Impact de la mise en place d’un réseau de soins en traumatologie sur la mortalité des patients traumatisés graves du bassin

Aim

To evaluate the impact of a regional trauma network on intra-hospital mortality rates of patients admitted with severe pelvic trauma.

Study

Retrospective observational study.

Patients

Sixty-five trauma patients with serious pelvic fracture (pelvic abbreviated injury scale [AIS] score of 3 or more).

Methods

Demographic, physiologic and biological parameters were recorded. Observed mortality rates were compared to predicted mortality according to the Trauma Revised Injury Severity Score methodology adjusted by a case mix variation model.

Results

Twenty-nine patients were admitted in a level I trauma centre (reference centre) and 36 in level II trauma centres (centres with interventional radiology facility and/or neurosurgery). Patients from the level I trauma centre were more severely injured than those who were admitted at the level II trauma centres (Injury Severity Score [ISS]: 30 [13–75] vs 22 [9–59]; P < 0.01). Time from trauma to hospital admission was also longer in level I trauma centre (115 [50–290] min vs 90 [28–240] min, P < 0.01). Observed mortality rates (14%; 95% confidence interval, 95% CI, [1–26%]) were lower than the predicted mortality (29%; 95% CI [13–44%]) in the level I trauma centre. No difference in mortality rates was found in the level II trauma centres.

Conclusion

The regional trauma network could screen the most severely injured patients with pelvic trauma to admit them at a level I trauma centre. The observed mortality of these patients was lower than the predicted mortality despite increased time from trauma to admission.     

Meta-analysis of plasma to red blood cell ratios and mortality in massive blood transfusions for trauma

Background

The current military paradigm for blood transfusion in major trauma favours high plasma:RBC ratios. This study aimed determine whether high plasma:red blood cell (RBC) ratios during massive transfusion for trauma decrease mortality, using meta-analysis of contemporaneous groups matched for injury severity score.

Methods

A systemic review of the published literature for massive blood transfusions in trauma was performed. Patients were categorised into groups based on plasma:RBC transfusion ratios. Meta-analysis was only performed when there were no significant differences in Injury Severity Score (ISS) between ratio groups within studies. The main endpoint was 30-day mortality.

Results

Six observational studies reporting outcomes for 1885 patients were included in this meta-analysis. Five studies were from civilian environments and one from a military setting. Ratio cut-offs at 1:2 were the most commonly reported, demonstrating a survival advantage with higher ratios (OR 0.49, 95% CI 0.31–0.80, p = 0.004). Ratios ≥ 1:2 showed a significant reduction in mortality compared to lower ratios (OR 0.56, 95% CI 0.40–0.78, p < 0.001). Reducing the cut-off level was still protective (ratios between 1:2.5 and 1:4, OR 0.41), although the confidence interval was wide (0.16–1.00, p = 0.05) and data heterogenous (I² = 78%). Ratios of 1:1 were not proven to confer additional benefit beyond ratios of 1:2 (OR 0.50, 95% CI 0.37–0.68, p < 0.001).

Conclusions

In groups matched for ISS, there was a survival benefit with high plasma:RBC resuscitation ratios. No additional benefits of 1:1 over 1:2 ratios were identified.     

Temporal Trends,Practice Patterns,and Treatment Outcomes for Infected Upper Urinary Tract Stones in the United States

Background

The incidence of infected urolithiasis is unknown, and evidence describing the optimal management strategy for obstruction is equivocal.

Objective

To examine the trends of infected urolithiasis in the United States, the practice patterns of competing treatment modalities, and to compare adverse outcomes.

Design, setting, and participants

A weighted estimate of 396 385 adult patients hospitalized with infected urolithiasis was extracted from the Nationwide Inpatient Sample, 1999–2009.

Outcome measurements and statistical analysis

Time trend analysis examined the incidence of infected urolithiasis and associated sepsis, as well as rates of retrograde ureteral catheterization and percutaneous nephrostomy (PCN) for urgent/emergent decompression. Propensity-score matching compared the rates of adverse outcomes between approaches.

Results and limitations

Between 1999 and 2009, the incidence of infected urolithiasis in women increased from 15.5 (95% confidence interval [CI], 15.3–15.6) to 27.6 (27.4–27.8)/100 000); men increased from 7.8 (7.7–7.9) to 12.1 (12.0–12.3)/100 000. Rates of associated sepsis increased from 6.9% to 8.5% (p = 0.013), and severe sepsis increased from 1.7% to 3.2% (p < 0.001); mortality rates remained stable at 0.25–0.20% (p = 0.150). Among those undergoing immediate decompression, 113 459 (28.6%), PCN utilization decreased from 16.1% to 11.2% (p = 0.001), with significant regional variability. In matched analysis, PCN showed higher rates of sepsis (odds ratio [OR]: 1.63; 95% CI, 1.52–1.74), severe sepsis (OR: 2.28; 95% CI, 2.06–2.52), prolonged length of stay (OR: 3.18; 95% CI, 3.01–3.34), elevated hospital charges (OR: 2.71; 95%CI, 2.57–2.85), and mortality (OR: 3.14; 95%CI, 13–4.63). However, observational data preclude the assessment of timing between outcome and intervention, and disease severity.

Conclusions

Between 1999 and 2009, women were twice as likely to have infected urolithiasis. Rates of associated sepsis and severe sepsis increased, but mortality rates remained stable. Analysis of competing treatment strategies for immediate decompression demonstrates decreasing utilization of PCN, which showed higher rates of adverse outcomes. These findings should be viewed as preliminary and hypothesis generating, demonstrating the pressing need for further study.     

Developing a burn injury severity score (BISS): Adding age and total body surface area burned to the injury severity score (ISS) improves mortality concordance

Background

There is limited research validating the injury severity score (ISS) in burns. We examined the concordance of ISS with burn mortality. We hypothesized that combining age and total body surface area (TBSA) burned to the ISS gives a more accurate mortality risk estimate.

Methods

Data from the Royal Perth Hospital Trauma Registry and the Royal Perth Hospital Burns Minimum Data Set were linked. Area under the receiver operating characteristic curve (AUC) measured concordance of ISS with mortality. Using logistic regression models with death as the dependent variable we developed a burn-specific injury severity score (BISS).

Results

There were 1344 burns with 24 (1.8%) deaths, median TBSA 5% (IQR 2–10), and median age 36 years (IQR 23–50). The results show ISS is a good predictor of death for burns when ISS ≤ 15 (OR 1.29, p = 0.02), but not for ISS > 15 (ISS 16–24: OR 1.09, p = 0.81; ISS 25–49: OR 0.81, p = 0.19). Comparing the AUCs adjusted for age, gender and cause, ISS of 84% (95% CI 82–85%) and BISS of 95% (95% CI 92–98%), demonstrated superior performance of BISS as a mortality predictor for burns.

Conclusion

ISS is a poor predictor of death in severe burns. The BISS combines ISS with age and TBSA and performs significantly better than the ISS.     

Antibioprophylaxie pour césarienne avant incision ou après clampage du cordon ? Méta-analyse

Objective

The objective of this systematic review was to assess the effect of preoperative rather than after umbilical cord clamping antimicrobial prophylaxis for caesarean delivery on maternal and neonatal infectious postoperative morbidity.

Study design

Meta-analysis.

Methods

Three electronic databases (Pubmed, Cochrane Central Register of Randomized Controlled Trials and Embase) were searched without language restriction and retrieved 201 potentially relevant trials. Five randomized controlled trials (n = 1108) studying the timing of antimicrobial prophylaxis for caesarean section were included. The quality of included trials was assessed on the modified Oxford validity scale.

Results

Preoperative administration of antibiotics (n = 456) rather than after cord clamping (n = 563) provides a significant reduction in the incidence of endometritis (Odds Ratio (OR) 0.59 [95% Confidence Interval (CI) 0.35–0.98]) and of total maternal infectious morbidity (OR 0.51 [95% CI 0.32–0.82]). This benefit was not observed regarding the incidence of wound infection (Peto OR 0.58 [95% CI 0.29–1.16]), neonatal infection (Peto OR 1.06 [95% CI 0.57–1.96]), neonatal sepsis workup (OR 1.02 [95% CI 0.67–1.54]), neonatal documented sepsis (Peto OR 0.93 [95% CI 0.43–2.02]) or neonatal intensive care unit admission (OR 0.97 [95% CI 0.61–1.56]). No significant heterogeneity was observed between the included studies.

Conclusion

This meta-analysis provides strong evidence that the preoperative rather than after cord clamping administration of antimicrobial prophylaxis for caesarean delivery provides a reduction in the incidence of endometritis and maternal total infectious morbidity without affecting the incidence of wound infection and neonatal infectious morbidity.     

Primary fascial closure after damage control laparotomy: Sepsis vs haemorrhage

Objective

To compare the outcomes of patients undergoing damage control laparotomy (DCL) for intra-abdominal sepsis vs intra abdominal haemorrhage. We hypothesize that patients undergoing DCL for sepsis will have a higher rate of septic complications and a lower rate of primary fascial closure.

Settings and patients

Retrospective study of patients undergoing DCL from December 2006 to November 2009. Data are presented as medians and percentages where appropriate.

Results

111 patients were identified (55 men), 79 with sepsis and 32 with haemorrhage. There was no difference in age (63 vs 62 years), body mass index (BMI, 27 vs 28), diabetes mellitus (13% vs 9%), or duration of initial operation (125 vs 117 min). Patients with sepsis presented with a lower serum lactate (2.2 vs 4.7 mmol/L, p < 0.01), base deficit (4.0 vs 8.0, p ≤ 0.01) and ASA score (3.0 vs 4.0, p < 0.01). There was no statistical difference in overall morbidity (81% vs 66), mortality (19% vs 22%), intra-abdominal abscess (18% vs 16%), deep wound infection (9% vs 9%), enterocutaneous fistula (ECF) (8% vs 6%) and primary fascial closure (58% vs 59%). Multivariable analysis demonstrated that intra-abdominal abscess (OR 4.26, 95% CI 1.06–19.32), higher base deficit (OR 1.14, 95% CI 1.00–1.31) and more abdominal explorations (OR 1.54, 95% CI 1.23–2.07) were associated with lack of primary fascial closure, but BMI (OR 1.00, 95% CI 0.94–1.07), ECF (OR 2.02, 95% CI 0.23–19.98), wound infection (OR 0.93, 95% CI 0.15–5.27), amount of crystalloids infused within the first 24 h (OR 1.00, 95% CI 0.99–1.00) and intra-abdominal sepsis (OR 1.14, 95% CI 0.35–3.80) were not.

Conclusions

There was an equivalent rate of septic complications and primary fascial closure rates regardless of cause for DCL. Intra-abdominal abscess, worse base deficit and higher number of abdominal explorations were independently associated with the lack of primary fascial closure.     

Gonadotropin-releasing Hormone Agonists and Acute Kidney Injury in Patients with Prostate Cancer

Background

Androgen deprivation therapy (ADT) might increase the risk of acute kidney injury (AKI) in patients with prostate cancer (PCa).

Objective

To examine the impact of ADT on AKI in a large contemporary cohort of patients with nonmetastatic PCa representing the US population.

Design, setting, and participants

Overall, 69 292 patients diagnosed with nonmetastatic PCa between 1995 and 2009 were abstracted from the Surveillance Epidemiology and End Results–Medicare database.

Outcomes measurements and statistical analyses

Patient in both treatment arms (ADT vs no ADT) were matched using propensity-score methodology. Ten-year AKI rates were estimated. Competing-risks regression analyses tested the association between ADT and AKI, after adjusting for the risk of death during follow-up.

Results and limitations

Overall, the 10-yr AKI rates were 24.9% versus 30.7% for ADT-naive patients versus those treated with ADT, respectively (p < 0.001). When patients were stratified according to the type of ADT, the 10-yr AKI rates were 31.1% versus 26.0% for men treated with gonadotropin-releasing hormone (GnRH) agonists and bilateral orchiectomy, respectively (p < 0.001). In multivariable analyses, the administration of GnRH agonists (hazard ratio [HR]: 1.24; 95% confidence interval [CI], 1.18–1.31; p < 0.001), but not bilateral orchiectomy (HR: 1.11; 95% CI, 0.96–1.29; p = 0.1), was associated with the risk of experiencing AKI. Our study is limited by its retrospective design.

Conclusions

ADT is associated with an increased risk of AKI in patients with nonmetastatic PCa. In particular, the administration of GnRH agonists, but not surgical castration, may substantially increase the risk of experiencing AKI. These observations should help provide physicians with better patient selection to reduce the risk of AKI.

Patient summary

The administration of gonadotropin-releasing hormone agonists, but not bilateral orchiectomy, increases the risk of acute kidney injury (AKI) in patients with prostate cancer (PCa). These observations should help provide physicians with better patient selection to reduce the risk of AKI in PCa patients.     

The effect of admission spontaneous hypothermia on patients with severe traumatic brain injury

Introduction

Recent information has emerged regarding the harmful effects of spontaneous hypothermia at time of admission in trauma patients. However the volume of evidence regarding the role of spontaneous hypothermia in TBI patients is inadequate.

Methods

We performed secondary data analysis of 10 years of the Pennsylvania trauma outcome study (PTOS) database. Unadjusted comparisons of the association of admission spontaneous hypothermia with mortality were performed. In addition, full assessment of the association of hypothermia with mortality was conducted using multivariable logistic regressions reporting the odds ratios (OR) with the 95% confidence intervals (CI) and P-values.

Results

There were 11,033 patients identified from the PTOS with severe TBI. There were 4839 deaths (43.9%). The proportion of deaths in hypothermic patients was higher than the proportion of deaths in normothermic patients (53.9% vs. 37.4% respectively; P value < 0.001). In a multivariable logistic regression model adjusted for demographics, injury characteristics, and information at admission to the trauma centre, the odds of death among patients with hypothermia were 1.70 times the odds of death among patients with normothermia (OR 1.70, 95% CI 1.50–1.93), indicating that the probability of death was significantly higher when patients arrived hypothermic at the trauma centre.

Conclusion

The presence of spontaneous hypothermia at hospital admission is associated with a significant increase in the risk of mortality in patients with severe TBI. The benefit of maintaining normothermia in severe TBI patients, the impact of prolonged re-warming in patients with established hypothermia and the introduction of prophylactic measures to complications of hypothermia are key points that require further investigation.     

Analgesia in the management of paediatric and adolescent trauma during the resuscitative phase: The role of the pediatric trauma centre

Background

The objective of this study was to evaluate the use of analgesia in the resuscitative phase of severely injured children and adolescents.

Methods

A retrospective cohort of paediatric (age < 18 years), severely injured (ISS ≥ 12) patients were identified from the London Health Sciences Centre's Trauma Registry from 2007 to 2010. Variables were compared between Analgesia and Non-analgesia groups with Pearson Chi-square and Mann–Whitney U tests. Resuscitative analgesia use was assessed through multivariable logistic regression controlling for age, gender, mechanism, arrival and Trauma Team Activation (TTA).

Results

Analgesia was used in 32% of cases. Univariate analysis did not reveal any differences in gender, age, injury type, injury profile and arrival patterns. Significant differences were found with analgesia used more frequently in patients injured in a motor vehicle collision (58% vs. 42%, p = 0.026) and having parents in the resuscitation room (17% vs. 6%, p = 0.01). Analgesia patients were more injured (median ISS 22 vs. 17, p = 0.027) and had 2.25 times more TTA (39% vs. 17%). Logistic regression revealed patients arriving directly to a trauma centre had a higher incidence of receiving analgesia (OR 2.01, 95% CI: 1.03–3.93), as did TTA (OR 2.18, 95% CI: 1.01–4.73) and having parents in resuscitation room (3.56, 95% CI: 1.23–10.33). Narcotics were most commonly used (85%), followed by benzodiazepines (16%), with 66% given during the primary survey.

Conclusion

Use of analgesia is important in the acute management of paediatric trauma. Direct presentation to a level I trauma centre, TTA and the presence of parents lead to higher appropriate use of analgesia in paediatric trauma resuscitation.     

Laparoendoscopic Single-site Partial Nephrectomy: A Multi-institutional Outcome Analysis

Background

Laparoendoscopic single-site surgery (LESS) has been developed in an attempt to further reduce the surgical trauma associated with conventional laparoscopy. Partial nephrectomy (PN) represents a challenging indication for LESS.

Objective

To report a large multi-institutional series of LESS-PN and to analyze the predictors of outcomes after LESS-PN.

Design, setting, and participants

Consecutive cases of LESS-PN done between November 2007 and March 2012 at 11 participating institutions were included in this retrospective analysis.

Intervention

Each group performed LESS-PN according to its own protocols, entry criteria, and techniques.

Outcome measurements and statistical analysis

Demographic data, main perioperative outcome parameters, and perioperative complications were gathered and analyzed. A multivariable analysis was used to assess the factors predicting a short (≤20 min) warm ischemia time (WIT), the occurrence of postoperative complication of any grade, and a favorable outcome, arbitrarily defined as a combination of the following events: short WIT plus no perioperative complications plus negative surgical margins plus no conversion to open surgery or standard laparoscopy.

Results and limitations

A total of 190 cases were included in this analysis. Mean renal tumor size was 2.6, and PADUA score 7.2. Median operative time was 170 min, with median estimated blood loss (EBL) of 150 ml. A clampless technique was adopted in 70 cases (36.8%), and the median WIT was 16.5 min. PADUA score independently predicted length of WIT (low vs high score: odds ratio [OR]: 5.11 [95% confidence interval (CI), 1.50–17.41]; p = 0.009; intermediate vs high score: OR: 5.13 [95% CI, 1.56–16.88]; p = 0.007). The overall postoperative complication rate was 14.7%. The adoption of a robotic LESS technique versus conventional LESS (OR: 20.92 [95% CI, 2.66–164.64]; p = 0.003) and the occurrence of lower (≤250 ml) EBL (OR: 3.60 [95% CI, 1.35–9.56]; p = 0.010) were found to be independent predictors of no postoperative complications of any grade. A favorable outcome was obtained in 83 cases (43.68%). On multivariate analysis, the only predictive factor of a favorable outcome was the PADUA score (low vs high score: OR: 4.99 [95% CI, 1.98–12.59]; p < 0.001). Limitations of the study were the retrospective design and different selection criteria for the participating centers.

Conclusions

LESS-PN can be safely and effectively performed by experienced hands, given a high likelihood of a single additional port. Anatomic tumor characteristics as determined by the PADUA score are independent predictors of a favorable surgical outcome. Thus patients presenting tumors with low PADUA scores represent the best candidates for LESS-PN. The application of a robotic platform is likely to reduce the overall risk of postoperative complications.     

Systematic Review and Meta-Analysis of Robotic-Assisted versus Conventional Laparoscopic Pyeloplasty for Patients with Ureteropelvic Junction Obstruction: Effect on Operative Time,Length of Hospital Stay,Postoperative Complications,and Success Rate

Background

Although robotic-assisted procedures may theoretically be more advantageous than conventional laparoscopic ones, few studies have shown clear superiority of robotic-assisted laparoscopic pyeloplasty (RAP) over conventional laparoscopic pyeloplasty (CLP) for ureteropelvic junction obstruction (UPJO).

Objective

To undertake a systematic review and meta-analysis to evaluate the effect of RAP versus CLP for patients with UPJO, focusing on operative time, length of hospital stay, postoperative complications, and success rate.

Design, setting, and participants

We searched four electronic bibliographic databases, including the related articles PubMed feature, reference lists from articles, and program abstracts from scientific meetings. Consequently, 58 citations were identified. Two individuals independently screened the titles and abstracts of each citation to select the articles (90% agreement).

Intervention

Studies that compared RAP with CLP for treatment of UPJO were included. Case series on RAP or CLP were excluded because of large heterogeneity.

Measurements

We utilized weighted mean difference (WMD) to measure operative time and length of hospital stay and odds ratio (OR) and risk difference (RD) to measure complication and success rates. These ORs were pooled using a random effects model and were tested for heterogeneity.

Results

We identified eight publications that strictly met our eligibility criteria. Meta-analysis of extractable data showed that RAP was associated with a 10-min operative time reduction (WMD: −10.4 min; 95% CI: −24.6–3; p = 0.15) and significantly shorter hospital stay compared with CLP (WMD: −0.5 d; 95% CI: −0.6–−0.4; p < 0.01). There were no differences between the approaches with regard to rates of complication (OR: 0.7; 95% CI: 0.3–1.6; p = 0.40) and success (OR: 1.3; 95% CI: 0.5–3.5; p = 0.62).

Conclusions

RAP and CLP appear to be equivalent with regard to postoperative urinary leaks, hospital readmissions, success rates, and operative time.     

Impact of the severity of trauma on early retirement

Objective

To assess the association between Injury Severity Score (ISS) and subsequent risk of early retirement.

Design

Observational cohort study with follow-up based on prospectively collected data. Hospital-based data were linked to national register data on pension reception and vital status.

Setting

Level-one urban trauma centre.

Participants

Patients aged 18–64 years entering the trauma centre in Copenhagen during 1999–2007 who were alive after three days were followed until early retirement, death or emigration.

Main outcome measures

Primary outcome was early retirement, defined as receiving disability pension (unintentional) or voluntary early retirement pension (intentional) before the regular age of retirement (65 years). Relative risk of early retirement according to ISS (low, ISS 1–15 vs. high, ISS 16–75) was assessed using Cox proportional hazards regression, adjusted for age and gender.

Results

Of all 6687 patients admitted to the trauma centre, a total of 1722 trauma patients were included and followed for a median of 6.2 years (interquartile range (IQR) 3.7–9.1). Of these, 1305 (75.8%) were males, median age was 35.0 years (IQR 25.4–46.5), and median ISS was 16 (IQR 9–25). Three hundred and twenty-two patients retired during follow-up. Patients with high ISS, compared to patients with low ISS, had an increased risk of early retirement, adjusted hazard ratio 2.60 (95% confidence interval (CI) 2.05–3.30; p < 0.001). Relative increase in retirement risk was 1.04 (95% CI 1.03–1.05) per ISS point and 1.03 (95% CI 1.03–1.04) per year older. Gender was not found to be a significant risk factor (p = 0.69). Five-year absolute risks of early retirement were 9.9% (95% CI 7.8–12.0%) for the low ISS group and 24.6% (95% CI 21.6–27.5%) for the high ISS group.

Conclusions

The risk of early retirement is 2.6 times higher in severely injured patients (ISS 16–75) than the risk in low to moderately injured patients (ISS 1–15) and they have a high absolute 5-year risk as well. Early, targeted interventions to assist with return to work might be able to reduce this risk.     

Counting the lives lost: how many black trauma deaths are attributable to disparities?

Background

The number of black trauma deaths attributable to racial disparities is unknown. The objective of this study was to quantify the excess mortality experienced by black patients given disparities in the risk of mortality.

Materials and methods

We performed a retrospective analysis of patients aged 16–65 y with blunt and penetrating injuries, who were included in the National Trauma Data Bank from 2007–2010. Generalized linear modeling estimated the relative risk of death for black patients versus white patients, adjusting for known confounders. This analysis determined the difference in the observed number of black trauma deaths at Level I and II centers and the expected number of deaths if the risk of mortality for black patients had been equivalent to that of white patients.

Results

A total of 1.06 million patients were included. Among patients with blunt and penetrating injuries at Level I trauma centers, white males and females had a relative risk of death of 0.82 (95% confidence interval [CI], 0.80–0.85) and 0.78 (95% CI, 0.74–0.83), respectively, compared with black patients. Similarly, at Level II trauma centers, white males and females had a relative risk of death of 0.84 (95% CI, 0.80–0.88) and 0.82 (95% CI, 0.73–0.91). Overall, of the estimated 41,613 deaths that occurred at Level I and II centers, 2206 (5.3%) were excess deaths among black patients.

Conclusions

Over a 4-y period, approximately 5% of trauma center deaths could be attributed to racial disparities in trauma outcomes. These data underscore the need to better understand and intervene against the mechanisms that lead to trauma outcomes disparities.     

Supratherapeutic vancomycin levels after trauma predict acute kidney injury and mortality

Introduction

High-dose vancomycin is increasingly prescribed for critically ill trauma patients at risk for methicillin-resistant Staphylococcus aureus pneumonia. Although trauma patients have multiple known risk factors for acute kidney injury (AKI), a link between vancomycin and AKI or mortality has not been established. We hypothesize that high vancomycin trough concentration (VT) after trauma is associated with AKI and increased mortality.

Methods

This was a retrospective analysis from a single institution Level I trauma center. Data were reviewed for all adult trauma patients who were admitted between 2006 and 2010. Patients were included if they received intravenous vancomycin, had serum creatinine levels before and after vancomycin administration, and had at least one recorded VT. Patients were stratified by VT into four groups: VT1 = 0–10 mg/L, VT2 = 10.1–15 mg/L, VT3 = 15.1–20 mg/L, VT4 >20 mg/L. Multivariable logistic regression was performed to determine the association between VT, AKI, and mortality.

Results

Of the 6781 trauma patients reviewed, 263 (3.9%) fit inclusion criteria. Ninety-seven (36.9%) patients developed AKI and 25 (9.5%) died. AKI and mortality increased progressively with VT. Ninety-one patients (34.6%) had troughs >20 mg/L and VT4 was independently associated with AKI (AOR 4.7, P < 0.01) and mortality (AOR 4.8, P = 0.05).

Conclusion

AKI is common in trauma patients who receive intravenous vancomycin. A supratherapeutic trough level of >20 mg/L is an independent predictor of AKI and mortality in trauma patients.     

Predictors of transfer to rehabilitation for trauma patients admitted to a level 1 trauma centre—A model derivation and internal validation study

Objective

Determine the predictors of transfer to rehabilitation in a cohort of trauma patients and derive a risk score based clinical prediction tool to identify such patients during the acute phase of injury management.

Methods

Trauma registry data at a single level one trauma centre were obtained for all patients aged between 15 and 65 years admitted due to injury between 2007 and 2011. Multivariable logistic regression with stepwise selection was performed to derive a prediction model for transfer to rehabilitation. The model was tested on a validation dataset using receiver operator characteristic analyses and bootstrap cross validation on the entire dataset. A clinical prediction risk score was developed based on the final model.

Results

There were 4900 patients included in the study. Variables found to be the strongest predictors of rehabilitation after logistic regression with stepwise selection were pelvic injuries (OR 12.6 95% CI 6.2, 25.2 p < 0.001), need for intensive care unit admission (OR 7.2 95% CI 4.2, 12.3 p < 0.001) and neurosurgical operation (OR 10.5 95% CI 4.7, 23.1 p < 0.001). After bootstrap cross validation the mean AUC was 0.86 (95% CI 0.84, 0.89). The model had a sensitivity of 89% and specificity of 64%.

Conclusion

Intensive unit admission, neurosurgical operation, pelvic injuries and other lower limb injuries were the most important predictors of the need for rehabilitation after trauma. The prediction model has good overall sensitivity, discrimination and could be further validated for use in clinical practice.     

The full spectrum of handlebar injuries in children: A decade of experience

Background

Traumatic paediatric handlebar injury (HBI) is known to occur with different vehicles, affect different body regions, and have substantial associated morbidity. However, previous handlebar injury research has focused on the specific combination of abdominal injury and bicycle riding. Our aim was to fully describe the epidemiology and resultant spectrum of injuries caused by a HBI.

Methods

Retrospective data analysis of all paediatric patients (<18 years) in a prospectively identified trauma registry over a 10-year period. Primary outcome was the HBI, its location and management. The effects of patient age, vehicle type, the impact region, and Injury Severity Score (ISS) were also evaluated. HBI patients were compared against a cohort injured while riding similar vehicles, but not having sustained a HBI.

Results

1990 patients were admitted with a handlebar-equipped vehicle trauma; 236 (11.9%) having sustained a HBI. HBI patients were twice as likely to be aged between 6 and 14 years old compared with non-HBI patients (OR 2.2; 95% CI 1.5–3.2). 88.6% of the HBI patients sustained an isolated injury, and 45.3% had non-abdominal handlebar impact. There were no significant differences in median ISS (p = 0.4) or need for operative intervention (OR 1.1; 95% CI 0.9–1.5) between HBI and non-HBI patients. HBI patients had a significantly longer LOS (1.8 days vs. 1.2 days; p = 0.001), and more frequently required a major operation (OR 3.4; 95% CI 2.2–5.4). The majority of splenic, renal and hepatic injuries were managed conservatively.

Conclusions

Although the majority of paediatric HBI is associated with both intra-abdominal injury and bicycle riding, it produces a spectrum of potentially serious injuries and patients are more likely to undergo major surgery. Therefore these patients should always be treated with a high degree of suspicion.     

Trends in moderate to severe paediatric trauma in Central Netherlands

Introduction

Trend analyses of hospital discharge data can raise signals for prevention policies, but are often flawed by changes in health care consumption. This is a trend analysis of the clinical incidence of paediatric trauma that used international criteria to overcome this bias. The objective is to describe trends in clinical incidence of moderate to severe paediatric trauma, and to identify target groups for prevention activities.

Patients and methods

Included were all paediatric trauma patients (0–18 years) that were discharged from the hospitals of trauma care region Central Netherlands from 1996 to 2009. Selection was made on ISS ≥ 4, and on trauma related International Classification of Diseases diagnostic codes, and trauma related external causes of injury and poisoning codes. Trend analyses were performed using Poisson loglinear regression with correction for age and gender.

Results

23,682 Patients were included, the mean incidence rate was 477/100,000 person-years. Since 2001 the incidence rate of moderate to severe trauma increased with 1.1% annually (95% confidence interval (CI) 0.7–1.5), caused by an increase of falls (3.9%, 95% CI 3.3–4.5), sport injuries (5.4%, 95% CI 4.3–6.5), and bicycle injuries (3.8%, 95% CI 2.8–4.8). The incidence of falls and sport injuries peaked in young children (0–9) and older boys (10–18) respectively. Bicycle injuries affected all children between 5 and 18.

Conclusions

The incidence of paediatric trauma in the centre of the Netherlands increased since 2001. Trend analyses on moderate and severe injuries may identify target groups for prevention in a trauma region.     

Partial Nephrectomy Is Associated with Improved Overall Survival Compared to Radical Nephrectomy in Patients with Unanticipated Benign Renal Tumours

Background

Partial nephrectomy (PN) has been associated with improved overall survival (OS) in select cohorts with localised renal masses when compared to radical nephrectomy (RN). The driving forces behind these differences have been difficult to elucidate given the heterogeneity of previously compared cohorts.

Objective

Compare OS in a subset of patients with unanticipated benign renal masses to minimise the confounding effect of cancer.

Design, setting, and participants

We retrospectively evaluated 2608 consecutive clinical T1 enhancing renal masses that were treated with extirpative surgery at our institution between 1999 and 2006. Of these, 499 tumours (19%) were found to be benign on final pathology. Preoperative data and renal functional data were used to generate a propensity model that was then plugged into a multivariate model of survival. Median follow-up for the entire cohort was 50 mo (interquartile range [IQR]: 32–73).

Intervention

All patients underwent PN or RN.

Measurements

We measured OS and cardiac-specific survival.

Results and limitations

Five-year OS estimates for the PN (n = 388) and RN (n = 111) cohorts were 95% (95% confidence interval [CI], 93–98) versus 83% (95% CI, 74–90), respectively (P < 0.0001). On multivariate analysis, controlling for both comorbidity and age, RN was associated with a 2.5-fold increased risk of death compared to PN (hazard ratio [HR]: 2.5; 95% CI, 1.3–5.1). Postoperative estimated glomerular filtration rate (eGFR) was also an independent predictor of OS and cardiac-specific survival (HR: 0.97; 95% CI, 0.95–0.99 and HR: 0.96; 95% CI, 0.93–0.99, respectively). The retrospective nature of this analysis limits the strength of the conclusions.

Conclusions

PN was associated with better OS when compared to RN in patients with unanticipated benign tumours. This observed survival advantage appears partly to be the result of better preservation of eGFR, but other kidney functions or unmeasured factors may also play a role. These data indicate that PN should be aggressively pursued in any patient where PN is technically feasible.     

Prognostic factors for amputation in severe burn patients

Introduction

Amputation is a rare procedure among burned patients. However, it has significant physical and psychological consequences which impact quality of life.

Objective

To study the incidence, etiology and prognostic factors associated with amputation among burned patients in Chile.

Methods

Cohort study of patients admitted to the Reference Burn Center of Chile from 2006 to 2011. Association of demographic, event and injury variables with the likelihood of amputation were evaluated by using multivariable analysis.

Results

Amputation incidence was 5.8% in 1090 admitted patients. Male amputee patients were significantly more frequent (p = 0.01), with more electrical and high voltage burns (p < 0.01) and had greater frequency of impaired consciousness (p = 0.03). Multivariable analysis identified electrical burns (OR 13.7; 95% CI 6.7–28.1) and impaired consciousness (OR 2.8; 95% CI 1.4–5.7) as prognostic factors for amputation.

Conclusion

Amputation is a low incidence procedure among burned patients. Patients who underwent amputations are frequently at working age. Patients with high-voltage electrical burns and impaired consciousness are more likely to undergo amputation. Since these are highly incapacitating injuries, it is very important to implement preventive measures.     

Risks associated with red blood cell transfusion in the trauma population,a meta-analysis

Introduction

A previous meta-analysis has found an association between red blood cell (RBC) transfusions and mortality in critically ill patients, but no review has focused on the trauma population only.

Objectives

To determine the association between RBC transfusion and mortality in the trauma population, with secondary outcomes of multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI).

Data sources

EMBASE (1947–2012) and MEDLINE (1946–2012).

Study eligibility criteria

Randomized controlled trials and observational studies were to be included if they assessed the association between RBC transfusion and either the primary (mortality) or secondary outcomes (MOF, ARDS/ALI).

Participants

Trauma patients.

Exposure

Red blood cell transfusion.

Methods

A literature search was completed and reviewed in duplicate to identify eligible studies. Studies were included in the pooled analyses if an attempt was made to determine the association between RBC and the outcomes, after adjusting for important confounders. A random effects model was used for and heterogeneity was quantified using the I² statistic. Study quality was assessed using the Newcastle-Ottawa Scale.

Results

40 observational studies were included in the qualitative review. Including studies which adjusted for important confounders found the odds of mortality increased with each additional unit of RBC transfused (9 Studies, OR 1.07, 95%CI 1.04–1.10, I² 82.9%). The odds of MOF (3 studies, OR 1.08, 95%CI 1.02–1.14, I² 95.9%) and ARDS/ALI (2 studies, OR 1.06, 95%CI 1.03–1.10, I² 0%) also increased with each additional RBC unit transfused.

Conclusions

We have found an association between RBC transfusion and the primary and secondary outcomes, based on observational studies only. This represents the extent of the published literature. Further interventional studies are needed to clarify how limiting transfusion can affect mortality and other outcomes.