Trajectory of functional outcome and health status after moderate-to-major trauma in Hong Kong: A prospective 5 year cohort study.

BACKGROUND: Trauma care systems in Asia have been developing in recent years, but there has been little long-term outcome data from injured survivors. This study aims to evaluate the trajectory of functional outcome and health status up to five years after moderate to major trauma in Hong Kong. METHODS: We report the five year follow up results of a multicentre, prospective cohort from the trauma registries of three regional trauma centres in Hong Kong. The original cohort recruited 400 adult trauma patients with ISS ≥ 9. Telephone follow up was conducted longitudinally at seven time points, and the extended Glasgow Outcome Scale (GOSE) and Short-Form 36 (SF36) were tracked. RESULTS: 119 out of 309 surviving patients (39%) completed follow up after 5 years. The trajectory of GOSE, PCS and MCS showed gradual improvements over the seven time points. 56/119 (47.1%) patients reported a GOSE = 8 (upper good recovery), and the mean PCS and MCS was 47.8 (95% CI 45.8, 49.9) and 55.8 (95% CI 54.1, 57.5) respectively at five years. Univariate logistic regression showed change in PCS - baseline to 1 year and 1 year to 2 years, and change in MCS - baseline to 1 year were associated with GOSE = 8 at 5 years. Linear mixed effects model showed differences in PCS and MCS were greatest between 1-month and 6-month follow up. CONCLUSIONS: After injury, the most rapid improvement in PCS and MCS occurred in the first six to 12 months, but further recovery was still evident for MCS in patients aged under 65 years for up to five years.

Assessment of quality of life and functional outcome in patients sustaining moderate and major trauma: a multicentre, prospective cohort study.

BACKGROUND: Trauma care systems aim to reduce both death and disability, yet there is little data on post-trauma health status and functional outcome. OBJECTIVES: To evaluate baseline, discharge, six month and 12 month post-trauma quality of life, functional outcome and predictors of quality of life in Hong Kong. METHODS: Multicentre, prospective cohort study using data from the trauma registries of three regional trauma centres in Hong Kong. Trauma patients with an ISS≥9 and aged≥18 years were included. The main outcome measures were the physical component summary (PCS) score and mental component summary (MCS) scores of the Short-Form 36 (SF36) for health status, and the extended Glasgow Outcome Scale (GOSE) for functional outcome. RESULTS: Between 1 January 2010 and 31 September 2010, 400 patients (mean age 53.3 years; range 18-106; 69.5% male) were recruited to the study. There were no statistically significant differences in baseline characteristics between responders (N=177) and surviving non-responders (N=163). However, there were significant differences between these groups and the group of patients who died (N=60). Only 16/400 (4%) cases reported a GOSE≥7. 62/400 (15.5%) responders reached the HK population norm for PCS. 125/400 (31%) responders reached the HK population norm for MCS. If non-responders had similar outcomes to responders, then the percentages for GOSE≥7 would rise from 4% to 8%, for PCS from 15.5% to 30%, and for MCS from 31% to 60%. Univariate analysis showed that 12-month poor quality of life was significantly associated with age>65 years (OR 4.77), male gender (OR 0.44), pre-injury health problems (OR 2.30), admission to ICU (OR 2.15), ISS score 26-40 (OR 3.72), baseline PCS (OR 0.89), one-month PCS (OR 0.89), one-month MCS (OR 0.97), 6-month PCS (OR 0.76) and 6-month MCS (OR 0.97). CONCLUSION: For patients sustaining moderate or major trauma in Hong Kong at 12 months after injury<1 in 10 patients had an excellent recovery, ≤3 in 10 reached a physical health status score≥Hong Kong norm, although as many as 6 in 10 patients had a mental health status score which is≥Hong Kong norm.

Simulation of survivorship bias in observational studies on plasma to red blood cell ratios in massive transfusion for trauma.

BACKGROUND: Observational studies on injured patients requiring massive transfusion have found a survival advantage associated with use of equivalent number of units of fresh frozen plasma (FFP) and packed red blood cells (RBCs) compared with use of FFP based on conventional guidelines. However, a survivorship bias might have favoured the higher use of FFP because patients who died early never had the chance to receive sufficient FFP to match the number of RBC units transfused. METHODS: A Markov model using trauma data from local hospitals was constructed and various FFP transfusion scenarios were applied in Monte Carlo simulations in which the relative risk of death associated with exposure to high FFP transfusion was set at 1.00, so that the FFP : RBC ratio had no influence on mortality outcome. RESULTS: Simulation results showed that the relative risk associated with exposure to high FFP transfusion was less than 1.00 (0.33-0.56 based on programmed delays in achieving an FFP : RBC ratio of 1 : 1-2), thus demonstrating a survivorship bias in favour of FFP : RBC equal to or more than 1 : 1-2 in certain observational trauma studies. This bias was directly proportional to the delay in achieving a FFP : RBC ratio of 1 : 1-2 during resuscitation. CONCLUSION: Some observational studies comparing low and high FFP administration in injured patients requiring massive transfusion probably involve survivorship bias that inflates or creates a survival advantage in favour of a higher FFP : RBC ratio.

Functional outcome after head injury: comparison of 12-45 year old male and female hormonally active patients.

OBJECTIVES: Head injury is the leading cause of death in patients with major trauma, but little is known of post-trauma rehabilitation morbidity in Hong Kong. The purpose of this study was to identify factors affecting functional outcome in hormonally active patients 6 months after head injury. METHODS: Secondary analysis of the trauma registry database with data collected prospectively at two trauma centres between January 2001 and December 2007. Demographic and trauma data for patients aged 12-45 years with a head Abbreviated Injury Score ≥3 were analysed. The Glasgow outcome scale (GOS) was used for assessment and was assessed 6 months after head injury. The primary outcome measure was a composite poor outcome, namely "dead, vegetative and severely disabled" measured using the GOS. RESULTS: Of 698 patients included in the study (mean age 29 years; range 12-45 years; 75.8% male), 581 (83.2%) had a good outcome, and 117 (16.8%) met the primary outcome measure, namely a poor outcome, including 88 (12.6%) patients who died. 453 (64.9%) patients had an injury severity score (ISS) of 16-40, and 102 (14.6%) patients had an ISS>40. 220 (31.5%) patients underwent head injury related operation. The mean length of stay in the intensive care unit (ICU) was 3.9 days. Univariate analysis showed that high ISS, Emergency Department (ED) systolic blood pressure (SBP)>160mmHg or <90mmHg, respiratory rate<12/min or >24/min, low ED Glasgow Coma Score (GCS), trauma call activation, head related operation and ICU admission were related to poor outcome. Multivariate analysis showed that high ISS, low or high ED SBP and low ED GCS were related to poor functional outcome. CONCLUSION: This study showed that ISS, ED SBP and ED GCS were related to poor functional outcome. Gender showed no statistically significant relationship with functional outcome.

Traumatic intracerebral haemorrhage: is the CT pattern related to outcome?

It is believed by many neurosurgeons that in addition to age and neurological status, the CT patterns of traumatic intracerebral haemorrhages are related to outcome. The aim of this study was to find out whether this is the case. The study was conducted in a regional level I trauma centre in Hong Kong. We prospectively collected data of patients with traumatic intracerebral haematomas over a 4-year period. Of 464 patients with head injuries, traumatic intracerebral haematoma was significantly associated with inpatient mortality and one year unfavorable outcome after adjustment for age, sex, post-resuscitation GCS, and presence of acute subdural haematoma. One hundred-and-fourteen patients had traumatic intracerebral haematomas and were included for further analysis. The mean age was 49, the male to female ratio was 2 to 1, and the median Glasgow Coma Scale (GCS) score on admission was 12. Logistic regression analysis showed that age and GCS score/GCS motor component score were significant factors for inpatient mortality, one-year mortality and one-year outcome. There was an association between temporal haematomas and inpatient mortality, subdural haematomas and inpatient mortality, and bilateral haematomas and unfavourable one-year outcome. In patients with severe head injury, a traumatic haematoma of more than 50 ml was associated higher inpatient mortality. In addition to age and GCS score, the CT patterns of bilateral haematomas, temporal haematomas and associated subdural haematomas were suggestive of poor outcome or mortality.

Bicycle related injuries presenting to a trauma centre in Hong Kong.

BACKGROUND: Bicycle riding is a popular leisure activity and an important means of transportation in Hong Kong. Young cyclists' riding behaviour causes injury patterns which may differ from older riders. The aim of this study is firstly to describe bicycle related injuries presenting to a regional trauma centre in Hong Kong, and secondly to compare patients aged > 15 years with those patients aged < or = 15 years. METHODS: This retrospective observational study examined all bicycle related injury patients presenting to the ED of the Prince of Wales Hospital (PWH) in 2006. RESULTS: Results showed that bicycle helmet use was low in Hong Kong suggesting that the wearing of helmets when cycling should be promoted. Bicycle related injuries were common in children but the injuries in adults were more serious. Head and limb injuries were common and limbs on the left side were 2.5 times more likely to be injured than those on the right. The older group were more likely to be involved in a motor vehicle collision and sustained more severe injuries than the younger group. They had more serious head and neck, face, thorax and abdominal injuries compared to the younger group. CONCLUSION: Prevention strategies should include more widespread helmet use and increasing bicycle lane provision to enable traffic separation in Hong Kong. The three 'E' approaches (education, enforcement and environment) should be implemented to prevent bicycle injuries in Hong Kong.