与疼痛分级、坏死分期进行列联表资料x^2检验及多个独立样本比较的秩和检验。结果149髋中109髋发生骨髓水肿，发生率为73．15％。疼痛128髋中108髋（84．38％）存在骨髓水肿，其中2级疼痛34髋中，32髋（94．12％）存在骨髓水肿。疼痛分级与骨髓水肿分级有关（P〈0．001）。各级疼痛间的骨髓水肿差异有统计学意义（P〈0．001），随疼痛程度的加重骨髓水肿分级的平均秩次逐渐加大，0级、1级和2级分别为28．19、78．94和96．12。以坏死Ⅱ期（77．05％）、Ⅲ期（82．81％）患者骨髓水肿最多见且明显。坏死Ⅰ～Ⅲ期与骨髓水肿分级有关（P〈0．001）。Ⅰ～Ⅲ期坏死间骨髓水肿分级比较差异有统计学意义（P〈0．001），且随病变程度的加重，骨髓水肿分级的平均秩次逐渐加大，0级、1级和2级分别为39．07、60．16和86．15。结论骨髓水肿是NONFH发展过程中的一种伴随征象，骨髓水肿发生的几率和程度与NONFH疼痛分级、坏死分期密切相关，骨髓水肿的情况可作为评价病情进展及疗效判定的指标。     

一次性便携式氧气流速调控瓶的研制

目的:研制一种能供医务人员适时调节氧气袋氧导管腔内氧气流速的一次性便携式氧气流速调控瓶.方法:在圆球形瓶体上开设2个互对的瓶口,将柔性氧气引入管及排氧管分别设置在2个互对的瓶口上,在柔性氧气引入管的进氧接口上增设一个调挡式氧流调节器.结果:该装置不仅能够防止因开启氧气袋氧导管的动作过猛或过大导致的氧气袋内极其有限的救生氧瞬间丢失或过快流失,而且能够防止开启氧导管过小导致的患者虚无吸氧.结论:该一次性便携式氧气流速调控瓶优于现有技术的一次性便携式氧气流速/湿化瓶,能够实现真正意义上的便携给氧和急救.     

Post-discharge rehabilitation and functional recovery after pediatric injury

IntroductionVariability in rehabilitation disposition has been proposed as a trauma center quality metric. Benchmarking rehabilitation disposition is limited by a lack of objective measures of functional impairment at discharge. The primary aim of this study was to determine the relative contribution of patient characteristics and hospitalization factors associated with inpatient and outpatient rehabilitation after discharge. The secondary aims were to evaluate the sensitivity of the Functional Status Scale (FSS) score for identifying functional impairments at hospital discharge and track post-discharge recovery.Patients and methodsWe report a planned secondary analysis of a prospective observational study of seriously injured children (<15 years old) enrolled at seven pediatric trauma centers. Functional Status Scale (FSS) score was measured for pre-injury, hospital discharge, and 6-month follow-up timepoints. Multinomial logistic regression identified factors associated with three dispositions: home without rehabilitation services, home with outpatient rehabilitation, and inpatient rehabilitation. Relative weight analysis was used to identify the impact of individual factors associated with inpatient or outpatient rehabilitation disposition.ResultsWe analyzed 427 children with serious injuries. Functional impairment at discharge was present in 103 (24.1%) children, including 43/337 (12.8%) discharged without services, 12/38 (31.6%) discharged with outpatient rehabilitation, and 44/47 (93.6%) discharged to inpatient rehabilitation. In multivariable modeling, variables most contributing to prediction of inpatient rehabilitation were severe initial Glasgow coma scale (GCS), injured body region, and functional impairment at discharge. Severe initial GCS, private insurance, and extremity injury were independently associated with disposition with outpatient rehabilitation. Patients discharged without services or with outpatient rehabilitation most frequently had motor impairments that improved during the next 6 months. Patients discharged to inpatient rehabilitation had impairments in all domains, with many improving within 6 months. A higher proportion of patients discharged to inpatient rehabilitation had residual impairments at follow-up.ConclusionInjury characteristics and discharge impairment were associated with discharge to inpatient rehabilitation. The FSS score identified impairments needing inpatient rehabilitation and characterized improvements after discharge. Less severe impairments needing outpatient rehabilitation were not identified by the FSS score.