The addition of an anti-rotation screw to the dynamic hip screw.

The aim of this study is to assess if there is a difference in outcomes between a dynamic hip screw with or without an anti-rotation screw in the treatment of hip fractures. All patients with an intracapsular hip fracture who underwent dynamic hip screw osteosynthesis between January 2010 and December 2013 in three Dutch hospitals were reviewed. Minimal follow-up was one year. The study included a total of 364 patients. 24 patients were lost to follow-up and excluded. 297 (87.4%) were in the dynamic hip screw group and 43 (12.6%) in the dynamic hip with anti-rotation screw group. Direct comparison of patient characteristics of the two groups showed significant differences in age, sex, Garden classification and Pauwels classification. Patients operated with a dynamic hip screw and anti-rotation screw are significantly younger and their fractures are significantly more dislocated and steeper. To draw conclusions about differences in outcome, a randomised clinical trial should be performed.

Routine Follow-Up Radiographs for Ankle Fractures Seldom Add Value to Clinical Decision-Making: A Retrospective, Observational Study.

Currently, the routine use of radiographs for uncomplicated ankle fractures represents good clinical practice. However, radiographs are associated with waiting time, radiation exposure, and costs. Studies have suggested that radiographs seldom alter the treatment strategy if no clinical indication for the imaging study was present. The objective of the present study was to evaluate the effect of routine radiographs on the treatment strategy during the follow-up period of ankle fractures. All patients aged ≥18 years, who had visited 1 of the participating clinics with an eligible ankle fracture in 2012 and with complete follow-up data were included. The data were retrospectively analyzed. The sociodemographic and clinical characteristics and the number of, and indications for, the radiographs taken were collected from the medical records of the participating clinics. We assessed the changes in treatment strategy according to the radiographic findings. In 528 patients with an ankle fracture, 1174 radiographs were performed during the follow-up period. Of these radiographs, 936 (79.7%) were considered routine. Of the routine radiographs taken during the follow-up period, only 11 (1.2 %) resulted in changes to the treatment strategy. Although it is common practice to take radiographs routinely during the follow-up period for ankle fractures, the results from the present study suggest that routine radiographs seldom alter the treatment strategy. This limited clinical relevance should be weighed against the health care costs and radiation exposure associated with the use of routine radiographs. For a definitive recommendation, however, the results of our study should be confirmed by a prospective trial, which we are currently conducting.

Preoperative chest radiographs in hip fracture patients: is there any additional value?

PURPOSE: Preoperative screening in hip fracture patients is vital to minimize perioperative complications. Preoperative chest radiographs (POCR) are performed in many hip fracture patients. Earlier research showed that few POCR abnormalities influence perioperative policy. However, no studies in nonelective patient with a specific surgical conditions have been performed. With many hip fractures per year worldwide, a significant cost reduction could be made by performing selective POCR without compromising the quality of care. This study assessed the need for POCR in hip fracture patients. METHOD: Retrospective analysis of low-energy trauma patients was performed aged 18 years and older in the VU University Medical Center for a hip fracture in a 5-year period. All preoperative diagnostics were analyzed. All adjourned operations were evaluated. RESULTS: A total of 642 patients were included, 70% female, matching current epidemiologic figures. The POCR showed abnormalities in 22.6%. In 0.6% the POCR lead to an adjournment of the operation (2.8% of abnormal POCR's). These patients suffered from pneumonia. The POCR in these cases acted as a confirmation of the clinical diagnosis. CONCLUSION: Many factors involving the treatment of hip fracture patients are of importance in minimizing the risk of complications and mortality during and after admission. In 0.6% of all performed POCR's an abnormality leads to the adjournment of the operation. In all four cases the POCR matched the clinical findings. Because the additional value of the POCR in hip fracture patients was limited, we think that its selective use in clinical abnormalities is safe and will reduce unnecessary costs.

Complications after laparotomy for trauma: a retrospective analysis in a level I trauma centre.

PURPOSE: Laparotomy is a potential life-saving procedure after traumatic abdominal injury. There is limited literature about morbidity and mortality rates after trauma laparotomy. The primary aim of this study is to describe the complications which may occur due to laparotomy for trauma. METHODS: Retrospective evaluated single-centre study with data registry up to 1 year after initial laparotomy for trauma was performed in a level 1 trauma centre in The Netherlands. Between January 2000 and January 2011, a total of 2390 severely injured trauma patients (ISS ≥ 16) were transported to the VUMC. Patient demographics; mechanism of injury; injury patterns defined by Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and Revised Trauma Score (RTS); surgical interventions and findings; and morbidity and mortality were documented. RESULTS: A total of 92 trauma patients who underwent a trauma laparotomy met the inclusion criteria. Of these patients, 71 % were male. Median age was 37 years. Median ISS was 27. Mechanisms of injury comprised of car accidents (20 %), fall from height (17 %), motorcycle accidents (12 %), pedestrian/cyclist hit by a vehicle (9 %) and other in three patients (5 %). Penetrating injuries accounted for 37 % of the injuries, consisting of stab wounds (21 %) and gunshot wounds (16 %). Complications classified by the Clavien-Dindo Classification of Surgical Complications showed grade I complications in 21 patients (23 %), grade II in 36 patients (39 %), grade III in 21 patients (23 %), grade IV in 2 patients (2 %) and grade V in 16 patients (17 %). CONCLUSION: Laparotomy for trauma has a high complication rate resulting in significant morbidity and mortality. Most events occur in the early postoperative period. Further prospective research needs to be conducted in order to identify possibilities to improve care in the future.

HUMeral shaft fractures: measuring recovery after operative versus non-operative treatment (HUMMER): a multicenter comparative observational study.

BACKGROUND: Fractures of the humeral shaft are associated with a profound temporary (and in the elderly sometimes even permanent) impairment of independence and quality of life. These fractures can be treated operatively or non-operatively, but the optimal tailored treatment is an unresolved problem. As no high-quality comparative randomized or observational studies are available, a recent Cochrane review concluded there is no evidence of sufficient scientific quality available to inform the decision to operate or not. Since randomized controlled trials for this injury have shown feasibility issues, this study is designed to provide the best achievable evidence to answer this unresolved problem. The primary aim of this study is to evaluate functional recovery after operative versus non-operative treatment in adult patients who sustained a humeral shaft fracture. Secondary aims include the effect of treatment on pain, complications, generic health-related quality of life, time to resumption of activities of daily living and work, and cost-effectiveness. The main hypothesis is that operative treatment will result in faster recovery. METHODS/DESIGN: The design of the study will be a multicenter prospective observational study of 400 patients who have sustained a humeral shaft fracture, AO type 12A or 12B. Treatment decision (i.e., operative or non-operative) will be left to the discretion of the treating surgeon. Critical elements of treatment will be registered and outcome will be monitored at regular intervals over the subsequent 12 months. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcome measures are the Constant score, pain level at both sides, range of motion of the elbow and shoulder joint at both sides, radiographic healing, rate of complications and (secondary) interventions, health-related quality of life (Short-Form 36 and EuroQol-5D), time to resumption of ADL/work, and cost-effectiveness. Data will be analyzed using univariate and multivariable analyses (including mixed effects regression analysis). The cost-effectiveness analysis will be performed from a societal perspective. DISCUSSION: Successful completion of this trial will provide evidence on the effectiveness of operative versus non-operative treatment of patients with a humeral shaft fracture. TRIAL REGISTRATION: The trial is registered at the Netherlands Trial Register (NTR3617).

Very long-term effects of conservatively treated blunt thoracic trauma: A retrospective analysis.

INTRODUCTION: Despite the high incidence of blunt thoracic trauma and frequently performed conservative treatment, studies on very long-term consequences for these patients remain sparse in current literature. In this study, we identify prevalence of long-term morbidity such as chronic chest pain, shortness of breath, and analyze the effect on overall quality of life and health-related quality of life. METHODS: Questionnaires were send to patients admitted for blunt thoracic trauma at our institution and who were conservatively treated between 1997 and 2019. We evaluated the presences of currently existing chest pain, persistence of shortness of breath after their trauma, the perceived overall quality of life, and health-related quality of life. Furthermore, we analyzed the effect of pain and shortness of breath on overall quality of life and health-related quality of life. RESULTS: The study population consisted of 185 trauma patients with blunt thoracic trauma who were admitted between 1997 and 2019, with a median long term follow up of 11 years. 60 percent still experienced chronic pain all these years after trauma, with 40,7 percent reporting mild pain, 12,1 percent reporting moderate pain, and with 7,7 percent showing severe pain. 18 percent still experienced shortness of breath during exercise. Both pain and shortness of breath showed no improvement in this period. Pain and shortness of breath due to thoracic trauma were associated with a lower overall quality of life and health-related quality of life. CONCLUSION: Chronic pain and shortness of breath may be relatively common long after blunt thoracic trauma, and are of influence on quality of life and health-related quality of life in patients with conservatively treated blunt thoracic trauma.

Merging of two level-1 trauma centers in Amsterdam: premerger demand in integrated acute trauma care.

PURPOSE: Availability of adequate and appropriate trauma care is essential. A merger of two Dutch academic level-1 trauma centers is upcoming. However, in the literature, volume effects after a merger are inconclusive. This study aimed to examine the premerger demand for level-1 trauma care on integrated acute trauma care and evaluate the expected demand on the system. METHODS: A retrospective observational study was conducted between 1-1-2018 and 1-1-2019 in two level-1 trauma centers in the Amsterdam region using data derived from the local trauma registries and electronic patient records. All trauma patients presented at both centers' Emergency Departments (ED) were included. Patient- and injury characteristics and data concerning all prehospital and in-hospital-delivered trauma care were collected and compared. Pragmatically, the demand for trauma care in the post-merger setting was considered a sum of care demand for both centers. RESULTS: In total, 8277 trauma patients were presented at both EDs, 4996 (60.4%) at location A and 3281 (39.6%) at location B. Overall, 462 patients were considered severely injured patients (Injury Severity Score ≥ 16). In total, 702 emergency surgeries (< 24 h) were performed, and 442 patients were admitted to the ICU. The sum care demand of both centers resulted in a 167.4% increase in trauma patients and a 151.1% increase in severely injured patients. Moreover, on 96 occasions annually, two or more patients within the same hour would require advanced trauma resuscitation by a specialized team or emergency surgery. CONCLUSION: A merger of two Dutch level-1 trauma centers would, in this scenario, result in a more than 150% increase in the post-merger setting's demand for integrated acute trauma care.

Classification of trauma-related preventable death; protocol of a Delphi procedure.

BACKGROUND: Trauma-related (preventable) death is used to evaluate the management and quality of trauma care worldwide. Therefore, it is necessary to identify fatalities in the trauma care population and assess them on preventability. However, the definition on trauma-related preventable death lacks validity due to differences in terminology and classifications. This study aims to reach consensus on the definition of trauma-related preventable death by performing a Delphi procedure, thereby, improving the assessment of trauma-related preventable death and thereby enhancing the quality of trauma care. METHODS: Based on the results of a recently performed systematic review Hakkenbrak (2021). The definitions used to describe trauma-related preventable death could be divided into four categories: 1) Clinical definition based on panel review or expert opinion, 2) Trauma prediction algorithm, 3) Clinical definition with an additional trauma prediction algorithm and 4) Others (e.g., errors in care or detailed clinical definition). A three round, electronic Delphi study will be performed in the Netherlands to reach consensus. Experts from the department of Trauma surgery, Neurosurgery, Forensic medicine, Anaesthesiology and Emergency medicine, of the designated Level 1 trauma centres in the Netherlands, will be invited to participate. In the first round the panel will comment on the composed categories and trauma prediction algorithms. In the second and third round a feedback report will be presented and the questions with disagreement will be retested. DISCUSSION: The identification and assessment of trauma-related preventable death is necessary to evaluate and improve trauma care. Therefore, a valid, fair, and applicable definition of trauma-related preventable death is required. The Delphi technique is utilized to reach group consensus to obtain a scientifically valid definition of trauma-related preventable death.

Current consensus and clinical approach to fragility fractures of the pelvis: an international survey of expert opinion.

Introduction: Fragility fractures of the pelvis (FFP) in elderly patients are an underappreciated injury with a significant impact on mobility, independency, and mortality of affected patients and is a growing burden for society/health care. Given the lack of clinical practice guidelines for these injuries, the authors postulate there is heterogeneity in the current use of diagnostic modalities, treatment strategies (both operative and nonoperative), and follow-up of patients with FFP. The goal of this study was to assess international variation in the management of FFP. Methods: All International Orthopaedic Trauma Association (IOTA) steering committee members were asked to select 15 to 20 experts in the field of pelvic surgery to complete a case-driven international survey. The survey addresses the definition of FFP, use of diagnostic modalities, timing of imaging, mobilization protocols, and indications for surgical management. Results: In total, 143 experts within 16 IOTA societies responded to the survey. Among the experts, 86% have >10 years of experience and 80% works in a referral center for pelvic fractures. However, only 44% of experts reported having an institutional protocol for the management of FFP. More than 89% of experts feel the need for a (inter)national evidence-based guideline. Of all experts, 73% use both radiographs and computed tomography (CT) to diagnose FFP, of which 63% routinely use CT and 35% used CT imaging selectively. Treatment strategies of anterior ring fractures were compared with combined (anterior and posterior ring) fractures. Thirty-seven percent of patients with anterior ring fractures get admitted to the hospital compared with 75% of patients with combined fractures. Experts allow pain-guided mobilization in 72% after anterior ring fracture but propose restricted weight-bearing in case of a combined fracture in 44% of patients. Surgical indications are primarily based on the inability to mobilize during hospital admission (33%) or persistent pain after 2 weeks (25%). Over 92% plan outpatient follow-up independent of the type of fracture or treatment. Conclusion: This study shows that there is a great worldwide heterogeneity in the current use of diagnostic modalities and both nonoperative and surgical management of FFP, emphasizing the need for a consensus meeting or guideline.

Sex Dimorphism in Outcome of Trauma Patients Presenting with Severe Shock: A Multicenter Cohort Study.

Background: The objective of this study was to determine the association between sex and outcome among severely injured patients who were admitted in severe shock. Methods: A retrospective multicenter study was performed in trauma patients (Injury Severity Score (ISS) ≥ 16) aged ≥ 16 presenting with severe shock (Shock Index > 1.3) over a 4-year period. To determine if sex was associated with mortality, Intensive Care Unit (ICU) admission, mechanical ventilation, blood transfusion and in-hospital complications, multivariable logistic regressions were performed. Results: In total, 189 patients were admitted to the Emergency Department in severe shock. Multivariable logistic regression analysis showed that female sex was independently associated with a decreased likelihood of acute kidney injury (OR 0.184; 95% CI 0.041-0.823; p = 0.041) compared to the male sex. A significant association between female sex and mortality, ICU admission, mechanical ventilation, other complications and packed red blood cells transfusion after admission could not be confirmed. Conclusion: Female trauma patients in severe shock were significantly less likely to develop AKI during hospital stay. These results could suggest that female trauma patients may manifest a better-preserved physiologic response to severe shock when compared to their male counterparts. Prospective studies with a larger study population are warranted.

Sex Differences in Outcome of Trauma Patients Presented with Severe Traumatic Brain Injury: A Multicenter Cohort Study.

The objective of this study was to determine whether there is an association between sex and outcome in trauma patients presented with severe traumatic brain injury (TBI). A retrospective multicenter study was performed in trauma patients aged ≥ 16 years who presented with severe TBI (Head Abbreviated Injury Scale (AIS) ≥ 4) over a 4-year-period. Subgroup analyses were performed for ages 16-44 and ≥45 years. Also, patients with isolated severe TBI (other AIS ≤ 2) were assessed, likewise, with subgroup analysis for age. Sex differences in mortality, Glasgow Outcome Score (GOS), ICU admission/length of stay (LOS), hospital LOS, and mechanical ventilation (MV) were examined. A total of 1566 severe TBI patients were included (831 patients with isolated TBI). Crude analysis shows an association between female sex and lower ICU admission rates, shorter ICU/hospital LOS, and less frequent and shorter MV in severe TBI patients ≥ 45 years. After adjusting, female sex appears to be associated with shorter ICU/hospital LOS. Sex differences in mortality and GOS were not found. In conclusion, this study found sex differences in patient outcomes following severe TBI, potentially favoring (older) females, which appear to indicate shorter ICU/hospital LOS (adjusted analysis). Large prospective studies are warranted to help unravel sex differences in outcomes after severe TBI.

Criteria for cancelling helicopter emergency medical services (HEMS) dispatches.

INTRODUCTION: In The Netherlands there is no consensus about criteria for cancelling helicopter emergency medical services (HEMS) dispatches. This study assessed the ability of the primary HEMS dispatch criteria to identify major trauma patients. The predictive power of other early prehospital parameters was evaluated to design a safe triage model for HEMS dispatch cancellations. METHODS: All trauma-related dispatches of HEMS during a period of 6 months were included. Data concerning prehospital information and inhospital treatment were collected. Patients were divided into two groups (major and minor trauma) according to the following criteria: injury severity score 16 or greater, emergency intervention, intensive care unit admission, or inhospital death. Logistic regression analysis was used to design a prediction model for the early identification of major trauma patients. RESULTS: In total, 420 trauma-related dispatches were evaluated, of which 155 concerned major trauma patients. HEMS was more often cancelled for minor trauma patients than for major trauma patients (57.7% vs 20.6%). Overall, HEMS dispatch criteria had a sensitivity of 87.7% and a specificity of 45.3% for identifying major trauma patients. Significant differences were found for vital sign abnormalities, anatomical components and several parameters of the mechanism of injury. A triage model designed for cancelling HEMS correctly identified major trauma patients (sensitivity 99.4%). CONCLUSION: The accuracy of the current HEMS dispatch criteria is relatively low, resulting in high cancellation rates and low predictability for major trauma. The new HEMS cancellation triage model identified all major trauma patients with an acceptable overtriage and will probably reduce unjustified HEMS dispatches.

Operative results after xiphoidectomy in patients with xiphodynia.

BACKGROUND: Xiphodynia, the painful xiphoid process, is a rare condition with an atypical presentation. Symptoms differ in severity and site, and can consist of chest, throat, and upper abdominal pain. Primarily, other more severe causes of these symptoms need to be excluded. After this exclusion as xiphodynia is diagnosed, treatment can consist of a multitude of options, since there is no consensus regarding the optimal treatment. The aim of this study was to describe the outcomes and efficacy of one of the options, namely surgical resection of the xiphoid in patients with xiphodynia. METHODS: In this retrospective case series, all consecutive patients that underwent xiphoidectomy for xiphodynia between January 2014 and December 2017 were included. Patients' medical files including pre-operative work up, NRS scores, surgical outcomes, and follow up were reviewed. All patients received a questionnaire with follow-up questions. RESULTS: A total of 19 patients were included. None of the patients had surgery-related complications. Response rate of the questionnaire was 84% and showed that 94% of patients had an improvement of complaints after surgery, with 10 patients (63%) being totally pain free, after a mean follow-up from 34 months after surgery. CONCLUSIONS: Xiphoidectomy is feasible and safe for the treatment of patients with xiphodynia with an improvement of complaints in nearly all patients.

Trends in the Treatment of Pectus Excavatum in the Netherlands.

INTRODUCTION: Pectus excavatum (PE) is the most common deformity of the anterior chest wall and can be corrected surgically with different techniques. In the past years, medical literature suggests that the minimal invasive surgical correction of PE (MIRPE) has currently become the operation technique of choice in Europe, and the number of PE patients undergoing surgery has increased. The aim of this study was to evaluate trends in the number of patients operated on and the surgical techniques generally used in patients with PE in the Netherlands. MATERIALS AND METHODS: From the registration by Statistics Netherlands, the numbers of live births and gender were obtained for the period 1980 to 2017. Furthermore, from the Dutch hospital registration performed by Kiwa Prismant systems, the number of total surgical procedures of PE patients from the period 1998 to 2017, and the numbers of open and MIRPE surgery were obtained over the period 2005 to 2013. RESULTS: The birth rate in Netherlands has stayed more or less stable in the last two decades. The number of PE patients asking for correction, however, has increased. In addition, the percentage of thoracoscopic assisted correction has increased. CONCLUSION: The increase in correction of PE is not due to an increased incidence but to an increase of patient wishes. The use of MIRPE is gaining popularity over time.

The Quality of Web Sites' Health Information on Minimal Invasive Repair of Pectus Excavatum Using the DISCERN Instrument.

INTRODUCTION: The Internet is a frequently used tool for patients with pectus excavatum (PE) to get information about symptoms and treatment options. In addition, it is used by both health care providers as a marketing tool and support group systems. The Internet health information varies in precision, quality, and reliability. The study purpose was to determine the quality of information on the PE Web sites using the DISCERN instrument, including information about operation and potential complications after a Nuss bar procedure. MATERIALS AND METHODS: Four search engines, Google, Yahoo, Ask, and Bing, were used to explore seven key terms concerning PE. Search language was English. The DISCERN quality instrument was used to evaluate the Web sites. Also, information on possible complications was scored per Web site. RESULTS: A total of 560 Web sites were assessed in March 2019. Excluded were 139 Web sites. There were 333 duplicates, leaving 88 unique Web sites. Of these, 58.1% were hospital-related information Web sites, 28.4% medical information Web sites, and 3.4% patient forum sites. Interactive multimedia was used on 21.6% of the sites. Pain postoperatively was mentioned on 64.8% of the sites, while only 9.1% mentioned the mortality risk of the surgical correction of PE for Nuss bar placement. The quality of the unique Web sites showed a mean DISCERN score of 42.5 (standard deviation 12.2). Medical information Web sites, encyclopedia, and government-sponsored sites had higher DISCERN scores. Hospital-related information sites, medical companies, and lay persons' sites, had lower total scores. CONCLUSION: The overall quality of PE Web sites is low to moderate, with serious shortcomings.

Distribution of radiation exposure in patients with partially stable and unstable pelvic ring fractures: first-time use of highly accurate assessment by Monte Carlo calculations.

PURPOSE: Radiological examinations including X-ray and CT play a critical role in the assessment and treatment of trauma patients. The ionizing radiation used is known to be carcinogenic. However, little is known about the total radiation exposure in trauma patients. The objective of this study was to accurately estimate radiation exposure of patients with severe pelvic ring fractures. METHODS: In this retrospective dynamic cohort study, adult patients with partially stable and unstable pelvic ring fractures were included. For each patient, data concerning demography and injury characteristics were collected. Subsequently, the total effective radiation dose due to all trauma-related X-rays and CT scans during initial assessment, treatment and follow-up was calculated using Monte Carlo software. RESULTS: A total of 114 patients were included. The median total effective dose was 49.7 millisievert (mSv). 57 patients (50.0%) received more than 50 mSv and 13 patients (11.4%) received more than 100 mSv. 62.4% of the total effective dose was received within the 24 h after admission. The median total effective dose for survivors (n = 95) was 52.0 mSv. Polytrauma patients received a significantly higher total effective dose than non-polytrauma patients. CONCLUSIONS: This study showed that a substantial number of patients with partially stable and unstable pelvic ring fractures have an increased cancer risk due to trauma-related medical imaging. Physicians should be aware of the amount of radiation their patients are exposed to, and minimize imaging related increase of cancer risks during initial assessment, treatment and follow-up.

The effect of socioeconomic status on severe traumatic injury: a statistical analysis.

PURPOSE: The amount of studies performed regarding a link between socioeconomic status (SES) and fatal outcome after traumatic injury is limited. Most research is focused on work-related injuries without taking other important characteristics into account. The aim of this study is to examine the association between SES and outcome after traumatic injury. METHODS: The study involved polytrauma patients [Injury Severity Score (ISS) ≥ 16] admitted to the Amsterdam University Medical Center (location VUmc) and Northwest Clinics Alkmaar (level 1 trauma centers). The SES of every patient was based on their postal code and represented with a "status score". Univariate and multivariable analyses were performed to estimate the association between SES and mortality, length of stay at the hospital and length of stay at the Intensive Care Unit (ICU). Z-statistics were used to determine the difference between the expected and actual survival, based on Trauma Revised Injury Severity Score (TRISS) and PSNL15 (probability of survival based on the Dutch population). RESULTS: A total of 967 patients were included in this study. The lowest SES group was significantly associated with more penetrating injuries and a younger age (45 years versus 55 years). Additionally, severely injured patients with lower SES were noted to have a prolonged stay at the ICU. Furthermore, differences were found in the expected and observed survival, especially for the lower SES groups. CONCLUSION: Polytrauma patients with lower SES have more often penetrating injuries, are younger and have a longer stay at the ICU. No association was found between SES and length of hospital stay and neither between SES and mortality.

Signs of post-traumatic hypovolemia on abdominal CT and their clinical importance: A systematic review.

PURPOSE: Our aim was to assess the findings of hypovolemia on abdominal CT that are most frequently seen in blunt abdominal trauma patients. When possible, we assessed the correlation of these CT signs with clinical outcome. METHODS: MEDLINE, CENTRAL and EMBASE were systematically searched. Two reviewers independently screened and included articles and performed the data-extraction. Primary outcomes of interest were the frequency of each sign and its correlation with mortality. Secondary outcomes were need for intervention, transfusion need, intensive care unit admission rate and length of stay. RESULTS: A flat inferior vena cava and an inferior vena cava halo, a diminished aortic calibre, shock bowel, altered enhancement of the liver, pancreas, adrenals, kidneys, spleen and gallbladder, peripancreatic fluid and splenic volume changes have been described in the setting of hypovolemic trauma patients to constellate a CT hypovolemic shock complex. It is argued that vascular signs represent the true hypovolemic state and the visceral signs represent hypoperfusion. There is no consensus on the frequency or clinical relevance of these signs, which at least partly can be explained by the heterogeneity in study design, study population, scanning protocols and outcome parameters. Available evidence suggests a good predictive value for occult shock and a higher mortality rate when a flat inferior vena cava is present. Evidence regarding the other signs is scarce. CONCLUSIONS: The hypovolemic shock complex is an entity of both vascular and visceral CT signs that can be seen in blunt trauma patients. It can offer guidance to a swift primary imaging survey in the acute trauma setting, allowing the radiologist to alert the treating physicians to possible pending hypovolemic shock.

Correlation of Preoperative State Anxiety and Pain Six Weeks After Surgical Correction of Pectus Excavatum.

BACKGROUND: Pain is a major concern in the early postoperative phase after correction of pectus excavatum. Most studies only focus on pain management in the first days after surgery and describe methods to alleviate the pain immediately postoperatively. The severity of postoperative pain may be influenced by anxiety. So far, few studies have looked into the relationship between anxiety and postoperative pain after pectus excavatum correction. OBJECTIVES: This study aimed to investigate the correlation between preoperative anxiety and late postoperative pain scores. METHODS: This was a prospective cohort study. Anxiety was assessed with the State and Trait Anxiety Inventory questionnaire. Visual analogue scale (VAS) for pain scores assessed the pain at rest and activity. Anxiety was measured before surgery and pain scores six weeks after surgery. A hierarchical linear regression analysis was performed to investigate the correlation between baseline anxiety and pain measurements six weeks after surgery. RESULTS: In this study, 136 patients were included. State anxiety was not associated with postoperative pain (mean of pain on activity and in rest), only with pain on activity after six weeks. Age and sex were not effect modifiers in any of the models. Relevant confounding factors, although not significant, consisted of trait, sex, minor complications, epidural duration, major complications, and the number of stabilizer plates. The explained variance of state anxiety on VAS for pain scores was minimum after 6 weeks. CONCLUSIONS: Preoperative anxiety does not appear to influence postoperative pain after PE correction.