Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial.

BACKGROUND: Patients with traumatic wounds frequently present to the ED. Literature on whether to treat these wounds sterile or non-sterile is sparse. Non-sterile treatment has the advantage of saving resources and costs, and could be of value in health settings where sterile materials are not readily available. Our objective was to compare the rate of wound infection after suturing traumatic lacerations with non-sterile gloves and dressings versus sterile gloves, dressings and drapes in the ED. We hypothesised that non-sterile gloves and dressings would be non-inferior to sterile gloves, dressings and drapes. The non-inferiority margin was set at 2%. METHODS: A multicentre single-blinded randomised controlled trial testing for non-inferiority of non-sterile gloves and dressings versus sterile gloves, dressings and drapes for suturing of traumatic wounds was performed in 3 EDs in The Netherlands. Adults with uncomplicated wounds were included from July 2012 to December 2016. At the time of treatment, patient and wound characteristics and management were documented. The outcome was wound infection, which was identified during follow-up in the treating ED at 5-14 days postprocedure. RESULTS: From 2468 eligible patients, 1480 were randomised in a sterile (n=747) or non-sterile (n=733) protocol. Baseline characteristics were similar in both study arms. The observed wound infection rate in the non-sterile group was 5.7% (95% CI 4.0% to 7.5%) vs 6.8% (95% CI 5.1% to 8.8%) in the sterile group. The mean difference of the wound infection rate of the two groups was -1.1% (95% CI -3.7% to 1.5%). CONCLUSION: Although recruitment ceased prior to reaching our planned sample size, the findings suggest that there is unlikely to be a large difference between the non-sterile gloves, dressings and sterile gloves, dressings and drapes for suturing of traumatic wounds in the ED. TRIAL REGISTRATION NUMBER: NL 34798.078.11, NTR3541.

Improving design choices in Delphi studies in medicine: the case of an exemplary physician multi-round panel study with 100% response.

BACKGROUND: A proper application of the Delphi technique is essential for obtaining valid research results. Medical researchers regularly use Delphi studies, but reports often lack detailed information on methodology and controlled feedback: in the medical literature, papers focusing on Delphi methodology issues are rare. Since the introduction of electronic surveys, details on response times remain scarce. We aim to bridge a number of gaps by providing a real world example covering methodological choices and response times in detail. METHODS: The objective of our e(lectronic)-Delphi study was to determine minimum standards for emergency departments (EDs) in the Netherlands. We opted for a two-part design with explicit decision rules. Part 1 focused on gathering and defining items; Part 2 addressed the main research question using an online survey tool. A two-person consensus rule was applied throughout: even after consensus on specific items was reached, panellists could reopen the discussion as long as at least two panellists argued similarly. Per round, the number of reminders sent and individual response times were noted. We also recorded the methodological considerations and evaluations made by the research team prior to as well as during the study. RESULTS: The study was performed in eight rounds and an additional confirmation round. Response rates were 100% in all rounds, resulting in 100% consensus in Part 1 and 96% consensus in Part 2. Our decision rules proved to be stable and easily applicable. Items with negative advice required more rounds before consensus was reached. Response delays were mostly due to late starts, but once panellists started, they nearly always finished the questionnaire on the same day. Reminders often yielded rapid responses. Intra-individual differences in response time were large, but quick responders remained quick. CONCLUSIONS: We advise those considering Delphi study to follow the CREDES guideline, consider a two-part design, invest in personal commitment of the panellists, set clear decision rules, use a consistent lay-out and send out your reminders early. Adopting this overall approach may assist researchers in future Delphi studies and may help to improve the quality of Delphi designs in terms of improved rigor and higher response rates.

Correction to: The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study.

In the publication of this article [1], there are two errors in contributing author affiliations. This has now been included in this correction article.

The early identification of disease progression in patients with suspected infection presenting to the emergency department: a multi-centre derivation and validation study.

BACKGROUND: There is a lack of validated tools to assess potential disease progression and hospitalisation decisions in patients presenting to the emergency department (ED) with a suspected infection. This study aimed to identify suitable blood biomarkers (MR-proADM, PCT, lactate and CRP) or clinical scores (SIRS, SOFA, qSOFA, NEWS and CRB-65) to fulfil this unmet clinical need. METHODS: An observational derivation patient cohort validated by an independent secondary analysis across nine EDs. Logistic and Cox regression, area under the receiver operating characteristic (AUROC) and Kaplan-Meier curves were used to assess performance. Disease progression was identified using a composite endpoint of 28-day mortality, ICU admission and hospitalisation > 10 days. RESULTS: One thousand one hundred seventy-five derivation and 896 validation patients were analysed with respective 28-day mortality rates of 7.1% and 5.0%, and hospitalisation rates of 77.9% and 76.2%. MR-proADM showed greatest accuracy in predicting 28-day mortality and hospitalisation requirement across both cohorts. Patient subgroups with high MR-proADM concentrations (≥ 1.54 nmol/L) and low biomarker (PCT < 0.25 ng/mL, lactate < 2.0 mmol/L or CRP < 67 mg/L) or clinical score (SOFA < 2 points, qSOFA < 2 points, NEWS < 4 points or CRB-65 < 2 points) values were characterised by a significantly longer length of hospitalisation (p < 0.001), rate of ICU admission (p < 0.001), elevated mortality risk (e.g. SOFA, qSOFA and NEWS HR [95%CI], 45.5 [10.0-207.6], 23.4 [11.1-49.3] and 32.6 [9.4-113.6], respectively) and a greater number of disease progression events (p < 0.001), compared to similar subgroups with low MR-proADM concentrations (< 1.54 nmol/L). Increased out-patient treatment across both cohorts could be facilitated using a derivation-derived MR-proADM cut-off of < 0.87 nmol/L (15.0% and 16.6%), with decreased readmission rates and no mortalities. CONCLUSIONS: In patients presenting to the ED with a suspected infection, the blood biomarker MR-proADM could most accurately identify the likelihood of further disease progression. Incorporation into an early sepsis management protocol may therefore aid rapid decision-making in order to either initiate, escalate or intensify early treatment strategies, or identify patients suitable for safe out-patient treatment.

Effectiveness of medication withdrawal in older fallers: results from the Improving Medication Prescribing to reduce Risk Of FALLs (IMPROveFALL) trial.

Objectives: To investigate the effect of withdrawal of fall-risk-increasing-drugs (FRIDs) versus 'care as usual' on reducing falls in community-dwelling older fallers. Design: Randomised multicentre trial Participants: Six hundred and twelve older adults who visited an Emergency Department (ED) because of a fall. Interventions: Withdrawal of FRIDs. Main Outcomes and Measures: Primary outcome was time to the first self-reported fall. Secondary outcomes were time to the second self-reported fall and to falls requiring a general practitioner (GP)-consultation or ED-visit. Intention-to-treat (primary) and a per-protocol (secondary) analysis were conducted. The hazard ratios (HRs) for time-to-fall were calculated using a Cox-regression model. Differences in cumulative incidence of falls were analysed using Poisson regression. Results: During 12 months follow-up, 91 (34%) control and 115 (37%) intervention participants experienced a fall; 35% of all attempted interventions were unsuccessful, either due to recurrence of the initial indication for prescribing, additional medication for newly diagnosed conditions or non-compliance. Compared to baseline, the overall percentage of users of ≥3 FRIDs at 12 months did not change in either the intervention or the control group. Our intervention did not have a significant effect on time to first fall (HR 1.17; 95% confidence interval 0.89­1.54), time to second fall (1.19; 0.78­1.82), time to first fall-related GP-consultation (0.66; 0.42­1.06) or time to first fall-related ED-visit (0.85; 0.43­1.68). Conclusion: In this population of complex multimorbid patients visiting an ED because of a fall, our single intervention of FRIDs-withdrawal was not effective in reducing falls. Trial Registration: Netherlands Trial Register NTR1593.

Early mobilisation versus plaster immobilisation of simple elbow dislocations: results of the FuncSiE multicentre randomised clinical trial.

BACKGROUND/AIM: To compare outcome of early mobilisation and plaster immobilisation in patients with a simple elbow dislocation. We hypothesised that early mobilisation would result in earlier functional recovery. METHODS: From August 2009 to September 2012, 100 adult patients with a simple elbow dislocation were enrolled in this multicentre randomised controlled trial. Patients were randomised to early mobilisation (n=48) or 3 weeks plaster immobilisation (n=52). Primary outcome measure was the Quick Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) score. Secondary outcomes were the Oxford Elbow Score, Mayo Elbow Performance Index, pain, range of motion, complications and activity resumption. Patients were followed for 1 year. RESULTS: Quick-DASH scores at 1 year were 4.0 (95% CI 0.9 to 7.1) points in the early mobilisation group versus 4.2 (95% CI 1.2 to 7.2) in the plaster immobilisation group. At 6 weeks, early mobilised patients reported less disability (Quick-DASH 12 (95% CI 9 to 15) points vs 19 (95% CI 16 to 22); p<0.05) and had a larger arc of flexion and extension (121° (95% CI 115° to 127°) vs 102° (95% CI 96° to 108°); p<0.05). Patients returned to work sooner after early mobilisation (10 vs 18 days; p=0.020). Complications occurred in 12 patients; this was unrelated to treatment. No recurrent dislocations occurred. CONCLUSIONS: Early active mobilisation is a safe and effective treatment for simple elbow dislocations. Patients recovered faster and returned to work earlier without increasing the complication rate. No evidence was found supporting treatment benefit at 1 year. TRIAL REGISTRATION NUMBER: NTR 2025.

Procalcitonin-guided therapy for the initiation of antibiotics in the ED: a systematic review.

BACKGROUND: Procalcitonin (PCT) is a new biomarker with a higher accuracy in the diagnosis of bacterial infections. Utilization of PCT may reduce the number of unnecessary antibiotics prescribed to patients and consequently may decrease the rise in antibiotic resistance. The aim of this systematic review is to determine if a PCT-guided algorithm can safely reduce the number of antibiotics prescribed to all patients with a suspected of infection in the emergency department (ED). METHODS: MEDLINE, EMBASE, Web of Science, COCHRANE central, PubMed publisher, and Google scholar were searched. Two reviewers performed the screening independently. The QUADAS 2 tool was used to assess quality. RESULTS: In total, 1621 articles were screened. Nine articles were included in the analysis. In the 6 studies on adult patients, only patients with respiratory tract infections were investigated. In these studies, a cutoff value of 0.25 µg/L was used, and PCT-guided therapy reduced the number of prescribed antibiotics significantly. Three studies were on pediatric patients, 2 on fever without source and 1 on respiratory complaints. Procalcitonin-guided therapy did not reduce antibiotic prescription in children. Procalcitonin-guided therapy did not result in an increase in adverse events in any of the studies. DISCUSSION: Procalcitonin-guided therapy in the ED is only studied in subpopulations, where it was effective and safe in adult patients with respiratory tract infections and not effective but safe nonetheless in specific pediatric populations. Nonadherence is a significant problem in prospective PCT-guided therapy studies. There is not enough evidence to use PCT-guided therapy in a general ED population.

Cost-utility of medication withdrawal in older fallers: results from the improving medication prescribing to reduce risk of FALLs (IMPROveFALL) trial.

BACKGROUND: The use of Fall-Risk-Increasing-Drugs (FRIDs) has been associated with increased risk of falls and associated injuries. This study investigates the effect of withdrawal of FRIDs versus 'care as usual' on health-related quality of life (HRQoL), costs, and cost-utility in community-dwelling older fallers. METHODS: In a prospective multicenter randomized controlled trial FRIDs assessment combined with FRIDs-withdrawal or modification was compared with 'care as usual' in older persons, who visited the emergency department after experiencing a fall. For the calculation of costs the direct medical costs (intramural and extramural) and indirect costs (travel costs) were collected for a 12 month period. HRQoL was measured at baseline and at 12 months follow-up using the EuroQol-5D and Short Form-12 version 2. The change in EuroQol-5D and Short Form-12 scores over 12 months follow-up within the control and intervention groups was compared using the Wilcoxon Signed Rank test for continuous variables and the McNemar test for dichotomous variables. The change in scores between the control and intervention groups were compared using a two-way analysis of variance. RESULTS: We included 612 older persons who visited an emergency department because of a fall. The mean cost of the FRIDs intervention was €120 per patient. The total fall-related healthcare costs (without the intervention costs) did not differ significantly between the intervention group and the control group (€2204 versus €2285). However, the withdrawal of FRIDs reduced medication costs with a mean of €38 per participant. Furthermore, the control group had a greater decline in EuroQol-5D utility score during the 12-months follow-up than the intervention group (p = 0.02). The change in the Short Form-12 Physical Component Summary and Mental Component Summary scores did not differ significantly between the two groups. CONCLUSIONS: Withdrawal of FRID's in older persons who visited an emergency department due to a fall, did not lead to reduction of total health-care costs. However, the withdrawal of FRIDs reduced medication costs with a mean of €38 per participant in combination with less decline in HRQoL is an important result. TRIAL REGISTRATION: The trial is registered in the Netherlands Trial Register ( NTR1593 - October 1st 2008).

The reliability and reproducibility of the Hertel classification for comminuted proximal humeral fractures compared with the Neer classification.

INTRODUCTION: The Neer classification is the most commonly used fracture classification system for proximal humeral fractures. Inter- and intra-observer agreement is limited, especially for comminuted fractures. A possibly more straightforward and reliable classification system is the Hertel classification. The aim of this study was to compare the inter- and intra-observer variability of the Hertel with the Neer classification in comminuted proximal humeral fractures. MATERIALS AND METHODS: Four observers evaluated blinded radiographic images (X-rays, CT-scans, and CT-scans with 3D-reconstructions) of 60 patients. After at least two months classification was repeated. RESULTS: Inter-observer agreement on plain X-rays was fair for both Hertel (κ = 0.39; 95% CI 0.23-0.62) and Neer (κ = 0.29; 0.09-0.42). Inter-observer agreement on CT-scans was substantial (κ = 0.63; 0.56-0.72) for Hertel and moderate for Neer (κ = 0.51; 0.29-0.68). Inter-observer agreement on 3D-reconstructions was moderate for both Hertel (κ = 0.60; 0.53-0.72) and Neer (κ = 0.51; 0.39-0.58). Intra-observer agreement on plain X-rays was fair for both Hertel (κ = 0.38; 0.27-0.59) and Neer (κ = 0.40; 0.15-0.52). Intra-observer agreement on CT-scans was moderate for both Hertel (κ = 0.50; 0.38-0.66) and Neer (κ = 0.42; 0.35-0.52). Intra-observer agreement on 3D-reconstructions was moderate for Hertel (κ = 0.55; 0.45-0.64) and substantial for Neer (κ = 0.63; 0.48-0.79). CONCLUSIONS: The Hertel and Neer classifications showed a fair to substantial inter- and intra-observer agreement on the three diagnostic modalities used. Although inter-observer agreement was highest for Hertel classification on CT-scans, Neer classification had the highest intra-observer agreement on 3D-reconstructions. Data of this study do not confirm superiority of either classification system for the classification of comminuted proximal humeral fractures.

Higher diagnostic accuracy and cost-effectiveness using procalcitonin in the treatment of emergency medicine patients with fever (The HiTEMP study): a multicenter randomized study.

BACKGROUND: Fever is a common symptom in the emergency department(ED). Fever can be caused by bacterial infections, which are treated with antibiotics. Often, bacterial infections cannot be ruled out in the ED using standard diagnostics, and empiric antibiotic treatment is started. Procalcitonin(PCT) is a biomarker for bacterial infections, but its role in an undifferentiated ED population remains unclear. We hypothesize that PCT-guided therapy may reduce antibiotics prescription in undifferentiated febrile ED patients. The primary objectives of this study are to determine a) the efficacy, b) the safety of PCT-guided therapy, and c) the accuracy of the biomarker PCT for bacterial infections. The secondary objective is to study the cost-effectiveness of PCT-guided therapy. METHODS/DESIGN: This is a multicenter noninferiority randomized controlled trial. All adult ED patients with fever(≥38.2 °C) are randomized between standard care with and without the addition of a PCT level, after written informed consent. a) For efficacy, the reduction of patients receiving antibiotics is calculated, using a superiority analysis: differences between the PCT-guided group and control group are assessed using a Fisher's exact test, and a multivariable logistic regression analysis to account for the effects of demographic and medical variables on the percentage of febrile patients receiving antibiotics. b) Safety consists of a composite endpoint, defined as mortality, intensive care admission and ED return visit within 14 days. Noninferiority of PCT will be tested using a one-sided 95 % confidence interval for the difference in the composite safety endpoint between the PCT-guided and control groups using a noninferiority margin of 7.5 %. c) Accuracy of PCT and CRP for the diagnosis of bacterial infections will be reported, using the sensitivity, specificity, and the area under the receiver-operating-characteristic curve in the definitive diagnosis of bacterial infections. The sample size is 550 patients, which was calculated using a power analysis for all primary objectives. Enrollment of patients started in August 2014 and will last 2 years. DISCUSSION: PCT may offer a more tailor-made treatment to the individual ED patient with fever. Prospective costs analyses will reveal the economic consequences of implementing PCT-guided therapy in the ED. THIS TRIAL IS REGISTERED IN THE DUTCH TRIAL REGISTER: NTR4949.

Good functional recovery of complex elbow dislocations treated with hinged external fixation: a multicenter prospective study.

BACKGROUND: After a complex dislocation, some elbows remain unstable after closed reduction or fracture treatment. Function after treatment with a hinged external fixator theoretically allows collateral ligaments to heal without surgical reconstruction. However, there is a lack of prospective studies that assess functional outcome, pain, and ROM. QUESTIONS/PURPOSES: We asked: (1) In complex elbow fracture-dislocations, does treatment with a hinged external fixator result in reduction of disability and pain, and in improvement in ROM, function, and quality of life? (2) Does delayed treatment (7 days or later) have a negative effect on ROM after 1 year? (3) What are the complications seen after external fixator treatment? METHODS: During a 2-year period, 11 centers recruited 27 patients 18 years or older who were included and evaluated at 2 and 6 weeks and at 3, 6, and 12 months after surgery as part of this prospective case series. During the study period, the participating centers agreed on general indications for use of the hinged external fixator, which included persistent instability after closed reduction alone or closed reduction combined with surgical treatment of associated fracture(s), when indicated. Functional outcome was evaluated using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH; primary outcome) score, the Mayo Elbow Performance Index (MEPI), the Oxford Elbow Score, and the level of pain (VAS). ROM, adverse events, secondary interventions, and radiographs also were evaluated. A total of 26 of the 27 patients (96%) were available for followup at 1 year. RESULTS: All functional and pain scores improved. The median QuickDASH score decreased from 30 (25(th)-75(th) percentiles [P25-P75], 23-40) at 6 weeks to 7 (P25-P75, 2-12) at 1 year with a median difference of -25 (p < 0.001). The median MEPI score increased from 80 (P25-P75, 64-85) at 6 weeks to 100 (P25-P75, 85-100) at 1 year with a median difference of 15 (p < 0.001). The median Oxford Elbow Score increased from 60 (P25-P75, 44-68) at 6 weeks to 90 (P25-P75, 73-96) at 1 year with a median difference of 29 (p < 0.001). The median VAS decreased from 2.8 (P25-P75, 1.0-5.0) at 2 weeks to 0.5 (P25-P75, 0.0-1.9) at 1 year with a median difference of -2.1 (p = 0.001). ROM also improved. The median flexion-extension arc improved from 50° (P25-P75, 33°-80°) at 2 weeks to 118° (P25-P75, 105°-138°) at 1 year with a median difference of 63° (p < 0.001). Similarly, the median pronation-supination arc improved from 90° (P25-P75, 63°-124°) to 160° (P25-P75, 138°-170°) with a median difference of 75° (p < 0.001). At 1 year, the median residual deficit compared with the uninjured side was 30° (P25-P75, 5°-35°) for the flexion-extension arc, and 3° (P25-P75, 0°-25°) for the pronation-supination arc. Ten patients (37%) experienced a fixator-related complication, and seven patients required secondary surgery (26%). One patient reported recurrent instability. CONCLUSIONS: A hinged external elbow fixator provides enough stability to start early mobilization after an acute complex elbow dislocation and residual instability. This was reflected in good functional outcome scores and only slight disability despite a relatively high complication rate.

Cumulative incidence and treatment of non-simultaneous bilateral femoral neck fractures in a cohort of one thousand two hundred and fifty patients.

PURPOSE: In the Netherlands, over 20,000 patients sustain a hip fracture yearly. A first hip fracture is a risk factor for a second, contralateral fracture. Data on the similarity of the treatment of bilateral femoral neck fractures is only scarcely available. The objectives of this study were to determine the cumulative incidence of non-simultaneous bilateral femoral neck fractures and to describe the patient characteristics and treatment characteristics of these patients. METHODS: A database of 1,250 consecutive patients with a femoral neck fracture was available. Patients with a previous contralateral femoral neck fractures were identified by reviewing radiographs and patient files. Patient characteristics, previous fractures, hip fracture type and details on treatment were collected from the patient files. RESULTS: One hundred nine patients (9%, 95% confidence interval 7-10%) had sustained a non-simultaneous bilateral femoral neck fracture. The median age at the first fracture was 81 years; the median interval between the fractures was 25 months. Overall, 73% was treated similarly for both fractures in terms of non-operative treatment, internal fixation or arthroplasty. In patients with identical Garden classification (30%), treatment similarity was 88%. CONCLUSIONS: The cumulative incidence of non-simultaneous bilateral femoral neck fractures was 9%. Most patients with identical fracture types were treated similarly. The relatively high risk of sustaining a second femoral neck fracture supports the importance of secondary prevention, especially in patients with a prior wrist or vertebral fracture.

Trends in incidence and costs of injuries to the shoulder, arm and wrist in The Netherlands between 1986 and 2008.

BACKGROUND: Upper extremity injuries account for a large proportion of attendances to the Emergency Department. The aim of this study was to assess population-based trends in the incidence of upper extremity injuries in the Dutch population between 1986 and 2008, and to give a detailed overview of the associated health care costs. METHODS: Age-standardized incidence rates of upper extremity injuries were calculated for each year between 1986 and 2008. The average number of people in each of the 5-year age classes for each year of the study was calculated and used as the standard (reference) population. Injury cases were extracted from the National Injury Surveillance System (non-hospitalized patients) and the National Medical Registration (hospitalized patients). An incidence-based cost model was applied in order to estimate associated direct health care costs in 2007. RESULTS: The overall age-adjusted incidence of upper extremity injuries increased from 970 to 1,098 per 100,000 persons (13%). The highest incidence was seen in young persons and elderly women. Total annual costs for all injuries were 290 million euro, of which 190 million euro were paid for injuries sustained by women. Wrist fractures were the most expensive injuries (83 million euro) due to high incidence, whereas upper arm fractures were the most expensive injuries per case (4,440 euro). Major cost peaks were observed for fractures in elderly women due to high incidence and costs per patient. CONCLUSIONS: The overall incidence of upper extremity injury in the Netherlands increased by 13% in the period 1986-2008. Females with upper extremity fractures and especially elderly women with wrist fractures accounted for a substantial share of total costs.

Adherence to a femoral neck fracture treatment guideline.

PURPOSE: In 2007 the Dutch Surgical Society published a clinical practice guideline for the treatment of hip fracture patients, based on the best available international evidence at that time. We investigated to what extent treatment of femoral neck fracture patients in the Netherlands corresponded with these guidelines, and determined differences in patient characteristics between the treatment groups. METHODS: All femoral neck fracture patients treated in 14 hospitals between February 2008 and August 2009 were included. Patient characteristics, X-rays, and treatment data were collected retrospectively. RESULTS: From a total of 1,250 patients 59% had been treated with arthroplasty, 39% with internal fixation, and 2% with a non-operative treatment. While 74% of the treatment choices complied with the guideline, 12% did not. In 14% adherence could not be determined from the available data. Arthroplasty was preferred over internal fixation in elderly patients with severe comorbidity, pre-fracture osteoporosis and a displaced fracture, who were ambulatory with aids pre-fracture (odds ratio, OR 2.2-58.1). Sliding hip screws were preferred over cancellous screws in displaced fractures (OR 1.9). CONCLUSIONS: Overall guideline adherence was good. Most deviations concerned treatment of elderly patients with a displaced fracture and implant use in internal fixation. Additional data on these issues, preferably at a higher scientific level of evidence, is needed in order to improve the guideline and to reinforce a more uniform treatment of these patients.

End of the spectacular decrease in fall-related mortality rate: men are catching up.

OBJECTIVES: We determined time trends in numbers and rates of fall-related mortality in an aging population, for men and women. METHODS: We performed secular trend analysis of fall-related deaths in the older Dutch population (persons aged 65 years or older) from 1969 to 2008, using the national Official-Cause-of-Death-Statistics. RESULTS: Between 1969 and 2008, the age-adjusted fall-related mortality rate decreased from 202.1 to 66.7 per 100,000 older persons (decrease of 67%). However, the annual percentage change (change per year) in mortality rates was not constant, and could be divided into 3 phases: (1) a rapid decrease until the mid-1980s (men -4.1%; 95% confidence interval [CI] = -4.9, -3.2; women -6.5%; 95% CI, -7.1, -5.9), (2) flattening of the decrease until the mid-1990s (men -1.4%; 95% CI = -2.4, -0.4; women -2.0%; 95% CI = -3.4, -0.6), and (3) stable mortality rates for women (0.0%; 95% CI = -1.2, 1.3) and rising rates for men (1.9%; 95% CI = 0.6, 3.2) over the last decade. CONCLUSIONS: The spectacular decrease in fall-related mortality ended in the mid-1990s and is currently increasing in older men at similar rates to those seen in women. Because of the aging society, absolute numbers in fall-related deaths are increasing rapidly.

Prevalence rate, predictors and long-term course of probable posttraumatic stress disorder after major trauma: a prospective cohort study.

BACKGROUND: Among trauma patients relatively high prevalence rates of posttraumatic stress disorder (PTSD) have been found. To identify opportunities for prevention and early treatment, predictors and course of PTSD need to be investigated. Long-term follow-up studies of injury patients may help gain more insight into the course of PTSD and subgroups at risk for PTSD. The aim of our long-term prospective cohort study was to assess the prevalence rate and predictors, including pre-hospital trauma care (assistance of physician staffed Emergency Medical Services (EMS) at the scene of the accident), of probable PTSD in a sample of major trauma patients at one and two years after injury. The second aim was to assess the long-term course of probable PTSD following injury. METHODS: A prospective cohort study was conducted of 332 major trauma patients with an Injury Severity Score (ISS) of 16 or higher. We used data from the hospital trauma registry and self-assessment surveys that included the Impact of Event Scale (IES) to measure probable PTSD symptoms. An IES-score of 35 or higher was used as indication for the presence of probable PTSD. RESULTS: One year after injury measurements of 226 major trauma patients were obtained (response rate 68%). Of these patients 23% had an IES-score of 35 or higher, indicating probable PTSD. At two years after trauma the prevalence rate of probable PTSD was 20%. Female gender and co-morbid disease were strong predictors of probable PTSD one year following injury, whereas minor to moderate head injury and injury of the extremities (AIS less than 3) were strong predictors of this disorder at two year follow-up. Of the patients with probable PTSD at one year follow-up 79% had persistent PTSD symptoms a year later. CONCLUSIONS: Up to two years after injury probable PTSD is highly prevalent in a population of patients with major trauma. The majority of patients suffered from prolonged effects of PTSD, underlining the importance of prevention, early detection, and treatment of injury-related PTSD.

A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2).

BACKGROUND: Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients. METHODS/DESIGN: The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness. DISCUSSION: The REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group. TRIAL REGISTRATION: ClinicalTrials.gov: (NCT01523626).

Update of the CHIP (CT in Head Injury Patients) decision rule for patients with minor head injury based on a multicenter consecutive case series.

OBJECTIVE: To update the existing CHIP (CT in Head Injury Patients) decision rule for detection of (intra)cranial findings in adult patients following minor head injury (MHI). METHODS: The study is a prospective multicenter cohort study in the Netherlands. Consecutive MHI patients of 16 years and older were included. Primary outcome was any (intra)cranial traumatic finding on computed tomography (CT). Secondary outcomes were any potential neurosurgical lesion and neurosurgical intervention. The CHIP model was validated and subsequently updated and revised. Diagnostic performance was assessed by calculating the c-statistic. RESULTS: Among 4557 included patients 3742 received a CT (82%). In 383 patients (8.4%) a traumatic finding was present on CT. A potential neurosurgical lesion was found in 73 patients (1.6%) with 26 (0.6%) patients that actually had neurosurgery or died as a result of traumatic brain injury. The original CHIP underestimated the risk of traumatic (intra)cranial findings in low-predicted-risk groups, while in high-predicted-risk groups the risk was overestimated. The c-statistic of the original CHIP model was 0.72 (95% CI 0.69-0.74) and it would have missed two potential neurosurgical lesions and one patient that underwent neurosurgery. The updated model performed similar to the original model regarding traumatic (intra)cranial findings (c-statistic 0.77 95% CI 0.74-0.79, after crossvalidation c-statistic 0.73). The updated CHIP had the same CT rate as the original CHIP (75%) and a similar sensitivity (92 versus 93%) and specificity (both 27%) for any traumatic (intra)cranial finding. However, the updated CHIP would not have missed any (potential) neurosurgical lesions and had a higher sensitivity for (potential) neurosurgical lesions or death as a result of traumatic brain injury (100% versus 96%). CONCLUSIONS: Use of the updated CHIP decision rule is a good alternative to current decision rules for patients with MHI. In contrast to the original CHIP the update identified all patients with (potential) neurosurgical lesions without increasing CT rate.

Increase in fall-related hospitalizations in the United States, 2001-2008.

BACKGROUND: The objective was to determine secular trends in unintentional fall-related hospitalizations in people aged 65 years and older in the United States. MATERIALS: Data were obtained from a nationally representative sample of emergency department visits from January 1, 2001, to December 31, 2008, available through the National Electronic Injury Surveillance System-All Injury Program. These data were weighted to estimate the number, incidence rates, and the annual percent change of fall-related hospitalizations. RESULTS: From 2001 to 2008, the estimated number of fall-related hospitalizations in older adults increased 50%, from 373,128 to 559,355 cases. During the same time period, the age-adjusted incidence rate, expressed per 100,000 population, increased from 1,046 to 1,368. Rates were higher in women compared with men throughout the study period. The age-adjusted incidence rate showed an average annual increase of 3.3% (95% CI, 1.66-4.95). DISCUSSION: Both the number and rate of fall-related hospitalizations in the United States increased significantly over the 8-year study period. Unless preventive action is taken, rising hospitalization rates in combination with the aging US population over the next decades will exacerbate the already stressed healthcare system and may result in poorer health outcomes for older adults in the future. Further research is needed to determine the underlying causes for this rising trend.

Societal consequences of falls in the older population: injuries, healthcare costs, and long-term reduced quality of life.

BACKGROUND: Fall incidents are a major cause of morbidity and mortality in older adults. The aim of this cohort study was to determine the incidence, costs, and quality of life for fall-related injuries in the older Dutch population presenting at the emergency department. METHODS: Data on fall-related injuries in persons aged 65 years or older were retrieved from the Dutch Injury Surveillance System, which records injuries treated at the emergency department, and a patient follow-up survey conducted between 2003 and 2007. Injury incidence, discharge rates, healthcare costs, and quality of life measures were calculated. RESULTS: Fall-related injuries were to the upper or lower limb in 70% of cases and consisted mainly of fractures (60%), superficial injuries (21%), and open wounds (8%). Falls led to a total healthcare cost of €474.4 million, which represents 21% of total healthcare expenses due to injuries. Both admitted and nonadmitted patients reported a reduced quality of life up to 9 months after the injury. CONCLUSIONS: Fall-related injuries in older adults are age and gender related, leading to high healthcare consumption, costs, and long-term reduced quality of life. Further implementation of falls prevention strategies is needed to control the burden of fall-related injuries in the aging population.