[Cost analysis of inpatient versus outpatient intravenous antibiotic treatment for periprosthetic joint infections : A simulation]. / Kostenanalyse stationärer und ambulanter intravenöser Antibiotikatherapie periprothetischer Gelenkinfektionen : Eine Simulation.

BACKGROUND: Parenteral antibiotic administration in the treatment of periprosthetic joint infections (PJI) often requires inpatient settings. This is associated with significant costs to the healthcare system. OBJECTIVE: The costs of inpatient parenteral antibiotic treatment (IPAT) and simulated costs of outpatient parenteral antibiotic treatment (OPAT) were compared in patients with PJI. Evaluations were carried out from the perspectives of cost bearers (insurances) and healthcare providers (hospitals). MATERIAL AND METHODS: The analysis and simulations were performed for all cases with the ICD-10 diagnosis T84 in the treatment year 2015. RESULTS: The simulated reduction of 159 bed-days in the 12 patients included in the study resulted in a reduction of the total costs of>18,000 € from the perspective of the health insurance. From the perspective of the hospitals the pure proceeds were improved by >22,000 €. The total costs of OPAT were >57,000 € for the health insurance. For hospitals the difference of policlinic proceeds and costs of OPAT showed a loss of >1500 €. CONCLUSION: For hospitals the OPAT is overall financially advantageous. Further advantages due to opportunity costs seem to be interesting. For cost bearers OPAT is associated with an additional financial expenditure, particularly due to costs of outpatient medication. The private sector should be considered due to the assumed additional burden as well as the assumed patient comfort.

[Interventional management of peripheral vascular injuries : From the exclusion indication to the procedure of first choice]. / Interventionelles Management peripherer Gefäßverletzungen : Von der Ausnahmeindikation zum Verfahren der 1. Wahl.

BACKGROUND: Approximately one third of all traumatic peripheral artery injuries affect the upper extremities, while two thirds involve the arteries of the lower extremities. Historically, these injuries were treated by open surgical repair. Nowadays, interventional treatment, such as embolization or stent grafting are increasingly used to treat peripheral artery injuries. OBJECTIVE: Determination of the current state of interventional treatment options for injuries of peripheral arteries. MATERIAL AND METHODS: Selective literature review on the current state of interventional management of peripheral artery injuries. RESULTS: Although scarce, the available data confirm the efficacy of interventional techniques for managing peripheral artery injuries; however, despite improvements in treatment techniques and interventional devices, not all patients are equally well suited for endovascular or open surgical treatment. Consequently, a multidisciplinary decision on the best treatment has to be made on a case by case basis. CONCLUSION: According to the promising clinical data, interventional treatment should be considered more often. Diagnostic algorithms need to be adapted accordingly.

Operative treatment of geriatric ankle fractures with conventional or locking plates. A retrospective case-control study.

BACKGROUND: The incidence of geriatric ankle fractures continues to rise due to demographic changes. While locking plates have become standard implants for injuries of other body regions, clinical studies on their use for geriatric ankle fractures are rare. METHODS: Therefore, a retrospective case-control study, including 333 patients with a mean age of 73.5 years was performed. 263 patients underwent operative fixation with one- third tubular plates and 70 were treated with locking plates. Early outcomes and complication rates of locking plates as compared with conventional one- third tubular plates are described. RESULTS: In the present study, patients treated with locking plates were older and suffered from more severe fracture patterns. In addition, these patients had more severe comorbidities. Treatment with conventional or locking plate fixation resulted in a comparable complication and revision rate. A matched pair analysis showed significantly more complications and required revision surgeries and a trend towards more implant failures in the group that underwent conventional plating. CONCLUSIONS: Therefore, we conclude that precontoured locking plates represent an appropriate treatment option for severe ankle fractures in patients suffering from relevant co-morbidities. Prospective randomized trials are warranted to prove superiority of locking plates for treatment of geriatric ankle fractures. Level 3: Retrospective case- control study.

Standardised pre-operative diagnostics and treatment of peripheral arterial disease reduce wound complications in geriatric ankle fractures.

PURPOSE: The aim of this study was to evaluate a standardised algorithm to assess and treat impaired limb perfusion prior to surgical fixation of geriatric ankle fractures and determine the prevalence of peripheral arterial disease (PAD) in geriatric patients presenting with ankle fractures. METHODS: Eighty-four patients >65 years pre-operatively diagnosed and treated according to an algorithm (study group) were compared with 84 patients diagnosed and treated before the algorithm was introduced (control group). RESULTS: In 14 patients of the study group, clinical noninvasive examination revealed signs of relevant PAD, which was confirmed with computed tomographic angiography (CTA) in nine patients, all of whom had successful angioplasty prior to surgical fixation of the ankle fracture. In three of these patients, PAD had previously been diagnosed. After standardised diagnostics and treatment of malperfusion, a significantly reduced overall and, particularly, wound complication rate was found. CONCLUSION: PAD is an underdiagnosed condition in geriatric patients presenting with ankle fractures. This study underlines the relevance of limb perfusion for adequate wound healing in geriatric ankle fractures. Therefore, special attention should be paid to diagnose and-if indicated-optimise limb perfusion prior to surgical fixation of geriatric ankle fractures.

Stimulation with bone morphogenetic protein-2 (BMP-2) enhances bone-tendon integration in vitro.

PURPOSE: Preclinical studies have reported that bone morphogenetic protein (BMP)-2 promotes bone-tendon healing following anterior cruciate ligament reconstruction. We examined the region-specific effects of BMP-2 on osteoblast and fibroblast differentiation in a highly standardized murine in vitro co-culture model of bone-tendon integration. MATERIALS AND METHODS: We used quantitative PCR to measure the dose- and time-dependent influence of BMP-2 on the expression of alkaline phosphatase, osteocalcin, collagen type 1 (alpha 1 chain), runt-related transcription factor 2, osteopontin, collagen type 1 (alpha 2 chain), collagen type 5 (alpha 1 chain), decorin, fibromodulin, mohawk homeobox, bone morphogenetic protein receptor, type 1A, bone morphogenetic protein receptor, type 2, and Noggin in the osteoblast, interface, and fibroblast regions of a co-culture model of the murine preosteoblast cell line MC3T3-E1 and the fibroblast cell line 3T6. RESULTS: Stimulation with BMP-2 resulted in a significant upregulation of alkaline phosphatase (p < 0.001), osteocalcin (p < 0.001), collagens (p < 0.001), runt-related transcription factor 2 (p < 0.05), and osteopontin (p < 0.001) expression in the osteoblast region. In the interface region, BMP-2 exposure led to dose- and time-dependent upregulation of alkaline phosphatase (p < 0.001), osteocalcin (p < 0.001), osteopontin (p < 0.001), runt-related transcription factor 2 (p < 0.001), and markers of extracellular matrix production (p < 0.001). Both BMP receptors showed a significant BMP-2-dependent upregulation at the interface region, and Noggin was downregulated at the osteoblast and interface region following BMP-2 exposure. CONCLUSIONS: Exposure to BMP-2 upregulated the expression of genes associated with bone-tendon integration in vitro, suggesting the stimulation of transdifferentiation processes at the interface and fibroblast regions as well as the induction of positive feedback mechanisms. Further studies will be needed to establish BMP-2 dose and treatment algorithms following tendon reinsertion and reconstruction.

The osseous morphology of nondegenerated shoulders shows no side-related differences in elderly patients: an analysis of 102 computed tomography scans.

BACKGROUND: A precise understanding of glenohumeral anatomy is required to optimize preoperative planning in shoulder joint arthroplasty, which is difficult in the presence of degenerative disease. In unilateral disease, the contralateral shoulder can be used as a representation of normal anatomy; however, intrasubject differences in shoulder morphology have not been investigated. METHODS: A retrospective study of all patients aged >65 years who received whole body computed tomography at our trauma center from 2010 through 2014 was conducted. Right and left shoulder computed tomography scans were examined, and the following anatomic parameters were measured: humeral head diameter in anteroposterior and axial views, glenoid diameter in anteroposterior and axial views, glenoid surface, scapula neck depth, neck-shaft angle, glenoid inclination, glenoid/head ratio, and glenoid version. Patients with inadequate scan quality, osseous lesions, pre-existing anatomic abnormality, or metallic implant at the shoulder region and significant osteoarthritis were excluded. RESULTS: The study analyzed 102 shoulders of 51 patients. Mean age was 71.4 ± 8.2 years. Humeral head and glenoid diameters, scapula neck depth (right, 36 ± 8 mm; left, 36 ± 7 mm; P = .684), glenoid/head ratio (right, 0.6 ± 0.1; left, 0.6 ± 0.0; P = .961), and glenoid surface (right, 790 ± 152 mm(2); left, 754 ± 134 mm(2); P = .215) showed no significant side-related differences. In addition, no significant difference was found regarding the neck-shaft angle (P = .211) and glenoid anteversion or retroversion (right, 65% [n = 33] anteversion and 35% [n = 18] retroversion; left, 69% [n = 35] anteversion and 31% [n = 16] retroversion; P = .417). CONCLUSION: There are no significant side-dependent differences in the osseous anatomy of the glenohumeral joint. In patients with unilateral shoulder degeneration, the contralateral shoulder can provide reference values during the planning of shoulder replacement surgery.

Agreement Between Proximal Femoral Geometry and Component Design in Total Hip Arthroplasty: Implications for Implant Choice.

BACKGROUND: The present study aimed to analyze the agreement between proximal femoral geometry of adult hips and femoral component design in total hip arthroplasty. METHODS: Anatomical femoral offset (FOAnat) and the anatomical neck-shaft angle (NSAAnat) of 800 adult hips were measured by computed tomography scans, and anatomical femoral neck height (FHAnat) was calculated. Corresponding best-fit implants of the most common hip system (standard, high offset and varus variant) were identified for each hip. Finally, the precision of the best possible anatomic reconstruction was assessed. RESULTS: The mean FOAnat was 38.0 mm (range: 19.8-57.9 mm, standard deviation [SD]: 6.4 mm), the mean NSAAnat was 130.8° (range: 107.1°-151.9°; SD: 6.5°), and the mean FHAnat was 32.6 mm (range: 14.4-52.0 mm; SD: 5.5 mm). In 450 (56.3%) hips, the standard variant was identified to be the best-fit implant, followed by the varus (n = 282, 35.3%) and the high offset (n = 68, 8.5%) variants. The mean minimal distance from the best-fit implant was 4.5 mm (range: 0.1-20.2 mm, SD: 3.4 mm). Excellent agreement (distance: <2 mm) between hip anatomy and best-fit implant was found in 203 (25.4%) hips, combined excellent and acceptable agreement (distance: <6 mm) in 569 (71.1%) hips, whereas 213 (28.9%) hips were graded as poor (distance: ≥6 mm). CONCLUSION: The present study revealed a mismatch between proximal femoral anatomy of a relevant proportion of adult hips and implant geometry of the most common femoral component in total hip arthroplasty.

Age-dependent variation of glenohumeral anatomy: a radiological study.

PURPOSE: Profound knowledge of variations in shoulder anatomy is gaining relevance in daily clinical work. In our study, we examine age-dependent variations of glenohumeral parameters in healthy individuals. METHODS: In this analysis, 774 severely injured patients who received a whole-body computed tomography (CT) scan were included. Patients with shoulder fractures were excluded. The resulting scans were split into two groups: patients younger than 25 (group 1) and older than 60 years (group 2). These groups were divided into four subgroups according to gender. Shoulder scans with advanced osteoarthritis were then removed. In order to maintain equal group size, redundant patients were randomly removed. RESULTS: A total of 210 measurements from 106 patients were included. The humeral head diameter (group 1: 41.6 ± 3.7 mm, group 2: 44.5 ± 3.7 mm, p < 0.001) and glenoid surface (group 1: 627.0 ± 110.8 mm(2), group 2: 763.9 ± 148.5 mm(2), p < 0.001) showed higher values in the group of older patients. Older patients also had a higher glenoid inclination (group 1: 50.9 ± 6.9°, group 2: 55.7 ± 8.8°, p < 0.001) as well as an increased glenoid to head ratio (group 1: 0.61 ± 0.04, group 2: 0.64 ± 0.05, p < 0.001). CONCLUSIONS: Increased sizes of humeral head and glenoid surface are present in older patients without signs of osteoarthritis. Moreover, in patients with increased age more glenoid inclination as well as an increased glenoid to head ratio was revealed. These age-dependent anatomical parameters should be considered during planning of operative procedures of the shoulder joint.

Functional implications of femoral offset following hemiarthroplasty for displaced femoral neck fracture.

PURPOSE: Inadequate reconstruction of femoral offset after total hip arthroplasty (THA) is associated with unfavourable outcomes, but its importance following hemiarthroplasty for displaced femoral neck fracture is unknown. METHODS: Our study examined the correlation between reconstructed femoral offset and functional outcome 12 months after post traumatic hemiarthroplasty in 126 prospectively enrolled elderly patients. Rotation-corrected femoral offset (FORC), relative femoral offset (FORL) and contralateral femoral offset (FOC) were measured on anteroposterior radiographs. The Harris Hip Score (HHS) was the primary outcome measure; the timed up and go (TUG) test and Lawton instrumental activities of daily living (IADL) score were secondary outcomes. Correlations were sought using the Spearman correlation coefficient (r). Sample size was calculated using an Altman nomogram, with the power set at 80 %, the significance level of 0.05 and a standardised difference of 0.75. RESULTS: The mean reconstructed FORC was 41 mm (17-67 mm) and showed a linear relationship and excellent correlation with the FOC. At 12 months, we found a significant positive correlation between FORC and HHS (r = 0.303, p = 0.025) and IADL (r = 0.325, p = 0.013), but not TUG (r = -0.026, p = 0.863). These findings were confirmed by bivariate and multivariate correlation between FORL and functional outcome parameters. CONCLUSIONS: We found a clinically relevant relationship between femoral offset and functional outcome after hemiarthroplasty in elderly patients, comparable with that of THA, for treating osteoarthritis.

Drowning Injuries: Analysis of a Decennial Air Medical Rescue Center Experience.

OBJECTIVE: Drowning is one of the leading injury death causes in younger children. Common intensive care measures seem not to improve neurologic outcome, and early prognostic options appear partially unreliable. Therefore, we evaluated a cohort of drowning patients cotreated by a helicopter emergency medical service regarding typical incident constellations, early and subsequent prognostic options, and relevant interventions. METHODS: All patients prehospitally cotreated by helicopter emergency medical service "Christoph 4" in primary missions because of drowning incidents during a 10-year period were evaluated. Patient, prehospital, and clinical data were recorded retrospectively; correlations and prognostic values were evaluated with appropriate statistical tests. RESULTS: Fifty-one patients were included. Various examination results (several vital, neurologic, and laboratory parameters) and sufficient prehospital first aid measures were significantly correlated with the final outcome (P < .05, respectively). Aspartate aminotransferase and alanine aminotransferase values precisely discriminated between the final outcome groups (P = .001 and area under the receiver operating characteristic curve = 1.0 in both cases). CONCLUSION: Aspartate aminotransferase and alanine aminotransferase values were the most useful predictors of outcome in our study. Sufficient prehospital first aid measures were correlated with improved outcome. Regular first aider training is recommended.

The effect of osteoarthritis on functional outcome following hemiarthroplasty for femoral neck fracture: a prospective observational study.

BACKGROUND: The influence of pre-existing radiographic osteoarthritis on the functional outcome of elderly patientents with displaced intracapsular fractures of the femoral neck treated by hemiarthroplasty is unclear. METHODS: We prospectively examined the impact of pre-existing osteoarthritis on the functional outcome of 126 elderly patients with displaced intracapsular fracture of the femoral neck treated by hemiarthroplasty. RESULTS: The mean age of the cohort was 82.7 years. At 12 months, we observed no statistically significant differences in the Harris hip score (p = 0.545), the timed up and go test (p = 0.298), the Tinetti test (p = 0.381) or the Barthel Index (p = 0.094) between patients with Kellgren and Lawrence grades 3 or 4 osteoarthritis, and patients with grades 0 to 2 changes. Furthermore, there were no differences in complication or revision rates. CONCLUSIONS: Our findings challenge the hypothesis that pre-existing osteoarthritis is a contraindication to hemiarthroplasty in elderly patients with femoral neck fracture.

Bone morphogenetic protein-7 enhances bone-tendon integration in a murine in vitro co-culture model.

PURPOSE: Bone-tendon healing following anterior cruciate ligament reconstruction is reportedly enhanced by bone morphogenetic protein (BMP)-7. To improve our understanding of the underlying biologic processes, we examined the effects of BMP-7 on region-specific gene expression in vitro. METHODS: A murine in vitro co-culture model simulating the osteoblast, interface and fibroblast regions was established. The dose- and time-dependent region-specific effects of BMP-7 exposure on gene expression of Alpl, Bglap, Col1a1, Runx2 and Spp1 were analysed by quantitative PCR. RESULTS: At the osteoblast region, BMP-7 significantly increased Alp, Bglap, Col1a1, and Runx2 expression, while Spp1 expression was suppressed. At the interface region, BMP-7 exposure resulted in a trend towards increased expression rates of Alpl and Col1a1, whereas Bglap (P < 0.001) and Runx2 (P < 0.01) were significantly upregulated without any detectable effect on Spp1 expression. At the fibroblast region, BMP-7 increased Alpl (P < 0.001), Bglap (P < 0.001) and Runx2 (P < 0.001) expression, but no significant effects were seen on Col1a1 or Spp1. Exposure to BMP-7 (100 ng/ml) had its most pronounced biologic impact on day ten. CONCLUSION: BMP-7 stimulation showed beneficial region-specific effects on bone-tendon healing in vitro, such as enhanced expression of parameters for ossification and fibroblast transdifferentiation, both key processes during successful graft integration.

The influence of pre-existing radiographic osteoarthritis on functional outcome after trochanteric fracture.

PURPOSE: It is crucially important to optimise functional outcome after fixation of trochanteric femoral fractures. While a number of risk factors that predict a poor clinical course have been identified, the influence of pre-existing radiographic osteoarthritis (OA) of the hip is unclear. METHODS: The influence of pre-existing radiographic OA of the hip on short- to mid-term functional outcome was prospectively analysed in a cohort of patients undergoing proximal femoral nailing for trochanteric fracture. OA was graded according to Kellgren and Lawrence; functional outcome was assessed at six and 12 months by the Harris hip score (HHS), the timed up and go (TUG) test and the Barthel Index. RESULTS: Our cohort comprised 188 patients (58 were male and 130 female), with a mean age of 82 years. At six and 12 months postoperatively, the HHS (p < 0.001 and p = 0.008, respectively) and Barthel Index (p < 0.001 and p = 0.02, respectively) correlated significantly with the grade of pre-existing OA. After adjustment for confounding variables, there was a significant association between the grade of pre-existing OA and the HHS at six months (p = 0.02). Although we observed trends suggestive of other relationships, none reached statistical significance. CONCLUSIONS: Pre-existing radiographic OA of the hip is an important determinant of clinical outcome in elderly patients with a trochanteric femoral fracture. Further studies will be needed to establish the most effective means of restoring hip function after trochanteric femoral fracture in patients with radiographic OA of the hip.

Physical and psychological long-term outcome after traumatic brain injury in children and adult patients.

BACKGROUND: Several studies have indicated that younger age is associated with worse recovery after pediatric traumatic brain injury (TBI) compared to elder children. In order to verify this association between long-term outcome after moderate to severe TBI and patient's age, direct comparison between different pediatric age groups as well as an adult population was performed. METHODS: This investigation represents a retrospective cohort study at a level I trauma center including patients with moderate to severe, isolated TBI with a minimum follow-up of 10 years. According to their age at time of injury, patients were divided in pre-school (0-7 years), school (8-17 years) and adult (18-65 years) patients. Physical examination and standardized questionnaire on physical and psychological aspects (Glasgow Outcome Scale, Barthel Index, Impact of Event Scale, Hospital Anxiety and Depression Scale, short form 12) were performed. RESULTS: 135 traumatized patients were included. Physical and psychological long-term outcome was associated with injury severity but not with patients' age at time of injury. Outcome recovery measured by Glasgow Outcome Scale was demonstrated with best results for pre-school aged children (p = 0.009). According to the Hospital Anxiety and Depression Scale an increased incidence of anxiety (p = 0.010) and depression (p = 0.026) was evaluated in older patients. CONCLUSION: Long-term outcome perceptions after moderate to severe TBI presented in this study question current views of deteriorated recovery for the immature brain. The sustained TBI impact seemed not to reduce the child's ability to overcome the suffered impairment measured by questionnaire based psychological, physical and health related outcome scores. These results distinguish the relevance of rehabilitation and family support in the long term.

The influence of hip rotation on femoral offset in plain radiographs.

BACKGROUND AND PURPOSE: Adequate restoration of femoral offset (FO) is critical for successful outcome after hip arthroplasty or fixation of hip fracture. Previous studies have identified that hip rotation influences the projected femoral offset (FOP) on plain anteroposterior (AP) radiographs, but the precise effect of rotation is unknown. PATIENTS AND METHODS: We developed a novel method of assessing rotation-corrected femoral offset (FORC), tested its clinical application in 222 AP hip radiographs following proximal femoral nailing, and validated it in 25 cases with corresponding computed tomography (CT) scans. RESULTS: The mean FORC was 57 (29-93) mm, which differed significantly (p < 0.001) from the mean FOP 49 (22-65) mm and from the mean femoral offset determined by the standard method: 49 (23-66) mm. FORC correlated closely with femoral offset assessed by CT (FOCT); the Spearman correlation coefficient was 0.94 (95% CI: 0.88-0.97). The intraclass correlation coefficient for the assessment of FORC by AP hip radiographs correlating the repeated measurements of 1 observer and of 2 independent blinded observers was 1.0 and 1.0, respectively. INTERPRETATION: Hip rotation affects the FOP on plain AP radiographs of the hip in a predictable way and should be adequately accounted for.

Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients.

INTRODUCTION: Physician-staffed helicopter emergency medical services (HEMS) are a well-established component of prehospital trauma care in Germany. Reduced rescue times and increased catchment area represent presumable specific advantages of HEMS. In contrast, the availability of HEMS is connected to a high financial burden and depends on the weather, day time and controlled visual flight rules. To date, clear evidence regarding the beneficial effects of HEMS in terms of improved clinical outcome has remained elusive. METHODS: Traumatized patients (Injury Severity Score; ISS≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2007 and 2009 were analyzed using the TraumaRegister DGU® of the German Society for Trauma Surgery. Only patients treated in German level I and II trauma centers with complete data referring to the transportation mode were included. Complications during hospital treatment included sepsis and organ failure according to the criteria of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) consensus conference committee and the Sequential Organ Failure Assessment (SOFA) score. RESULTS: A total of 13,220 patients with traumatic injuries were included in the present study. Of these, 62.3% (n=8,231) were transported by GEMS and 37.7% (n=4,989) by HEMS. Patients treated by HEMS were more seriously injured compared to GEMS (ISS 26.0 vs. 23.7, P<0.001) with more severe chest and abdominal injuries. The extent of medical treatment on-scene, which involved intubation, chest and treatment with vasopressors, was more extensive in HEMS (P<0.001) resulting in prolonged on-scene time (39.5 vs. 28.9 minutes, P<0.001). During their clinical course, HEMS patients more frequently developed multiple organ dysfunction syndrome (MODS) (HEMS: 33.4% vs. GEMS: 25.0%; P<0.001) and sepsis (HEMS: 8.9% vs. GEMS: 6.6%, P<0.001) resulting in an increased length of ICU treatment and in-hospital time (P<0.001). Multivariate logistic regression analysis found that after adjustment by 11 other variables the odds ratio for mortality in HEMS was 0.75 (95% CI: 0.636 to 862). CONCLUSIONS: Although HEMS patients were more seriously injured and had a significantly higher incidence of MODS and sepsis, these patients demonstrated a survival benefit compared to GEMS.

Impact of the body mass on complications and outcome in multiple trauma patients: what does the weight weigh?

Obesity is known as an independent risk factor for various morbidities. The influence of an increased body mass index (BMI) on morbidity and mortality in critically injured patients has been investigated with conflicting results. To verify the impact of weight disorders in multiple traumatized patients, 586 patients with an injury severity score >16 points treated at a level I trauma center between 2005 and 2011 were differentiated according to the BMI and analyzed regarding morbidity and outcome. Plasma levels of interleukin- (IL-) 6 and C-reactive protein (CRP) were measured during clinical course to evaluate the inflammatory response to the "double hit" of weight disorders and multiple trauma. In brief, obesity was the highest risk factor for development of a multiple organ dysfunction syndrome (MODS) (OR 4.209, 95%-CI 1.515-11.692) besides injury severity (OR 1.054, 95%-CI 1.020-1.089) and APACHE II score (OR 1.059, 95%-CI 1.001-1.121). In obese patients as compared to those with overweight, normal weight, and underweight, the highest levels of CRP were continuously present while increased systemic IL-6 levels were found until day 4. In conclusion, an altered posttraumatic inflammatory response in obese patients seems to determine the risk for multiple organ failure after severe trauma.

Predicting tracheostomy in multiple injured patients with severe thoracic injury (AIS ≥ 3) with the new T3P-Score: a multivariable regression prediction analysis.

Multiple trauma patients with severe chest trauma are at increased risk for tracheostomy. While the risk factors associated with the need for tracheostomy are well established in the general critical care population, they have not yet been validated in a cohort of patients suffering severe thoracic trauma. This retrospective cohort study analysed data on patients aged 18 years or older who were admitted to one of the six participating academic level I trauma centres with multiple injuries, including severe thoracic trauma (AISThorax ≥ 3) between 2010 and 2014. A multivariable binary regression was used to identify predictor variables for tracheostomy and to develop the Tracheostomy in Thoracic Trauma Prediction Score (T3P-Score). The study included 1019 adult thoracic trauma patients, of whom 165 underwent tracheostomy during their intensive care unit (ICU) stay. Prehospital endotracheal intubation (adjusted OR [AOR]: 2.494, 95% CI [1.412; 4.405]), diagnosis of pneumonia during the ICU stay (AOR: 4.374, 95% CI [2.503; 7.642]), duration of mechanical ventilation (AOR: 1.008/hours of intubation, 95% CI [1.006; 1.009]), and an AISHead ≥ 3 (AOR 1.840, 95% CI [1.039; 3.261]) were independent risk factors for tracheostomy. Patients with sepsis had a lower risk of tracheostomy than patients without sepsis (AOR 0.486, 95% CI [0.253; 0.935]). The T3P-Score had high predictive validity for tracheostomy (ROCAUC = 0.938, 95% CI [0.920, 0.956]; Nagelkerke's R2 was 0.601). The T3P-Score's specificity was 0.68, and the sensitivity was 0.96. The severity of thoracic trauma did not predict the need for tracheostomy. Follow-up studies should validate the T3P-Score in external data sets and study the reasons for the reluctant use of tracheostomy in patients with severe thoracic trauma and subsequent sepsis.Trial registration: The study was applied for and registered a priori with the respective ethics committees.

Comparison of different thoracic trauma scoring systems in regards to prediction of post-traumatic complications and outcome in blunt chest trauma.

BACKGROUND: As accurate assessment of thoracic injury severity in the early phase after trauma is difficult, we compared different thoracic trauma scores regarding their predictive ability for the development of post-traumatic complications and mortality. MATERIALS AND METHODS: Two hundred seventy-eight multiple trauma patients (ISS ≥ 16) age > 16 y with severe blunt chest trauma (AIS(chest) ≥ 3) admitted between 2000 and 2009 to Level I Trauma center were included. Exclusion criteria were severe traumatic brain injury (AIS(head) ≥ 3) and penetrating thoracic trauma. The association between AIS(chest), Pulmonary Contusion score (PCS), Wagner-score and Thoracic Trauma Severity score (TTS), and duration of ventilation, length of ICU stay, development of post-traumatic complications, and mortality was investigated. Statistical analysis was performed with χ(2)-test, ANOVA, logistic regression, and receiver operating characteristic (ROC) curve. RESULTS: Patients' mean age was 42.7 ± 17.0 y, the mean injury severity score was 28.7 ± 9.3 points. Overall, 60 patients (21.6%) developed ARDS, 143 patients (51.4%) SIRS, 110 patients (39.6%) sepsis, and 36 patients (13.0%) MODS. Twenty-two patients (7.9%) died. Among the examined thoracic trauma scores only the TTS was an independent predictor of mortality. With the TTS showing the best prediction power, the TTS, PCS, and Wagner-score were independent predictors of ventilation time, length of ICU stay, and the development of post-traumatic ARDS and MODS. CONCLUSIONS: Thoracic trauma scores combining anatomical and physiologic parameters like the TTS seem to be most suitable for severity assessment and prediction of outcome in multiple trauma patients with concomitant blunt chest trauma.

Facts and fiction: the impact of hypothermia on molecular mechanisms following major challenge.

Numerous multiple trauma and surgical patients suffer from accidental hypothermia. While induced hypothermia is commonly used in elective cardiac surgery due to its protective effects, accidental hypothermia is associated with increased posttraumatic complications and even mortality in severely injured patients. This paper focuses on protective molecular mechanisms of hypothermia on apoptosis and the posttraumatic immune response. Although information regarding severe trauma is limited, there is evidence that induced hypothermia may have beneficial effects on the posttraumatic immune response as well as apoptosis in animal studies and certain clinical situations. However, more profound knowledge of mechanisms is necessary before randomized clinical trials in trauma patients can be initiated.