The Applicability of Trauma and Injury Severity Score for a Blunt Trauma Population in Korea and a Proposal of New Models Using Score Predictors

PurposeThe purpose of this study was to verify the utility of existing Trauma and Injury Severity Score (TRISS) coefficients and to propose a new prediction model with a new set of TRISS coefficients or predictors.ResultsIn the statistical analysis, the AUCs (0.879–0.899) for predicting outcomes were lower than those of other countries. However, by adjusting the TRISS score using a continuous variable rather than a code for age, we were able to achieve higher AUCs [0.913 (95% confidence interval, 0.899 to 0.926)].ConclusionThese results support further studies that will allow a more accurate prediction of prognosis for trauma patients. Furthermore, Korean TRISS coefficients or a new prediction model suited for Korea needs to be developed using a sufficiently sized sample.     

Feasibility and Early Outcomes of Intensivist-Led Critical Care after Major Trauma in the Korean ICU

Purpose

Substantial evidence supports the benefits of an intensivist model of critical care delivery. However, currently, this mode of critical care delivery has not been widely adopted in Korea. We hypothesized that intensivist-led critical care is feasible and would improve ICU mortality after major trauma.

Materials and Methods

A trauma registry from May 2009 to April 2011 was reviewed retrospectively. We evaluated the relationship between modes of ICU care (open vs. intensivist) and in-hospital mortality following severe injury [Injury Severity Score (ISS) >15]. An intensivist-model was defined as ICU care delivered by a board-certified physician who had no other clinical responsibilities outside the ICU and who is primarily available to the critically ill or injured patients. ISS and Revised Trauma Score were used as measure of injury severity. The Trauma and Injury Severity Score methodology was used to calculate each individual patient''s probability of survival.

Results

Of the 251 patients, 57 patients were treated by an intensivist [intensivist group (IG)] while 194 patients were not [non-intensivist group (NIG)]. The ISS of IG was significantly higher than that for NIG (26.5 vs. 22.3, p=0.023). The hospital mortality rate for IG was significantly lower than that for NIG (15.8% and 27.8%, p<0.001).

Conclusion

The intensivist model of critical care is feasible, and there is room for improvement in the care of major trauma patients. Although trauma systems take time to mature, future studies are needed to evaluate the best model of critical care delivery for severely injured patients in Korea.     

Epidemiology and Clinical Patterns of Ocular Trauma at a Level 1 Trauma Center in Korea

BackgroundTo evaluate the patterns of distribution and clinical manifestations of ocular injuries referred to the level 1 trauma center of Pusan National University Hospital (PNUH) in Korea.MethodsWe analyzed 254 of 4,287 patients who were referred to the Department of Ophthalmology at the level 1 trauma center of the PNUH, from January 2016 through December 2018. Data on the incidence of ocular injuries, sex, age, monthly and seasonal distribution, day and time of injury, side of injury, cause, residence of patients, referral time to an ophthalmologist and subsequent examination time, final visual acuity (VA), and complications were obtained from medical records and retrospectively reviewed. The patients were grouped according to their main diagnosis using the Birmingham Eye Trauma Terminology System (BETTS) and Ocular Trauma Score (OTS).ResultsThe incidence of ocular injuries with major trauma was higher in men (n = 207, 81.5%), the median age at time of injury was 54 years, and Pusan recorded the most cases. The incidences of ocular injury were 1.47/100,000, 1.57/100,000, 1.48/100,000 in 2016, 2017 and 2018, respectively. The most common cause was by a motorbike accident, followed by a pedestrian traffic accident and falls. According to the BETTS classification, open-globe injuries represented 4% of cases, closed-globe injuries represented 12.6%, and other injuries represented 83.1%. Open-globe injuries were significantly associated with low final VA (P = 0.01). In the OTS, 79.4% of patients received 4 or 5 points and 13.7% of patients received 1 or 2 points. The patients who received 1 or 2 points in the OTS score showed final VA below hand movement (P < 0.001), except for two patients. Lid laceration and low initial VA were highly correlated with poor final VA (P < 0.001).ConclusionThis is the first study on the epidemiology and clinical manifestations in trauma patients with ocular injuries at a level 1 trauma center. The incidences of ocular injuries with major trauma were about 1.47–1.57/100,000. BETTS, OTS, lid laceration and initial VA were associated with final VA. We expect our study to provide a basis of data for the evaluation, prevention, and management of ocular injuries in patients with systemic trauma.     

Geriatric fall-related injuries

BackgroundFalls are the leading cause of geriatric injury.ObjectivesWe aimed to study the anatomical distribution, severity, and outcome of geriatric fall-related injuries in order to give recommendations regarding their prevention.MethodsAll injured patients with an age ≥ 60 years who were admitted to Al-Ain Hospital or died in the Emergency Department due to falls were prospectively studied over a four year period.ResultsWe studied 92 patients. Fifty six of them (60.9%) were females. The mean (standard deviation) of age was 72.2 (9.6) years. Seventy three (89%) of all incidents occurred at home. Eighty three patients (90.2%) fell on the same level. The median (range) ISS was 4 (1–16) and the median GCS (range) was 15 (12–15). The lower limb was the most common injured body region (63%). There were no statistical significant differences between males and females regarding age, ISS, and hospital stay (p = 0.85, p = 0.57, and p = 0.35 respectively).ConclusionThe majority of geriatric fall-related injuries were due to fall from the same level at home. Assessment of risk factors for falls including home hazards is essential for prevention of geriatric fall-related injuries.     

Validation of the Shock Index,Modified Shock Index,and Age Shock Index for Predicting Mortality of Geriatric Trauma Patients in Emergency Departments

The shock index (SI), modified shock index (MSI), and age multiplied by SI (Age SI) are used to assess the severity and predict the mortality of trauma patients, but their validity for geriatric patients is controversial. The purpose of this investigation was to assess predictive value of the SI, MSI, and Age SI for geriatric trauma patients. We used the Emergency Department-based Injury In-depth Surveillance (EDIIS), which has data from 20 EDs across Korea. Patients older than 65 years who had traumatic injuries from January 2008 to December 2013 were enrolled. We compared in-hospital and ED mortality of groups categorized as stable and unstable according to indexes. We also assessed their predictive power of each index by calculating the area under the each receiver operating characteristic (AUROC) curve. A total of 45,880 cases were included. The percentage of cases classified as unstable was greater among non-survivors than survivors for the SI (36.6% vs. 1.8%, P < 0.001), the MSI (38.6% vs. 2.2%, P < 0.001), and the Age SI (69.4% vs. 21.3%, P < 0.001). Non-survivors had higher median values than survivors on the SI (0.84 vs. 0.57, P < 0.001), MSI (0.79 vs. 1.14, P < 0.001), and Age SI (64.0 vs. 41.5, P < 0.001). The predictive power of the Age SI for in-hospital mortality was higher than SI (AUROC: 0.740 vs. 0.674, P < 0.001) or MSI (0.682, P < 0.001) in geriatric trauma patients.     

Quick Sequential Organ Failure Assessment Score and the Modified Early Warning Score for Predicting Clinical Deterioration in General Ward Patients Regardless of Suspected Infection

BackgroundThe quick sequential organ failure assessment (qSOFA) score is suggested to use for screening patients with a high risk of clinical deterioration in the general wards, which could simply be regarded as a general early warning score. However, comparison of unselected admissions to highlight the benefits of introducing qSOFA in hospitals already using Modified Early Warning Score (MEWS) remains unclear. We sought to compare qSOFA with MEWS for predicting clinical deterioration in general ward patients regardless of suspected infection.MethodsThe predictive performance of qSOFA and MEWS for in-hospital cardiac arrest (IHCA) or unexpected intensive care unit (ICU) transfer was compared with the areas under the receiver operating characteristic curve (AUC) analysis using the databases of vital signs collected from consecutive hospitalized adult patients over 12 months in five participating hospitals in Korea.ResultsOf 173,057 hospitalized patients included for analysis, 668 (0.39%) experienced the composite outcome. The discrimination for the composite outcome for MEWS (AUC, 0.777; 95% confidence interval [CI], 0.770–0.781) was higher than that for qSOFA (AUC, 0.684; 95% CI, 0.676–0.686; P < 0.001). In addition, MEWS was better for prediction of IHCA (AUC, 0.792; 95% CI, 0.781–0.795 vs. AUC, 0.640; 95% CI, 0.625–0.645; P < 0.001) and unexpected ICU transfer (AUC, 0.767; 95% CI, 0.760–0.773 vs. AUC, 0.716; 95% CI, 0.707–0.718; P < 0.001) than qSOFA. Using the MEWS at a cutoff of ≥ 5 would correctly reclassify 3.7% of patients from qSOFA score ≥ 2. Most patients met MEWS ≥ 5 criteria 13 hours before the composite outcome compared with 11 hours for qSOFA score ≥ 2.ConclusionMEWS is more accurate that qSOFA score for predicting IHCA or unexpected ICU transfer in patients outside the ICU. Our study suggests that qSOFA should not replace MEWS for identifying patients in the general wards at risk of poor outcome.     

Epidemiology of Trauma Patients and Analysis of 268 Mortality Cases: Trends of a Single Center in Korea

Purpose

There is an increasing incidence of mortality among trauma patients; therefore, it is important to analyze the trauma epidemiology in order to prevent trauma death. The authors reviewed the trauma epidemiology retrospectively at a regional emergency center of Korea and evaluated the main factors that led to trauma-related deaths.

Materials and Methods

A total of 17007 trauma patients were registered to the trauma registry of the regional emergency center at Wonju Severance Christian Hospital in Korea from January 2010 to December 2012.

Results

The mean age of patients was 35.2 years old. The most frequent trauma mechanism was blunt injury (90.8%), as well as slip-and-fall down injury, motor vehicle accidents, and others. Aside from 142 early trauma deaths, a total of 4673 patients were admitted for further treatment. The most common major trauma sites of admitted patients were on the extremities (38.4%), followed by craniocerebral, abdominopelvis, and thorax. With deaths of 126 patients during in-hospital treatment, the overall mortality (142 early and 126 late deaths) was 5.6% for admitted patients. Ages ≥55, injury severity score ≥16, major craniocerebral injury, cardiopulmonary resuscitation at arrival, probability of survival <25% calculated from the trauma and injury severity score were independent predictors of trauma mortality in multivariate analysis.

Conclusion

The epidemiology of the trauma patients studied was found to be mainly blunt trauma. This finding is similar to previous papers in terms of demographics and mechanism. Trauma patients who have risk factors of mortality require careful management in order to prevent trauma-related deaths.     

Trauma unit admissions at the Ugandan National Referral Hospital: a descriptive study

BackgroundInjuries are a neglected epidemic globally accounting for 9% global deaths; 1.7 times that of HIV, TB and malaria combined. Trauma remains overlooked with key research and data focusing on infectious diseases yet Uganda has one of the highest rates of traumatic injury. We described demographics of patients admitted to Mulago Hospital''s Shock Trauma Unit within the Emergency Department.MethodsThis was a retrospective record review Trauma Unit admissions from July 2012 to December 2015. Information collected included: age, sex, time of admission, indication for admission and mechanism of trauma.Results834 patient records were reviewed. The predominant age group was 18–35 with majority of patients being male. 54% of patients presented during daytime with 46% admitted in the evening hours or overnight. Mechanism of injury was documented in 484 cases. The most common mechanism was Road Traffic Accident (67.4%), followed by assault (12.8%) and mob violence (5.6%). The most common indication for admission was traumatic brain injury (84.5%), followed by haemodynamic instability (20.0%) and blunt chest injury (6.1%).ConclusionThere''s a significant burden of high-acuity injury particularly among males with RTAs as the leading cause of admission associated with Traumatic Brain Injury as main admission indication.     

Tangent function transformation of the Abbreviated Injury Scale improves accuracy and simplifies scoring

Introduction

The Injury Severity Score (ISS) and the New Injury Severity Score (NISS) are widely used for anatomic severity assessments after trauma. We present here the Tangent Injury Severity Score (TISS), which transforms the Abbreviated Injury Scale (AIS) as a predictor of mortality.

Material and methods

The TISS is defined as the sum of the tangent function of AIS/6 to the power 3.04 multiplied by 18.67 of a patient''s three most severe AIS injuries regardless of body regions. TISS values were calculated for every patient in two large independent data sets: 3,908 and 4,171 patients treated during a 6-year period at level-3 first-class comprehensive hospitals: the Affiliated Hospital of Hangzhou Normal University and Fengtian Hospital Affiliated to Shenyang Medical College, China. The power of TISS to predict mortality was compared with previously calculated NISS values for the same patients in each data set.

Results

The TISS is more predictive of survival than NISS (Hangzhou: receiver operating characteristic (ROC): NISS = 0.929, TISS = 0.949; p = 0.002; Shenyang: ROC: NISS = 0.924, TISS = 0.942; p = 0.008). Moreover, TISS provides a better fit throughout its entire range of prediction (Hosmer Lemeshow statistic for Hangzhou NISS = 29.71; p < 0.001, TISS = 19.59; p = 0.003; Hosmer Lemeshow statistic for Shenyang NISS = 33.49; p < 0.001, TISS = 21.19; p = 0.002).

Conclusions

The TISS shows more accurate prediction of prognosis and a linear relation to mortality. The TISS might be a better injury scoring tool with simple computation.     

Race/ethnicity and acute respiratory distress syndrome: a National Trauma Data Bank study

BackgroundA study in the general population has shown a higher acute respiratory distress syndrome (ARDS) mortality among blacks. We studied whether black blunt-trauma patients experience different ARDS incidence, ARDS-associ-ated mortality, or ARDS case fatality rates.MethodsNational Trauma Data Bank (NTDB) extracts of blunt-trauma patients with Injury Severity Score (ISS) greater than 16 and length of stay greater than 3 days were used for this study. ARDS incidence, ARDS-associated mortality, and ARDS case fatality rates were calculated for Caucasians, blacks, and Hispanics, and compared using χ². In order to adjust for con-founders (age, gender, comorbidities, hypotension, and injury severity) multiple logistic regression models were built for the 3 outcomes. Odd ratios (ORs) and 95% confidence intervals (CIs) were calculated. A p < .05 was used for all statistics.ResultsAmong the 96 350 patients studied, ARDS incidence, ARDS-associated mortality, and ARDS case fatality rates were 0.92%, 0.18%, and 19.1%, respectively. Differences among racial/ethnic groups were found between blacks and Caucasians for ARDS incidence (0.70% vs 0.93%) and between Hispanic and Caucasians for ARDS-associated mortality (0.27% vs 0.17%). Multiple logistic regression models adjusting for confounders, using Caucasian race/ethnicity as a reference, revealed a protective effect of black race/ethnicity for ARDS incidence (OR, 0.73; 95% CI, 0.580.91). Hispanics, but not blacks, experienced higher odds of adjusted ARDS-associated mortality (OR, 1.76; 95% CI, 1.152.62) and ARDS case fatality (OR, 1.92; 95% CI, 1.17-3.09).ConclusionsBlack race/ethnicity is not associated with ARDS mortality among blunt-trauma patients. Black race/ ethnicity seems to have a protective effect in relation to ARDS incidence. Hispanic ethnicity was associated with a higher mortality and case fatality rates for ARDS.     

Comparison of Base Deficit and Vital Signs as Criteria for Hemorrhagic Shock Classification in Children with Trauma

PurposeBase deficit (BD) is superior to vital signs in predicting trauma outcomes in adults. The authors aimed to compare BD and vital signs as criteria for the four-tiered hemorrhagic shock classification in children with trauma.Materials and MethodsWe retrospectively reviewed the data of 1046 injured children who visited a Korean academic hospital from 2010 through 2018. These children were classified separately based on BD (class I, BD ≤2.0 mmol/L; II, 2.1–6.0 mmol/L; III, 6.1–10 mmol/L; and IV, ≥10.1 mmol/L) and vital signs (<13 years: age-adjusted hypotension and tachycardia, and Glasgow Coma Scale; 13–17 years: the 2012 Advanced Trauma Life Support classification). The two methods were compared on a class-by-class basis regarding the outcomes: mortality, early transfusion (overall and massive), and early surgical interventions for the torso or major vessels.ResultsIn total, 603 children were enrolled, of whom 6.6% died. With the worsening of BD and vital signs, the outcome rates increased stepwise (most p<0.001; only between surgical interventions and vital signs, p=0.035). Mortality more commonly occurred in BD-based class IV than in vital signs-based class IV (58.8% vs. 32.7%, p=0.008). Early transfusion was more commonly performed in BD-based class III than in vital signs-based class III (overall, 73.8% vs. 53.7%, p=0.007; massive, 37.5% vs. 15.8%, p=0.001). No significant differences were found in the rates of early surgical interventions between the two methods.ConclusionBD can be a better predictor of outcomes than vital signs in children with severe hemorrhagic shock.     

A Clinical Risk Score to Predict In-hospital Mortality from COVID-19 in South Korea

BackgroundEarly identification of patients with coronavirus disease 2019 (COVID-19) who are at high risk of mortality is of vital importance for appropriate clinical decision making and delivering optimal treatment. We aimed to develop and validate a clinical risk score for predicting mortality at the time of admission of patients hospitalized with COVID-19.MethodsCollaborating with the Korea Centers for Disease Control and Prevention (KCDC), we established a prospective consecutive cohort of 5,628 patients with confirmed COVID-19 infection who were admitted to 120 hospitals in Korea between January 20, 2020, and April 30, 2020. The cohort was randomly divided using a 7:3 ratio into a development (n = 3,940) and validation (n = 1,688) set. Clinical information and complete blood count (CBC) detected at admission were investigated using Least Absolute Shrinkage and Selection Operator (LASSO) and logistic regression to construct a predictive risk score (COVID-Mortality Score). The discriminative power of the risk model was assessed by calculating the area under the curve (AUC) of the receiver operating characteristic curves.ResultsThe incidence of mortality was 4.3% in both the development and validation set. A COVID-Mortality Score consisting of age, sex, body mass index, combined comorbidity, clinical symptoms, and CBC was developed. AUCs of the scoring system were 0.96 (95% confidence interval [CI], 0.85–0.91) and 0.97 (95% CI, 0.84–0.93) in the development and validation set, respectively. If the model was optimized for > 90% sensitivity, accuracies were 81.0% and 80.2% with sensitivities of 91.7% and 86.1% in the development and validation set, respectively. The optimized scoring system has been applied to the public online risk calculator (https://www.diseaseriskscore.com).ConclusionThis clinically developed and validated COVID-Mortality Score, using clinical data available at the time of admission, will aid clinicians in predicting in-hospital mortality.     

An Evaluation of the Effect of Performance Improvement and Patient Safety Program Implemented in a New Regional Trauma Center of Korea

BackgroundThis study examined the impact of the performance improvement and patient safety (PIPS) program implemented in 2015 on outcomes for trauma patients in a regional trauma center established by a government-led project for a national trauma system in Korea.MethodsThe PIPS program was based on guidelines by the World Health Organization and American College of Surgeons. The corrective strategies were proceeded according to the loop closure principle: data-gathering and monitoring, identification of preventable trauma deaths (PTDs), evaluation of preventable factors, analysis of findings, and corrective action plans. We established guidelines and protocols for trauma care, conducted targeted education and peer review presentations for problematic cases, and enhanced resources for improvement accordingly. A comparative analysis was performed on trauma outcomes over a four-year period (2015–2018) since implementing the PIPS program, including the number of trauma team activation and admissions, time factors related to resuscitation, ventilator duration, and the rate of PTDs.ResultsHuman resources in the center significantly increased during the period; attending surgeons responsible for trauma resuscitation from 6 to 11 and trauma nurses from 85 to 218. Trauma admissions (from 2,166 to 2,786), trauma team activations (from 373 to 1,688), and severe cases (from 22.6 to 33.8%) significantly increased (all P < 0.001). Time to initial resuscitation and transfusion significantly decreased from 120 to 36 minutes (P < 0.001) and from 39 to 16 minutes (P < 0.001). Time to surgery for hemorrhage control and decompressive craniotomy improved from 99 to 54 minutes (P < 0.001) and 181 to 135 minutes (P = 0.042). Ventilator duration and rate of PTDs significantly decreased from 6 to 4 days (P = 0.001) and 22.2% to 8.4% (P = 0.008).ConclusionImplementation of the PIPS program resulted in improvements in outcomes at a regional trauma center that has just been opened in Korea. Further establishment of the PIPS program is required for optimal care of trauma patients.     

Trauma unit management and outcomes at an urban tertiary hospital in sub-Saharan Africa: a descriptive study

BackgroundInjuries are a neglected burden despite accounting for 9% of deaths worldwide which is 1.7 times that of hiv, tb and malaria combined. Trauma remains overlooked as research and resources are focused on infectious diseases. Uganda with limited trauma epidemiological data has one of the highest traumatic injury rates. This study describes demographics, management and outcomes of patients admitted to mulago hospital trauma unit.Materials and methodsThis study was a retrospective record review from july 2012 to december 2015. A data collected included age, time and vitals of admission plus interventions, management and outcomes after which it was analyzed.Results834 patient records were reviewed. The predominant age group was 18–35 and 86% of the patients were male. 54% of the patients presented during day and majority of the admission had gcs of less than 8. Antibiotics were given to 467 patients with mechanical ventilation (301) and intubation (289) as the frequent interventions done. 52% of admitted patients were discharged and 40% died.ConclusionMost admissions'' were of youthful age and had severe head injuries (gcs<8). 56% received antibiotics with frequent interventions beig mechanical ventilation and intubation. 52% of admitted patients were discharged and 40% died     

Epidemiology and Management Trend of Renal Trauma: Results of a Nationwide Population-Based Study

BackgroundTo analyze the incidence of renal trauma using the National Health Insurance Service Database (NHISD).MethodsUsing the NHISD, representative of all upper urinary tract injuries in Korea, data regarding renal trauma were analyzed. The International Classification of Diseases, Tenth Revision Clinical Modification codes were used to identify the diagnoses. The incidence estimates of renal traumas were analyzed using Poisson regression analysis. Risk factors for high-grade renal trauma were estimated using multivariable logistic regression analyses.ResultsPatients with renal trauma were identified from a nationwide database collected by the National Health Insurance Service of Korea between 2012 and 2016. Among 37,683 individuals with renal trauma, 1,293 (3.4%) were diagnosed with high-grade renal trauma. Surgical therapy was performed in 995 (2.6%) patients with renal trauma and 184 (14.2%) patients with high-grade renal trauma. Renal trauma occurred in all age groups, and the ratio between men and women was approximately 3:1. Men and women experienced 8,000 (31.82/100,000) and 2,365 (9.52/100,000) renal trauma in 2013 (total 10,365, 20.73/100,000) and 5,243 (20.56/100.000) and 2,168 (8.58/100,000) in 2016 (total 7,411, 14.60/100,000), respectively. In multivariable analysis, female sex, age (age; 41–60 and 61–80 years), and comorbidity of peripheral vascular disease, renal disease, and malignancy were revealed as risk factors for high-grade renal trauma.ConclusionAnnual incidence of renal trauma is 17.33 per 100,000 population from 2012 to 2016. The incidence of kidney damage decreased gradually from 2013 to 2016, and the majority of renal trauma cases were low-grade. Conservative management was the preferred treatment modality in most patients with renal trauma, including those with high-grade renal trauma.     

Validation of Biomarker-Based ABCD Score in Atrial Fibrillation Patients with a Non-Gender CHA2DS2-VASc Score 0–1: A Korean Multi-Center Cohort

PurposeAtrial fibrillation (AF) patients with low to intermediate risk, defined as non-gender CHA₂DS₂-VASc score of 0–1, are still at risk of stroke. This study verified the usefulness of ABCD score [age (≥60 years), B-type natriuretic peptide (BNP) or N-terminal pro-BNP (≥300 pg/mL), creatinine clearance (<50 mL/min/1.73 m²), and dimension of the left atrium (≥45 mm)] for stroke risk stratification in non-gender CHA₂DS₂-VASc score 0–1.Materials and MethodsThis multi-center cohort study retrospectively analyzed AF patients with non-gender CHA₂DS₂-VASc score 0–1. The primary endpoint was the incidence of stroke with or without antithrombotic therapy (ATT). An ABCD score was validated.ResultsOverall, 2694 patients [56.3±9.5 years; female, 726 (26.9%)] were followed-up for 4.0±2.8 years. The overall stroke rate was 0.84/100 person-years (P-Y), stratified as follows: 0.46/100 P-Y for an ABCD score of 0; 1.02/100 P-Y for an ABCD score ≥1. The ABCD score was superior to non-gender CHA₂DS₂-VASc score in the stroke risk stratification (C-index=0.618, p=0.015; net reclassification improvement=0.576, p=0.040; integrated differential improvement=0.033, p=0.066). ATT was prescribed in 2353 patients (86.5%), and the stroke rate was significantly lower in patients receiving non-vitamin K antagonist oral anticoagulant (NOAC) therapy and an ABCD score ≥1 than in those without ATT (0.44/100 P–Y vs. 1.55/100 P-Y; hazard ratio=0.26, 95% confidence interval 0.11–0.63, p=0.003).ConclusionThe biomarker-based ABCD score demonstrated improved stroke risk stratification in AF patients with non-gender CHA₂DS₂-VASc score 0–1. Furthermore, NOAC with an ABCD score ≥1 was associated with significantly lower stroke rate in AF patients with non-gender CHA₂DS₂-VASc score 0–1.     

Impact of nationwide hepatocellular carcinoma surveillance on the prognosis in patients with chronic liver disease

Background/AimsThis study aimed to investigate the effect of hepatocellular carcinoma (HCC) surveillance using the Korea National Liver Cancer Screening Program on the receipt of curative treatment for HCC and mortality in patients with chronic liver disease.MethodsThis population-based cohort study from the Korean National Health Insurance Service included 2003 to 2015 claims data collected from 1,209,825 patients aged ≥40 years with chronic hepatitis B, chronic hepatitis C, and liver cirrhosis. Patients were divided according to HCC surveillance using ultrasonography and serum alpha-fetoprotein every 6–12 months. The study outcomes were the receipt of curative treatment (surgical resection, radiofrequency ablation, or liver transplantation) and all-cause mortality.ResultsThe study population consisted of 1,209,825 patients with chronic hepatitis B, chronic hepatitis C, and liver cirrhosis (median age, 52.0 years; interquartile range, 46–55 years; 683,902 men [56.5%]). The proportion of participants who underwent HCC surveillance was 52.7% (n=657,889). During 10,522,940 person-years of follow-up, 74,433 HCC cases developed, including 36,006 patients who underwent curative treatment. The surveillance group had a significantly higher proportion of curative treatment for HCC than the non-surveillance group after adjusting for confounding factors (adjusted hazard ratio [HR], 5.64; 95% confidence interval [CI], 5.48–5.81). The surveillance group had a significantly lower mortality rate than the non-surveillance group (adjusted HR, 0.56; 95% CI, 0.55–0.56).ConclusionsHCC surveillance using the national screening program in patients with chronic viral hepatitis or liver cirrhosis provides better opportunity for curative treatment for HCC and improves overall survival.     

Black-white disparities in blunt trauma.

To uncover causes of increased mortality rates in black accident victims, patterns of injury and access to trauma care were compared between black and white patients. Over a 41-month period (February 1985 to June 1988), 2120 white and 468 black patients, each with an Injury Severity Score (ISS) > 14 as a result of blunt trauma, were admitted to a Level I regional trauma center, part of a statewide trauma system. Blacks were significantly older and more of them had premorbid illnesses. Although vehicular crashes accounted for the majority of injuries in both groups, blacks had significantly more injuries resulting from falls, pedestrian accidents, and assaults. Whereas 70.6% of whites were transported from the scene and 73% were transported by helicopter, 52.7% of blacks were transported from the scene and 44% by helicopter. Blacks made up 18% of the study group and accounted for 20% of deaths (mortality rate 17.3% for blacks and 14.9% for whites). Mortality was significantly increased for black patients admitted with a Glasgow Coma Scale (GCS) score > or = 13. Private medical insurance, available for 46.3% of black patients, accounted for 78% of payments for all trauma admissions. Increased mortality of black trauma patients may be related to risk factors (age, premorbid illness), increased rates of pedestrian accidents and falls, and disparities in access to Level I trauma centers.     

Role of Coronary Artery Calcium Scoring in Detection of Coronary Artery Disease according to Framingham Risk Score in Populations with Low to Intermediate Risks

Current guidelines recommend that coronary artery calcium (CAC) screening should only be used for intermediate risk groups (Framingham risk score [FRS] of 10%–20%). The CAC distributions and coronary artery disease (CAD) prevalence in various FRS strata were determined. The benefit to lower risk populations of CAC score-based screening was also assessed. In total, 1,854 participants (aged 40–79 years) without history of CAD, stroke, or diabetes were enrolled. CAC scores of > 0, ≥ 100, and ≥ 300 were present in 33.8%, 8.2%, and 2.9% of the participants, respectively. The CAC scores rose significantly as the FRS grew more severe (P < 0.01). The total CAD prevalence was 6.1%. The occult CAD prevalence in the FRS ≤ 5%, 6%–10%, 11%–20%, and > 20% strata were 3.4%, 6.7%, 9.0%, and 11.6% (P < 0.001). In multivariate logistic regression analysis adjusting, not only the intermediate and high risk groups but also the low risk (FRS 6%–10%) group had significantly increased odds ratio for occult CAD compared to the very low-risk (FRS ≤ 5%) group (1.89 [95% confidence interval, CI, 1.09–3.29] in FRS 6%–10%; 2.48 [95% CI, 1.47–4.20] in FRS 11%–20%; and 3.10 [95% CI, 1.75–5.47] in FRS > 20%; P < 0.05). In conclusion, the yield of screening for significant CAC and occult CAD is low in the very low risk population but it rises in low and intermediate risk populations.     

Thrombotic Microangiopathy Score as a New Predictor of Neurologic Outcomes in Patients after Out-of-Hospital Cardiac Arrest

PurposeGiven the morphological characteristics of schistocytes, thrombotic microangiopathy (TMA) score can be beneficial as it can be automatically and accurately measured. This study aimed to investigate whether serial TMA scores until 48 h post admission are associated with clinical outcomes in patients undergoing targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA).Materials and MethodsWe retrospectively evaluated a cohort of 185 patients using a prospective registry. We analyzed TMA scores at admission and after 12, 24, and 48 hours. The primary outcome measures were poor neurological outcome at discharge and 30-day mortality.ResultsIncreased TMA scores at all measured time points were independent predictors of poor neurological outcomes and 30-day mortality, with TMA score at time-12 showing the strongest correlation [odds ratio (OR), 3.008; 95% confidence interval (CI), 1.707–5.300; p<0.001 and hazard ratio (HR), 1.517; 95% CI, 1.196–1.925; p<0.001]. Specifically, a TMA score ≥2 at time-12 was closely associated with an increased predictability of poor neurological outcomes (OR, 6.302; 95% CI, 2.841–13.976; p<0.001) and 30-day mortality (HR, 2.656; 95% CI, 1.675–4.211; p<0.001).ConclusionIncreased TMA scores predicted neurological outcomes and 30-day mortality in patients undergoing TTM after OHCA. In addition to the benefit of being serially measured using an automated hematology analyzer, TMA score may be a helpful tool for rapid risk stratification and identification of the need for intensive care in patients with return of spontaneous circulation after OHCA.