Exploring the impact of traumatic injury on mortality: An analysis of the certified cause of death within one year of serious injury in the Scottish population.

BACKGROUND: Few studies effectively quantify the long-term incidence of death following injury. The absence of detailed mortality and underlying cause of death data results in limited understanding and a potential underestimation of the consequences at a population level. This study takes a nationwide approach to identify the one-year mortality following injury in Scotland, evaluating survivorship in relation to pre-existing comorbidities and incidental causes of death. STUDY DESIGN: This retrospective cohort study assessed the one-year mortality of adult trauma patients with an Injury Severity Score ≥ 9 during 2020 using the Scottish Trauma Audit Group (STAG) registry linked to inpatient hospital data and death certificate records. Patients were divided into three groups: trauma death, trauma-contributed death, and non-trauma death. Kaplan-Meier curves were used for survival analysis to evaluate mortality, and cox proportional hazards regression analysed risk factors linked to death. RESULTS: 4056 patients were analysed with a median age 63 years (58-88) and male predominance (55.2 %). Falls accounted for 73.1 % of injuries followed by motor vehicle accidents (16.3 %) and blunt force (4.9 %). Extremity was the most commonly injured region overall followed by chest and head. However, head injury prevailed in those who died. The registry demonstrated a one-year mortality of 19.3 % with 55 % deaths occurring post-discharge. Of all deaths reported, 35.3 % were trauma deaths, and 47.7 % were trauma-contributed deaths. These groups accounted for over 70 % of mortality within 30 days of hospital admission and continued to represent the majority of deaths up to 6 months post-injury. Patients who died after 6 months were mainly the result of non-traumatic causes, frequently circulatory, neoplastic, and respiratory diseases (37.7 %, 12.3 %, 9.1 %, respectively). Independent risk factors for one-year mortality included a GCS ≤ 8, modified Charlson Comorbidity score >5, Injury Severity Score >25, serious head injury, age and sex. CONCLUSION: With a one-year mortality of 19.3 %, and post-discharge deaths higher than previously appreciated, patients can face an extended period of survival uncertainty. As mortality due to index trauma lasted up to 6 months post-admission, short-term outcomes fail to represent trauma burden and so cogent survival predictions should be avoided in clinical and patient settings.

Epidemiology of major trauma in older adults within Scotland: A national perspective from the Scottish Trauma Audit Group (STAG).

BACKGROUND: Major trauma in older adults (MTOA) poses distinctive health and social care challenges, further underlined by the unique socioeconomic and geographical environment of Scotland. This study provides epidemiological trends of MTOA, to provide insight into areas where further evaluation and research are required. MATERIALS AND METHODS: Pseudonymised aggregated demographic, injury and outcome data from 2011 to 2020 were obtained from the Scottish Trauma Audit Group (STAG) Database, covering 28 hospitals across Scotland. Only individuals age ≥ 70 with an Injury Severity Score (ISS) > 15 were included. RESULTS: There was an average of 216 annual cases of MTOA, with a 259 % rise in incidence from 2011 to 2020. This was predominantly driven by a rise in low velocity trauma (fall <2 m height; 287 % increase). The proportion of all major trauma attributable to those aged ≥70 rose from 18.5 % in 2011 to 34.6 % in 2020. Death censored median (IQR) acute hospital length of stay was 18 days (9-30). Overall, 30-day survival was 65.3 %, with no improvement seen between 2011 and 2020 (p = 0.50). Independent predictors of improved 30-day survival included Ages 70-79 & 80-89 [compared to reference ≥ 90] (OR 3.12; 95 %CI 2.24,4.31; p < 0.001 and OR 1.66; 95 %CI 1.21,2.29; p = 0.002 respectively), and Extremity injury (OR 1.89; 95 %CI 1.48,2.41; p < 0.001). Head injury (OR 0.72; 95 %CI 0.54,0.96; p = 0.027) and increasing ISS score (OR 0.88, 95 %CI 0.86,0.89; p < 0.001) were associated with lower likelihood of 30-day survival. A further model also including the admission ward (from eSTAG data November 2017 onwards) demonstrated an association with reduced 30-day survival with admission to General Surgery (OR 0.42; 95 %CI 0.19,0.93; p = 0.033), Intensive Care (OR 0.25; 95 %CI 0.10,0.60; p = 0.002) and Medical Specialities (OR 0.33; 95 %CI 0.15,0.73; p = 0.007) compared to the reference (Major Trauma). Exponential Smoothing predictions revealed a further potential 184 % rise in incidence of MTOA from 2021 to 2030 (3657 per 100,000 population at risk to 10,392 per 100,000 population at risk). CONCLUSION: MTOA is likely to be a rising health care burden, requiring larger quantities of health and social care resource. Urgent preventative strategies are required to reduce low velocity trauma (standing height falls), as well as the high mortality and morbidity of MTOA.

Role of intraoperative PTH monitoring and surgical approach in primary hyperparathyroidism.

AIMS: The use of intraoperative PTH monitoring (IOPTH) in combination with preoperative imaging has been useful to surgeons performing minimally invasive parathyroidectomy principally for adequacy of excision. However, its role within patients with equivocal imaging remains less clear particularly regarding the reduction of bilateral neck explorations. This study investigated the influence of IOPTH monitoring on the type of surgical approach adopted for patients with primary hyperparathyroidism (PHPT). Specifically, determining its impact amongst patients with equivocal imaging results. METHODS: 165 patients undergoing parathyroidectomy for PHPT at a single institution by a single surgeon, between 2008 and 2012, were included. Patients were divided into 2 groups, IOPTH monitoring and non-IOPTH monitoring. They were sub-classified according to their imaging strengths: strongly positive, equivocal and negative imaging. The percentages of patients undergoing focused, unilateral and bilateral operations were determined. RESULTS: 108 patients had IOPTH monitoring and 57 patients did not based on the availability of IOPTH monitoring. Patients with strongly positive imaging had a higher frequency of focused operation in both groups; IOPTH 73.4% and non-IOPTH 71.4%. Patients with negative imaging results had a higher frequency of bilateral operations; IOPTH 77.8% and non-IOPTH 72.7%. In patients with equivocal imaging results more focused/unilateral operations were performed with IOPTH monitoring 66.6% versus non-IOPTH 25%. The use of intraoperative PTH increased the likelihood of a unilateral procedure with equivocal imaging compared to those with negative imaging p = 0.04. CONCLUSION: IOPTH monitoring is most useful as an adjunct to preoperative imaging when imaging results are equivocal allowing for more focused/unilateral operations to be performed.

External validation of the Intensive Care National Audit & Research Centre (ICNARC) risk prediction model in critical care units in Scotland.

BACKGROUND: Risk prediction models are used in critical care for risk stratification, summarising and communicating risk, supporting clinical decision-making and benchmarking performance. However, they require validation before they can be used with confidence, ideally using independently collected data from a different source to that used to develop the model. The aim of this study was to validate the Intensive Care National Audit & Research Centre (ICNARC) model using independently collected data from critical care units in Scotland. METHODS: Data were extracted from the Scottish Intensive Care Society Audit Group (SICSAG) database for the years 2007 to 2009. Recoding and mapping of variables was performed, as required, to apply the ICNARC model (2009 recalibration) to the SICSAG data using standard computer algorithms. The performance of the ICNARC model was assessed for discrimination, calibration and overall fit and compared with that of the Acute Physiology And Chronic Health Evaluation (APACHE) II model. RESULTS: There were 29,626 admissions to 24 adult, general critical care units in Scotland between 1 January 2007 and 31 December 2009. After exclusions, 23,269 admissions were included in the analysis. The ICNARC model outperformed APACHE II on measures of discrimination (c index 0.848 versus 0.806), calibration (Hosmer-Lemeshow chi-squared statistic 18.8 versus 214) and overall fit (Brier's score 0.140 versus 0.157; Shapiro's R 0.652 versus 0.621). Model performance was consistent across the three years studied. CONCLUSIONS: The ICNARC model performed well when validated in an external population to that in which it was developed, using independently collected data.