Accuracy and reliability of injury coding in the national Dutch Trauma Registry.

OBJECTIVE: Injury coding is well known for lack of completeness and accuracy. The objective of this study was to perform a nationwide assessment of accuracy and reliability on Abbreviated Injury Scale (AIS) coding by Dutch Trauma Registry (DTR) coders and to determine the effect on Injury Severity Score (ISS). Additionally, the coders' characteristics were surveyed. METHODS: Three fictional trauma cases were presented to all Dutch trauma coders in a nationwide survey (response rate 69%). The coders were asked to extract and code the cases' injuries according to the AIS manual (version 2005, update 2008). Reference standard was set by three highly experienced coders. Summary statistics were used to describe the registered AIS codes and ISS distribution. The primary outcome measures were accuracy of injury coding and inter-rater agreement on AIS codes. Secondary outcome measures were characteristics of coders: profession, work setting, experience in injury coding and training level in injury coding. RESULTS: The total number of different AIS codes used to describe 14 separate injuries in the three cases was 89. Mean accuracy per AIS code was 42.2% (range 2.4-92.7%). Mean accuracy on number of AIS codes was 23%. Overall inter-rater agreement per AIS code was 49.1% (range 2.4-92.7%). The number of assigned AIS codes varied between 0 and 18 per injury. Twenty-seven percentage of injuries were overlooked. ISS was correctly scored in 42.4%. In 31.7%, the AIS coding of the two more complex cases led to incorrect classification of the patient as ISS < 16 or ISS ≥ 16. Half (47%) of the coders had no (para)medical degree, 26% were working in level I trauma centers, 37% had less than 2 years of experience and 40% had no training in AIS coding. CONCLUSIONS: Accuracy of and inter-rater agreement on AIS injury scoring by DTR coders is limited. This may in part be due to the heterogeneous backgrounds and training levels of the coders. As a result of the inconsistent coding, the number of major trauma patients in the DTR may be over- or underestimated. Conclusions based on DTR data should therefore be drawn with caution.

The utility of peritoneal drains in patients with perforated appendicitis.

BACKGROUND: Intra-abdominal abscesses are the most common complication after perforated appendicitis and remain a significant problem ranging in incidence from 14 to 18%. Drainage following appendectomy is usually determined by whether the underlying appendicitis is simple or complicated and largely determined by the surgeons' belief, based on expertise or personal opinion. In this report we discuss the results of patients diagnosed with peritoneal drainage, treated with or without a peritoneal drain. PATIENTS AND METHODS: A retrospective study of patients diagnosed with perforated appendicitis having surgery was performed. Patients diagnosed with perforated appendicitis treated with a peritoneal drain and patients treated without a peritoneal drain. Both groups were evaluated in terms of complications: intra-abdominal abscess, re-intervention, readmission and duration of hospital stay. RESULTS: 199 patients diagnosed with perforated appendicitis underwent appendectomy. 120 patients were treated without a peritoneal drain and 79 patients with a peritoneal drain. Thirty-one (26%) patients from the group without a peritoneal drain had a re-intervention compared to 9 (11%) in the group with a peritoneal drain (p = 0.013). Overall complications and readmission were also significantly lower in patients treated with a peritoneal drain. CONCLUSION: A peritoneal drain seems to reduce overall complication rate, re-intervention rate and readmission rate in patients treated with perforated appendicitis.

[Coincidental finding in a man with a painful knee]. / Toevalsbevinding bij een man met een pijnlijke knie.

A 40-year-old man presented to the emergency department with a painful right knee. Conventional radiography and a CT-scan coincidentally found an asymptomatic intraosseous ganglion. The patient was treated conservatively, with success. Intraosseous ganglia are benign lesions of the metaphyseal area of the long bones. Treatment of asymptomatic lesions is not necessarily unless cortical bone is involved.

[Acquired haemophilia A: a rare but life-threatening auto-immune disorder]. / Verworven hemofilie A: een zeldzame maar levensbedreigende auto-immuunziekte.

A 31-year-old woman who was 5 months post partum, was presented to the Accident and Emergency Department because of acute abdominal pain and hypovolemic shock after being kicked in the stomach 3 days previously. She had a severe haemorrhage and a rupture of the liver. Attempts to selectively embolise the branches of the right hepatic artery failed and two laparotomies were performed. Analysis of the cause of the persistent liver bleeding and the prolonged APTT upon admission revealed the diagnosis acquired haemophilia A. The patient was treated with recombinant factor VIIa and a high dosage of corticosteroids. She made a good recovery after the corticosteroids had been replaced by rituximab.

C-reactive protein in peripheral arterial disease: relation to severity of the disease and to future cardiovascular events.

BACKGROUND: Serum C-reactive protein (CRP) has proven to be an independent marker of the extent of atherosclerosis in patients with coronary, cerebrovascular, and peripheral arterial disease. In this prospective observational study, we wanted to assess the relationship between serum CRP and extent of disease transversely and longitudinally in time, as well as future cardiovascular complications in patients with peripheral arterial disease (PAD). Hypothesizing that CRP not only is a marker of but also actively participates in atherogenesis, we explored the possibility of CRP production by femoral atherosclerotic plaques. METHODS: Serum CRP was measured as highly sensitive (hsCRP) in 387 patients with PAD attending the vascular clinic of a university and 2 affiliated teaching hospitals. Serum hsCRP was related to the ankle-brachial pressure index (ABPI) as an indication of severity of disease at inclusion and at 12 months' follow-up and to future events (death and coronary, cerebral, and peripheral arterial events). In femoral plaques, the production of CRP was analyzed with reverse transcription-polymerase chain reaction, and CRP plaque localization was assessed with immunostaining on serial tissue sections with antibodies toward CRP, smooth muscle cells, T cells, and macrophages. RESULTS: The hsCRP (average +/- SD) was 3.26 +/- 2.41 mg/L. Serum hsCRP showed a correlation with baseline and 12-month follow-up ABPI (Spearman rank correlation; P < .05 for both correlations). When the patients were divided into three equally sized groups according to baseline serum hsCRP, the ABPI at baseline and at 12 months decreased significantly from the low- to the high-hsCRP group (baseline ABPI: 0.70, 0.65, and 0.57, P < .01; 12-month follow-up ABPI: 0.78, 0.70, and 0.65, P < .01). These associations persisted after correction for conventional risk factors. Furthermore, serum hsCRP was related to the combined end point "death and/or any cardiovascular event" (log-rank test; P = .04) during a median 24-month follow-up period. Reverse transcription-polymerase chain reaction analysis showed CRP production in 4 of 14 femoral plaques. CRP was detected in all femoral plaques, but not in healthy brachial arteries. Immunoreactivity for CRP was observed in smooth muscle cells, macrophages, and T cells. CONCLUSIONS: Serum hsCRP was related to the severity of PAD, showing a relation to future hemodynamic function and cardiovascular events in PAD patients. In addition to coronary plaques, aneurysmal aortas, and failed venous coronary bypasses, femoral plaques also produce CRP, thus illustrating that the production of CRP may represent a universal response to vascular injury and suggesting that vascular CRP may contribute to plaque development.