Predicting Survival after Trauma: a Comparison of TRISS and ASCOT in the Netherlands

Background: Evaluating the performance of a trauma system may be attempted by comparing outcome in different trauma populations. Controlling for injury severity is a necessity for such evaluations. We compare two current models for doing so: the “Trauma and Injury Severity Score” (TRISS) and “A Severity Characterization Of Trauma” (ASCOT). Material and Methods: This study of high-energy trauma victims took place in Leiden, the Netherlands, between 1993 and 1998. Using the Hosmer-Lemeshow (HL) test and receiver operator characteristic (ROC) analysis, the TRISS and ASCOT models were compared for calibration and discrimination. Results: 1,024 patients, with an average Injury Severity Score (ISS) of 13.5, were eligible for inclusion. Blunt trauma was the predominant cause of injuries. Both models gave accurate, though pessimistic, results in predicting the actual number of fatalities (n = 71). The HL test indicated a sufficient fit for the ASCOT model (p = 0.28) and an insufficient fit (p = 0.02) for TRISS. The ROC curves were nearly identical (0.97). Including age as a linear variable, instead of using the current age groups, resulted in an improved discriminative power of the models. Conclusions: The ASCOT model proved superior over TRISS in its accuracy to estimate of survival chances. This difference was most evident for victims with an estimated survival chance of 60–90%. Future national trauma researchers should therefore collect ASCOT data. Improved ASCOT models could be developed, with age as a linear variable. Received: April 25, 2002; revision accepted: September 17, 2002 Correspondence Address Prof. Arie B. van Vugt, MD, PhD, Department of General Surgery and Traumatology, Erasmus MC Rotterdam, Dr. Molewaterplein 40, Postbus 2040, 3000 CA Rotterdam, The Netherlands, Phone (+31/10) 463-5735, Fax -4757, e-mail: vanvugt@hlkd.azr.nl     

Naturlatexallergie

As a consequence of AIDS prevention strategies, the use of powdered disposable latex gloves in hospitals and private medical practices has increased conspicuously in the past 10 years, and allergic reactions to natural latex have become a frequently observed problem. The clinical picture of type I allergies (immediate hypersensitivity) to natural latex ranges from slight, local allergic symptoms (urticaria, rhinitis, and conjunctivitis) to asthmatic complaints up to severest anaphylactic reactions. In addition to health care employees, patients are being affected with an increasing tendency during a variety of surgical and other medical interventions. Due to its enormous hygienic and economic significance, natural latex has become one of the most frequently studied sources of allergies. Efforts were undertaken to identify the causes and triggering factors, to develop diagnostic tools and continue to improve upon them, and to establish preventive measures and implement them successfully.     

Ulcus cruris an der Fußaußenkante

Ohne Zusammenfassung     

Mediastinal lymphoblastic lymphoma with an immature B-cell immunophenotype.

A 19-year-old woman presented with a large mediastinal mass, histologically shown to be malignant lymphoma of lymphoblastic type (LBL). Immunophenotypic and gene rearrangement analysis unequivocally demonstrated that the neoplasm was of B-cell lineage. The neoplastic cells expressed terminal deoxynucleotidyl transferase, the pan-B cell antigens CD19, CD20, and CD22, and were negative for immunoglobulins and numerous T-cell antigens tested. Southern blot analysis showed rearrangement of one allele of the immunoglobulin heavy chain gene while the immunoglobulin kappa and T-cell receptor beta chain genes were in the germline configuration. Thus, the immunophenotypic and molecular findings in this case correspond to an early stage of B-cell differentiation, the pre-pre B-cell stage as has been named by others. In contrast with LBL of immature T-cell lineage, precursor B-cell LBLs involving the mediastinum are truly rare. Occasional cases have been reported that have arisen elsewhere and subsequently involved the mediastinum at time of relapse or tumor progression. Well-documented examples of immature B-cell LBL arising in the mediastinum are virtually unreported. The site and cell population giving rise to this neoplasm is unknown. However, origin from precursors of normal thymic medullary B cells is proposed as one possibility.     

Primary stimulation of CD4+ cells in the presence of IL-4 or IFN-gamma alters the frequencies of cytokine-producing cells at restimulation.

The induction of specific effector functions in naive T cells may be directed by accessory signals during activation. These could be elicited through binding to cell surface molecules or through factors secreted by antigen-presenting cells or other simultaneously activated cells. We have investigated the influence of CD8+ cells and of exogenously added cytokines (interleukin (IL)-2, IL-4 and interferon (IFN)-gamma) on the cytokine production in splenic CD4+ T cells. IL-2, IL-4, IL-5 and IFN-gamma production in CD4+ cells was measured at the single cell level during primary mitogen stimulation in vitro in the presence or absence of factors or CD8+ cells. On day 5 the cells were restimulated with mitogen alone and analysed to evaluate the short-term development of cytokine-producing cells in such cultures. Preactivation in the presence of either exogenous IL-4 or IFN-gamma led to an increased production of IL-4 and IFN-gamma respectively at restimulation, and the effects of both IL-4 and IFN-gamma were augmented by IL-2. After preactivation in the presence of IL-2 and IL-4, every third CD4+ cell could be induced to produce IL-4. Exogenous IL-4 or IFN-gamma further decreased each other's production. Depletion of CD8+ cells before activation resulted in a slight increase of IL-4-producing cells, indicating that simultaneous activation of CD8+ cells will influence lymphokine production in CD4+ cells. The results suggest that the pattern of lymphokines induced in naive cells may be influenced by factors secreted by preactivated CD4+ and CD8+ cells, and that naive cells are preferentially 'recruited' to produce similar cytokines.     

Identifiability, exchangeability and confounding revisited

In 1986 the International Journal of Epidemiology published "Identifiability, Exchangeability and Epidemiological Confounding". We review the article from the perspective of a quarter century after it was first drafted and relate it to subsequent developments on confounding, ignorability, and collapsibility.     

Anticipatory postural adjustments during self-paced and reaction-time movements

We studied the changes in the anticipatory postural adjustments (APAs), associated with dropping a load from extended arms and during fast bilateral shoulder flexion movements, when movements were performed in a self-paced manner and under a simple reaction-time instruction. The latter instruction applied time pressure and did not allow the regular pattern of APAs to be used. In particular, the following questions were asked: (1) are there changes in the relative timing of APAs under the reaction time condition; (2) are changes in the relative timing of APAs associated with changes in APAs themselves; (3) can different postural strategies be used to maintain stability under self-paced and reaction time conditions; and (4) are changes in APAs related to actual reaction time or to a change in the instruction? In particular, under reaction-time conditions, APAs occurred later in time, typically simultaneously with the initiation of the focal movement. Additional changes in electromyographic (EMG) patterns in postural muscles included an increase in the amplitude of EMG bursts and “speeding-up” some of the tri-phasic patterns in postural dorsal-ventral muscle pairs. This was accompanied by a smaller early shift of the center of pressure followed by its more rapid delayed displacement. There was considerable variability in the changes of EMG and dynamic characteristics across subjects. Some of the changes in the EMG patterns in postural muscles depended on actual reaction time, while others were related to a change in the instruction and occurred even if actual reaction times were long enough to allow for the typical self-paced APA patterns to occur. These findings can be interpreted as supporting the parallel control hypothesis for the focal movement and postural adjustments. Alternatively, they can be interpreted within a framework that implies the generation of a single control function, which is transformed into two components, one directed at the focal muscles/joints and the other directed at postural muscles/joints.