Inter-rater reliability of the Abbreviated Injury Scale scores in patients with severe head injury shows good inter-rater agreement but variability between countries. An inter-country comparison study.

INTRODUCTION: Substantial difference in mortality following severe traumatic brain injury (TBI) across international trauma centers has previously been demonstrated. This could be partly attributed to variability in the severity coding of the injuries. This study evaluated the inter-rater and intra-rater reliability of Abbreviated Injury Scale (AIS) scores of patients with severe TBI across three international level I trauma centers. METHODS: A total 150 patients (50 per center) were randomly selected from each respective trauma registry: University Medical Center Utrecht (UMCU), the Netherlands; John Hunter Hospital (JHH), Australia; and Harborview Medical Center (HMC), the United States. Reliability between coders and trauma centers was measured with the intraclass correlation coefficient (ICC). RESULTS: The reliability between the coders and the original trauma registry scores was 0.50, 0.50, and 0.41 in, respectively, UMCU, JHH, and HMC. The AIS coders at UMCU scored the most AIS codes of ≥ 4. Reliability within the trauma centers was substantial in UMCU (ICC = 0.62) and HMC (ICC = 0.78) and almost perfect in JHH (ICC = 0.85). Reliability between trauma centers was 0.70 between UMCU and JHH, 0.70 between JHH and HMC, and 0.59 between UMCU and HMC. CONCLUSION: The results of this study demonstrated a substantial and almost perfect reliability of the AIS coders within the same trauma center, but variability across trauma centers. This indicates a need to improve inter-rater reliability in AIS coders and quality assessments of trauma registry data, specifically for patients with head injuries. Future research should study the effect of differences in AIS scoring on outcome predictions.

Venous thromboembolism (VTE) prophylaxis in severely injured patients: an international comparative assessment.

PURPOSE: Venous thromboembolisms (VTE) are a major concern after acute survival from trauma. Variations in treatment protocols for trauma patients exist worldwide. This study analyzes the differences in the number of VTE events and the associated complications of thromboprophylaxis between two level I trauma populations utilizing varying treatment protocols. METHODS: International multicenter trauma registry-based study was performed at the University Medical Center Utrecht (UMCU) in The Netherlands (early commencement chemical prophylaxis), and Harborview Medical Center (HMC) in the United States (restrictive early chemical prophylaxis). All severely injured patients (ISS ≥ 16), aged ≥ 18 years, and admitted in 2013 were included. Primary outcomes were VTE [deep venous thrombosis (DVT) (no screening), pulmonary embolism (PE)], and hemorrhagic complications. RESULTS: In UMCU, 279 patients were included and in HMC, 974 patients. Overall, 75% of the admitted trauma patients in UMCU and 81% in HMC (p < 0.001) received thromboprophylaxis, of which 100% in and 75% at, respectively, UMCU and HMC consisted of chemical prophylaxis. From these patients, 72% at UMCU and 47% at HMC (p < 0.001) were treated within 48 h after arrival. At UMCU, 4 patients (1.4%) (PE = 3, DVT = 1) and HMC 37 patients (3.8%) (PE = 22, DVT = 16; p = 0.06) developed a VTE. At UMCU, a greater percent of patients with VTE had traumatic brain injuries (TBI). Most VTE occurred despite adequate prophylaxis being given (75% UMCU and 81% HMC). Hemorrhagic complications occurred in, respectively, 4 (1.4%) and 10 (1%) patients in UMCU and HMC (p = 0.570). After adjustment for age, ISS, HLOS, and injury type, no significant difference was demonstrated in UMCU compared to HMC for the development of VTE, OR 2.397, p = 0.102 and hemorrhagic complications, OR 0. 586, p = 0.383. CONCLUSIONS: A more early commencement protocol resulted in almost twice as much chemical prophylaxis being started within the first 48 h in comparison with a more delayed initiation of treatment. Interestingly, most episodes of VTE developed while receiving recommended prophylaxis. Early chemical thromboprophylaxis did not significantly increase the bleeding complications and it appears to be safe to start early.

Association of pre-treatment radiographic characteristics of calcaneal fractures on patient-reported outcomes.

PURPOSES: Calcaneal fractures are known to influence patients' quality of life negatively. The type of calcaneal fracture might have a relation with the patient outcome. To inform patients in an early stage on how their calcaneal fracture may affect their lives, knowledge of the fracture characteristics is necessary. This study evaluates the association of type of calcaneal fracture, measurement of conventional radiograph angles, and the Sanders classification with patient-reported outcomes. MATERIAL AND METHODS: This is a retrospective study based on a prospective trauma database including all patients aged 16 years or older with a calcaneal fracture admitted in one of the participating trauma level I or II hospitals. Patients, trauma, and fracture characteristics were collected. The conventional radiographs were evaluated in which type of fracture, and Böhler's, Gissane's, and calcaneal compression angles were determined. Also, the CT images were classified according to Sanders. In addition, displaced intra-articular calcaneal fractures were separately analyzed. A questionnaire was sent to the included patients that consisted of the EQ-6D, patient-specific characteristics, satisfaction with foot appearance and wearable shoe range, complications, and capability to work. RESULTS: A total of 396 patients with 442 calcaneal fractures were eligible for follow-up. Two hundred fifteen patients with 246 calcaneal fractures participated. Patients with a calcaneal fracture into the talar surface reported a worse quality of life (p = 0.010), were less satisfied with their feet (p < 0.001), and had more complications (p = 0.001-0.006); extra-articular fractures had significantly opposite result. A negative Böhler's or calcaneal compression angle was related with unfavourable outcomes. Sanders classification was not related with any patient-reported outcome. CONCLUSION: Our study implies that patients with an intra-articular calcaneal fracture into the talar surface have a lower health-related quality of life, will be less satisfied with the outcome of their feet, and have more complications compared to patients with other type of calcaneal fractures. Furthermore, the Sanders classification was not associated with the patient-reported outcomes.

Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible?

INTRODUCTION: In an optimal trauma system, prehospital trauma triage ensures transport of the right patient to the right hospital. Incorrect triage results in undertriage and overtriage. The aim of this systematic review is to evaluate and compare prehospital trauma triage system quality worldwide and determine effectiveness in terms of undertriage and overtriage for trauma patients. METHODS: A systematic search of Pubmed/MEDLINE, Embase, and Cochrane Library databases was performed, using "trauma", "trauma center," or "trauma system", combined with "triage", "undertriage," or "overtriage", as search terms. All studies describing ground transport and actual destination hospital of patients with and without severe injuries, using prehospital triage, published before November 2017, were eligible for inclusion. To assess the quality of these studies, a critical appraisal tool was developed. RESULTS: A total of 33 articles were included. The percentage of undertriage ranged from 1% to 68%; overtriage from 5% to 99%. Older age and increased geographical distance were associated with undertriage. Mortality was lower for severely injured patients transferred to a higher-level trauma center. The majority of the included studies were of poor methodological quality. The studies of good quality showed poor performance of the triage protocol, but additional value of EMS provider judgment in the identification of severely injured patients. CONCLUSION: In most of the evaluated trauma systems, a substantial part of the severely injured patients is not transported to the appropriate level trauma center. Future research should come up with new innovative ways to improve the quality of prehospital triage in trauma patients.

Accuracy of prehospital triage protocols in selecting severely injured patients: A systematic review.

BACKGROUND: Prehospital trauma triage ensures proper transport of patients at risk of severe injury to hospitals with an appropriate corresponding level of trauma care. Incorrect triage results in undertriage and overtriage. The American College of Surgeons Committee on Trauma recommends an undertriage rate below 5% and an overtriage rate below 50% for prehospital trauma triage protocols. To find the most accurate prehospital trauma triage protocol, a clear overview of all currently available protocols and corresponding outcomes is necessary. OBJECTIVES: The aim of this systematic review was to evaluate the current literature on all available prehospital trauma triage protocols and determine accuracy of protocol-based triage quality in terms of sensitivity and specificity. METHODS: A search of Pubmed, Embase, and Cochrane Library databases was performed to identify all studies describing prehospital trauma triage protocols before November 2016. The search terms included "trauma," "trauma center," or "trauma system" combined with "triage," "undertriage," or "overtriage." All studies describing protocol-based triage quality were reviewed. To assess the quality of these type of studies, a new critical appraisal tool was developed. RESULTS: In this review, 21 articles were included with numbers of patients ranging from 130 to over 1 million. Significant predictors for severe injury were: vital signs, suspicion of certain anatomic injuries, mechanism of injury, and age. Sensitivity ranged from 10% to 100%; specificity from 9% to 100%. Nearly all protocols had a low sensitivity, thereby failing to identify severely injured patients. Additionally, the critical appraisal showed poor quality of the majority of included studies. CONCLUSION: This systematic review shows that nearly all protocols are incapable of identifying severely injured patients. Future studies of high methodological quality should be performed to improve prehospital trauma triage protocols. LEVEL OF EVIDENCE: Systematic review, level III.

Grade of dysplasia and malignant transformation in adults with premalignant laryngeal lesions.

BACKGROUND: The purpose of this systematic review was to determine the significance of the grade of dysplasia in the development of invasive carcinoma. METHODS: A systematic search was performed to identify all relevant evidence. Titles and abstracts were screened using predefined criteria. Remaining articles were critically appraised. Absolute risks and 95% confidence intervals (CIs) were calculated. RESULTS: Seven articles were included. Four studies demonstrated an increased risk for the development of laryngeal carcinoma from mild, moderate, and severe dysplasia. Three studies showed an increased risk between the categories of mild and moderate dysplasia. CONCLUSION: The risk of malignant transformation seems to increase with the grade of dysplasia, although percentages between studies are highly dissimilar. The wide variety and overlapping 95% CIs make it difficult to formulate a strong recommendation. However, moderate dysplasia is more prone for malignant transformation than previously thought, which might influence follow-up and treatment decisions in the future. © 2015 Wiley Periodicals, Head Neck 38: E2284-E2290, 2016.

Demographic Patterns and Outcomes of Patients in Level I Trauma Centers in Three International Trauma Systems.

INTRODUCTION: Trauma systems were developed to improve the care for the injured. The designation and elements comprising these systems vary across countries. In this study, we have compared the demographic patterns and patient outcomes of Level I trauma centers in three international trauma systems. METHODS: International multicenter prospective trauma registry-based study, performed in the University Medical Center Utrecht (UMCU), Utrecht, the Netherlands, John Hunter Hospital (JHH), Newcastle, Australia, and Harborview Medical Center (HMC), Seattle, the United States. INCLUSION: patients ≥18 years, admitted in 2012, registered in the institutional trauma registry. RESULTS: In UMCU, JHH, and HMC, respectively, 955, 1146, and 4049 patients met the inclusion criteria of which 300, 412, and 1375 patients with Injury Severity Score (ISS) > 15. Mean ISS was higher in JHH (13.5; p < 0.001) and HMC (13.4; p < 0.001) compared to UMCU (11.7). Unadjusted mortality: UMCU = 6.5 %, JHH = 3.6 %, and HMC = 4.8 %. Adjusted odds of death: JHH = 0.498 [95 % confidence interval (CI) 0.303-0.818] and HMC = 0.473 (95 % CI 0.325-0.690) compared to UMCU. HMC compared to JHH was 1.002 (95 % CI 0.664-1.514). Odds of death patients ISS > 15: JHH = 0.507 (95 % CI 0.300-0.857) and HMC = 0.451 (95 % CI 0.297-0.683) compared to UMCU. HMC = 0.931 (95 % CI 0.608-1.425) compared to JHH. TRISS analysis: UMCU: Ws = 0.787, Z = 1.31, M = 0.87; JHH, Ws = 3.583, Z = 6.7, M = 0.89; HMC, Ws = 3.902, Z = 14.6, M = 0.84. CONCLUSION: This study demonstrated substantial differences across centers in patient characteristics and mortality, mainly of neurological cause. Future research must investigate whether the outcome differences remain with nonfatal and long-term outcomes. Furthermore, we must focus on the development of a more valid method to compare systems.

Applicability of the predictors of the historical trauma score in the present Dutch trauma population: modelling the TRISS predictors.

BACKGROUND: The extensively used trauma scores to evaluate trauma center performances have been derived decades ago. This leaves its applicability in the current trauma population a subject of discussion.In this study, we evaluate the applicability of the current trauma scores in today's trauma population. METHODS: This study was performed in the central trauma region (Utrecht) of the Netherlands. Data from all admitted trauma patients were collected and split according to trauma mechanism, that is, blunt or penetrating trauma. The number of events in the penetrating trauma population was too small to derive or validate a model. We have validated the original predictors and their coefficients (i.e., Revised Trauma Score [RTS], Injury Severity Score [ISS] and age index) in a regional trauma population and derived a new model in a Level I trauma population. The model was checked for its quality and internally validated using bootstrapping methods. RESULTS: Regional data set included 10,235 patients, 9,903 (96.8%) of whom with blunt and 332 (3.2%) with penetrating trauma. Level I data set included 4,649 patients, of whom 4,373 (94.1%) with blunt and 276 (5.9%) with penetrating trauma. In the regional data set, the external validation showed an R of 0.293, a good fit (p = 0.168), and an area under the curve of 0.851. The new model in the Level I data set resulted in Glasgow Coma Scale (GCS) score, ISS, age index, and systolic blood pressure (SBP) in the model (R = 0.516; a good fit test, p = 0.104; and AUC, 0.939). The Wald test of the SBP in this model was 6.46. CONCLUSION: We conclude that the current trauma predictors are applicable in a regional mixed trauma population, but not in a Level I trauma population. The physiologic parameters, SBP and RR, must be excluded from the current model, and new coefficients should be calculated to maintain accurate predictions in a Level I trauma population. LEVEL OF EVIDENCE: Prognostic study, level III.

Operative or conservative treatment in patients with Rockwood type III acromioclavicular dislocation: a systematic review and update of current literature.

PURPOSE: Despite previous studies the management of Rockwood type III acromioclavicular (AC) dislocations remains controversial and the debate continues about whether patients with Rockwood type III AC injuries should be treated conservatively or operatively. In this study, we will review the current literature and present an overview of the outcome of conservative versus operative treatment of Rockwood type III dislocations. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was used to conduct this review. A systematic search was performed in the Pubmed, Cochrane library, Embase, Scopus and Cumulative Index to Nursing and Allied Health Literature databases. Titles and abstracts were screened using predefined criteria and articles were critically appraised on relevance and validity. RESULTS: After critical appraisal eight articles were included in the study. The objective and subjective shoulder function outcome was better in the operative group, especially in young adults, though the rate of complications and radiographic abnormalities were higher. The rehabilitation time was shorter in the conservative group, however the cosmetic outcome was worse. CONCLUSIONS: This review showed no conclusive evidence for the treatment of Rockwood type III AC dislocations. Overall, physically active young adults seem to have a slight advantage in outcome when treated operatively.

Evaluation of trauma care in a mature level I trauma center in the Netherlands: outcomes in a Dutch mature level I trauma center.

BACKGROUND: Trauma centers are associated with improved survival rates and outcomes in trauma patients. In 2000 our hospital officially became a level I trauma center. The implementation of the trauma center model showed a significant reduction in mortality and hospital length of stay in our hospital and throughout the trauma region. The aim of the present prospective database study was to present the outcomes of patients treated during the course of further maturation of a level I trauma center. METHODS: We performed the prospective database study and included and analyzed outcome data for all adult trauma patients admitted to our trauma center during the years 2003 through 2006 (period 1) and 2007 through 2010 (period 2). RESULTS: A total of 5,299 patients were included; 2,419 in period 1 and 2,880 in period 2. Mean Injury Severity Score (ISS) increased from 12.6 to 13.8 (p < 0.001). Mean Revised Trauma Score decreased from 7.4 to 7.2 (p < 0.001). Penetrating injuries increased from 111 (4.6 %) to 192 (6.7 %) (p < 0.001). More head injuries (+7.2 %) and spine injuries (+3.1 %), and fewer injuries to extremities (-6.5 %) were seen in the second period. Mortality, adjusted for age and ISS, was lower in period 2 (odds ratio [OR]: 0.736, p = 0.010). Adjusted for age, ISS, and survival, both the hospital stay and the intensive care unit stay were shortened (OR: 1.068, p < 0.018; OR: 1.188, p = 0.007). Mean probability of survival was significantly higher in the second period. Moreover, more unexpected survivors were seen in the second period (Z-score of 3.4 and W-value of 1.46). CONCLUSIONS: Maturation of the trauma center and the trauma system resulted in improved patient outcomes. A significant increase in unexpected survivors was noted, and shorter hospital stay and ICU stay were achieved. Of note, population-based studies on trauma system and trauma center performance with statistical analysis by logistic regression are considered strong class III evidence.

Circulating CD95-ligand as a potential prognostic marker for recurrence in patients with synchronous colorectal liver metastases.

AIM: To assess whether circulating soluble CD95 ligand (sCD95L) levels are associated with recurrence-free survival (RFS) in patients with synchronous colorectal liver metastases. PATIENTS AND METHODS: Blood samples were obtained from 62 patients with synchronous colorectal liver metastases before and after liver surgery. Serum sCD95L levels were determined using enzyme-linked immunosorbent assay (ELISA). Cox regression analysis was performed to determine the correlation between sCD95L levels and RFS and overall survival (OS). RESULTS: Median follow-up was 33 months. High pre-operative sCD95L levels were associated with poor RFS and OS in univariable (p=0.019 and p=0.020) and multivariable analyses (p=0.020 and p=0.003). CONCLUSION: Preoperatives CD95L is a potential prognostic factor for RFS and OS of patients undergoing surgery for synchronous colorectal liver metastases. Low preoperatives CD95L levels may help identify a subgroup of patients with synchronous liver metastases that are likely to benefit from liver surgery.