Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma.

BACKGROUND: Contrast-enhanced whole-body computed tomography (also called "pan-scanning") is considered to be a conclusive diagnostic tool for major trauma. We sought to determine the accuracy of this method, focusing on the reliability of negative results. METHODS: Between July 2006 and December 2008, a total of 982 patients with suspected severe injuries underwent single-pass pan-scanning at a metropolitan trauma centre. The findings of the scan were independently evaluated by two reviewers who analyzed the injuries to five body regions and compared the results to a synopsis of hospital charts, subsequent imaging and interventional procedures. We calculated the sensitivity and specificity of the pan-scan for each body region, and we assessed the residual risk of missed injuries that required surgery or critical care. RESULTS: A total of 1756 injuries were detected in the 982 patients scanned. Of these, 360 patients had an Injury Severity Score greater than 15. The median length of follow-up was 39 (interquartile range 7-490) days, and 474 patients underwent a definitive reference test. The sensitivity of the initial pan-scan was 84.6% for head and neck injuries, 79.6% for facial injuries, 86.7% for thoracic injuries, 85.7% for abdominal injuries and 86.2% for pelvic injuries. Specificity was 98.9% for head and neck injuries, 99.1% for facial injuries, 98.9% for thoracic injuries, 97.5% for abdominal injuries and 99.8% for pelvic injuries. In total, 62 patients had 70 missed injuries, indicating a residual risk of 6.3% (95% confidence interval 4.9%-8.0%). INTERPRETATION: We found that the positive results of trauma pan-scans are conclusive but negative results require subsequent confirmation. The pan-scan algorithms reduce, but do not eliminate, the risk of missed injuries, and they should not replace close monitoring and clinical follow-up of patients with major trauma.

The performance of two motivation measures and outcome after alcohol detoxification.

AIMS: The aims of this study were to investigate the performance of the treatment version of the Readiness to Change Questionnaire (RCQ[TV]) among individuals currently receiving alcohol detoxification and to develop a treatment version of the Treatment Readiness Tool (TReaT[TV]). METHODS: A total of 549 patients (86% men) recruited from two detoxification units were interviewed close to treatment intake and followed up 12 months later. Confirmatory factor analyses and logistic regression analyses were conducted. RESULTS: A modified nine-item version of the RCQ[TV] showed a good fit of the model (CFI = 0.95) and internal consistencies ranging between 0.49 and 0.91. Twelve months later, RCQ-Actors had an odds ratio of 1.95 (95% CI: 1.12-3.37) for being abstinent compared to Precontemplators/Contemplators. The development of the TReaT[TV] resulted in 15 items and 5 scales with a CFI of 0.97 and Cronbach's alphas ranging between 0.59 and 0.94. TReaT[TV] Precontemplators/Contemplators were less likely to utilize help than Maintainers (OR = 0.17, 95% CI: 0.06-0.45). CONCLUSIONS: The psychometric properties were modest for the modified RCQ[TV] and good for the TReaT[TV]. Readiness to change and readiness to seek help should be assessed separately among treatment seekers.

Dose reduction in whole-body computed tomography of multiple injuries (DoReMI): protocol for a prospective cohort study.

BACKGROUND: Single-pass, contrast-enhanced whole body multidetector computed tomography (MDCT) emerged as the diagnostic standard for evaluating patients with major trauma. Modern iterative image algorithms showed high image quality at a much lower radiation dose in the non-trauma setting. This study aims at investigating whether the radiation dose can safely be reduced in trauma patients without compromising the diagnostic accuracy and image quality. METHODS/DESIGN: Prospective observational study with two consecutive cohorts of patients. SETTING: A high-volume, academic, supra-regional trauma centre in Germany. STUDY POPULATION: Consecutive male and female patients who 1. had been exposed to a high-velocity trauma mechanism, 2. present with clinical evidence or high suspicion of multiple trauma (predicted Injury Severity Score [ISS] ≥16) and 3. are scheduled for primary MDCT based on the decision of the trauma leader on call.Imaging protocols: In a before/after design, a consecutive series of 500 patients will undergo single-pass, whole-body 128-row multi-detector computed tomography (MDCT) with a standard, as low as possible radiation dose. This will be followed by a consecutive series of 500 patients undergoing an approved ultra-low dose MDCT protocol using an image processing algorithm. DATA: Routine administrative data and electronic patient records, as well as digital images stored in a picture archiving and communications system will serve as the primary data source. The protocol was approved by the institutional review board. MAIN OUTCOMES: (1) incidence of delayed diagnoses, (2) diagnostic accuracy, as correlated to the reference standard of a synopsis of all subsequent clinical, imaging, surgical and autopsy findings, (3) patients' safety, (4) radiation exposure (e.g. effective dose), (5) subjective image quality (assessed independently radiologists and trauma surgeons on a 100-mm visual analogue scale), (6) objective image quality (e.g., contrast-to-noise ratio). ANALYSIS: Multivariate regression will be employed to adjust and correct the findings for time and cohort effects. An exploratory interim analysis halfway after introduction of low-dose MDCT will be conducted to assess whether this protocol is clearly inferior or superior to the current standard. DISCUSSION: Although non-experimental, this study will generate first large-scale data on the utility of imaging-enhancing algorithms in whole-body MDCT for major blunt trauma. TRIAL REGISTRATION: Current Controlled Trials ISRCTN74557102.

A new approach and first steps to strengthen trauma management and road safety in North Vietnam.

BACKGROUND: In Vietnam, the number of road traffic accidents increased dramatically which is a major threat for the national health system. Reliable data on the magnitude of traffic accidents as well as the current management of victims is missing. Our multistep international cooperation project aims to (1) identify local needs and knowledge related to trauma management, to (2) assess basic behavioural patterns and attitudes of road users in order to (3) establish a school-based educational programme and trauma courses for doctors. METHODS AND RESULTS: As part of a European Union co-financed cooperation, two European and one Vietnamese university set up three action lines (Trauma and Emergency Courses, school-based education programs, public awareness campaigns). Specific contents of the activities were derived from a literature search, a questionnaire pilot-study and by panel consensus technique. After adjustment to local capabilities (equipment, infrastructure, etc.) these were implemented within a professional network of hospitals, schools, public and media institutions.The literature research and questionnaire results from 1 000 young road users indicates that for pedestrian and two-wheelers accidents, low compliance with traffic regulations and high prevalence of risk-taking behaviour dominate Vietnam's road traffic environment. A school-based educational program (4 hrs/month) was set up using teachers who were trained on road safety issues. Also, major parts of the public awareness campaigns (i.e. broadcasts, media conferences) reflected these topics. From panel discussions and Delphi-technique, diagnosis and early treatment of severe head trauma and internal haemorrhage were identified as topics of highest interest for doctors therefore representing key topics of the Trauma and Emergency Courses. CONCLUSION: Knowledge on behaviour and attitudes of road users in Vietnam as well as on local infrastructure and effective networks is essential to establish sustainable and effective countermeasures. Our approach might serve as guideline for future small scale projects as it proved to be feasible, cost-effective but provided scientific base for immediate on spot activities.