[Bilateral thoracic trauma-"double the trouble"?] / Beidseitiges Thoraxtrauma ­ "double the trouble"?

BACKGROUND: Thoracic trauma is associated with a high morbidity and mortality. Assessing the risk for complications is essential for planning the further treatment strategies and managing resources in thoracic trauma. OBJECTIVE: The aim of the study was to analyze concomitant injuries in unilateral and bilateral rib fractures and pulmonary contusions and evaluate differences in complication rates between the two. MATERIAL AND METHODS: In a retrospective study, data from all patients diagnosed with thoracic trauma at a level I trauma center were analyzed. Bivariate and multivariate analysis were used to examine an association of unilateral or bilateral rib fractures, serial rib fractures, and pulmonary contusions with multiple injuries and outcomes. In addition, multivariate regression analysis was utilized to determine the impact of age, gender and additional injuries on outcome. RESULTS: A total of 714 patients were included in the analysis. The mean Injury Severity Score (ISS) was 19. Patients with an additional thoracic spine injury had a significantly higher incidence of bilateral rib fractures. Pulmonary contusions were associated with younger age. Abdominal injuries were predictors for bilateral pulmonary contusions. Complications occurred in 36% of the patients. Bilateral injuries increased the complication rate up to 70%. Pelvic and abdominal injuries as well as the need for a chest drain were significant risk factors for complications. The mortality rate was 10%, with higher age, head and pelvic injuries as predictors. CONCLUSION: Patients with bilateral chest trauma had an increased incidence of complications and a higher mortality rate. Bilateral injuries and significant risk factors must therefore be considered. Injury of the thoracic spine should be excluded in those patients.

Does the type of anesthesia (regional vs. general) represent an independent predictor for in-hospital complications in operatively treated malleolar fractures? A retrospective analysis of 5262 patients.

PURPOSE: The impact of the type of anesthesia (regional vs. general anesthesia) on in-hospital complications in ankle fractures has not been thoroughly studied yet. Identifying factors that place patients at risk for complications following ankle fractures may help reduce their occurrence. The primary goal of this study was (1) to describe the cohort of patients and (2) to evaluate independent risk factors for complications during hospitalization. METHODS: We analyzed patients from 2005 to 2019 with an operatively treated isolated fracture of the medial or lateral malleolus using a prospective national quality measurement database. Patients were selected based on international classifications (ICD) and national procedural codes (CHOP). Uni- and multivariate analysis were applied. RESULTS: In total, we analyzed 5262 patients who suffered a fracture of the malleolus; 3003 patients (57%) had regional and 2259 (43%) general anesthesia. Patients with regional anesthesia were significantly older (51 vs. 46 years), but healthier (23 vs. 28% comorbidities) than patients who received general anesthesia. The in-hospital complication rate was not significantly lower in regional anesthesia (2.2% vs 3.0%). The type of anesthesia was not an independent predictor for complications while controlling for confounders. CONCLUSION: Type of anesthesia was not an independent predictor of complications; however, higher ASA class, age over 70 years, fracture of the medial versus lateral malleolus, longer preoperative stay, and duration of surgery were significant predictors of complications. Patient and procedure characteristics, as well as changes in medical care and epidemiological changes along with patient requests, influenced the choice of the type of anesthesia.

Cobalt intoxication: mitochondrial features and condition.

Cobalt intoxication is a rare complication of joint arthroplasty with a metal-on-metal prothesis or metal implants after broken ceramic implants. Patients with metal components should be monitored closely for complications. The awareness for the wide range of clinical pictures of this cobalt intoxication should be increased. We here describe the clinical presentation, diagnostic and therapeutic work-up of a 70-year-old patient with a cobalt metallosis. The patient presented with a progressive deterioration of vision and hearing, axonal sensorimotor polyneuropathy and cataract. The extensive work-up resulted in the diagnosis of a cobalt metallosis as a complication of a metal hip prosthesis. Cobalt intoxication, especially after metal-on-metal total joint arthroplasty, is a rare complication; however, there have been several reports of similar cases. It is therefore recommended to avoid the implantation of a metal-on-metal prothesis or metal implants after broken ceramic implants as in this case whenever possible. Patients with exclusively metal components should be monitored closely for complications.

Impact of the first COVID-19 shutdown on traumatological patient volumes in Switzerland.

Background: The coronavirus has caused a worldwide pandemic with serious impacts on our healthcare systems. Many countries experienced a decline in traumatological patient volume. The aim of this study is to evaluate the impact of the first lockdown on traumatological patient volume in Switzerland. Methods: We retrospectively used a prospective national quality measurement database. We compared the period of the first lockdown in Switzerland from March 17 to April 26, 2020 to the same period in the years 2018 and 2019. Included were all adult patients with any S-code (trauma) according to the International Classification of Diseases. Results: In total, we assessed 3874 patients (1779 in the year 2018, 1303 in the year 2019, and 792 in the year 2020) with a mean age of 61 ± 21 years. The patients during the lockdown period had significantly more injuries to the hip and forearm, had more comorbidities, and were more likely to have statutory insurance. During the lockdown period, more thromboembolism prophylaxis or anticoagulation was applied, and more patients needed antibiotic treatment. Conclusions: The present study demonstrated a 40-55% reduction in patient volume during the lockdown period in Switzerland compared to the previous years. The in-hospital mortality and complication rate during the lockdown period remained stable. This study suggests that in-hospital care for trauma patients in Switzerland was not substantially affected by the first lockdown.

Incidence, impact and risk factors for multidrug-resistant organisms (MDRO) in patients with major trauma: a European Multicenter Cohort Study.

INTRODUCTION: The burden of MDRO in health systems is a global issue, and a growing problem. We conducted a European multicenter cohort study to assess the incidence, impact and risk factors for multidrug-resistant organisms in patients with major trauma. We conducted this study because the predictive factors and effects of MDRO in severely injured patients are not yet described. Our hypothesis is that positive detection of MDRO in severely injured patients is associated with a less favorable outcome. METHODS: Retrospective study of four level-1 trauma centers including all patients after major trauma with an injury severity score (ISS) ≥ 9 admitted to an intensive care unit (ICU) between 2013 and 2017. Outcome was measured using the Glasgow outcome scale (GOS). RESULTS: Of 4131 included patients, 95 (2.3%) had a positive screening for MDRO. Risk factors for MDRO were male gender (OR 1.73 [95% CI 1.04-2.89]), ISS (OR 1.01 [95% CI 1.00-1.03]), PRBC's given (OR 1.73 [95% CI 1.09-2.78]), ICU stay > 48 h (OR 4.01 [95% CI 2.06-7.81]) and mechanical ventilation (OR 1.85 [95% CI 1.01-3.38]). A positive MDRO infection correlates with worse outcome. MDRO positive cases GOS: good recovery = 0.6%, moderate disability = 2.1%, severe disability = 5.6%, vegetative state = 5.7% (p < 0.001). CONCLUSIONS: MDRO in severely injured patients are rare but associated with a worse outcome at hospital discharge. We identified potential risk factors for MDRO in severely injured patients. Based on our results, we recommend a standardized screening procedure for major trauma patients.

Short-term outcome of isolated lateral malleolar fracture treatment is independent of hospital trauma volume or teaching status: a nationwide retrospective cohort study.

INTRODUCTION: In light of current discussions about centralisation and teaching in medicine, we wanted to investigate the differences in in-hospital outcomes after surgical treatment of isolated ankle fractures, taking into account high-volume centres (HVCs) and low-volume centres (LVCs) and teaching procedures. METHODS: A retrospective analysis of malleolar fractures recorded in a National Quality Assurance Database (AQC) from the period 01-01-1998 to 31-12-2018 was carried out. Inclusion criteria were isolated, and operatively treated lateral malleolar fractures (ICD-10 Code S82.6 and corresponding procedure codes). Variables were sought in bivariate and multivariate analyses. A total of 6760 cases were included. By dividing the total cases arbitrarily in half, 12 HVCs (n = 3327, 49%) and 56 LVCs (n = 3433, 51%) were identified. RESULTS: Patients in HVCs were younger (48 vs. 50 years old), had more comorbidities (26% vs. 19%) and had more open fractures (0.48% vs. 0.15%). Open reduction and internal fixation was the most common operative treatment at HVCs and LVCs (95% vs. 98%). A more frequent use of external fixation (2.5% vs. 0.55%) was reported at HVCs. There was no difference in mortality between treatment at HVCs and LVCs. A longer hospitalisation of 7.2 ± 5 days at HVCs vs. 6.3 ± 4.8 days at LVCs was observed. In addition, a higher rate of complications of 3.2% was found at HVCs compared to 1.9% at LVCs. The frequency of teaching operations was significantly higher at HVCs (30% vs. 26%). Teaching status had no influence on mortality or complications but was associated with a prolonged length of stay and operating time. CONCLUSION: We found significant differences between HVCs and LVCs in terms of in-hospital outcomes for ankle fractures. These differences could be explained due to a more severely ill patient population and more complex (also open) fracture patterns with resulting use of external fixation and longer duration of surgery. However, structural and organisational differences, such as an extended preoperative stays at HVCs and a higher teaching rate, were also apparent. No difference in mortality could be detected.

Does the insurance status influence in-hospital outcome? A retrospective assessment in 30,175 surgical trauma patients in Switzerland.

INTRODUCTION: There has been growing evidence in trauma literature that differences in insurance status lead to inequality in treatment and outcome. Most studies comparing uninsured to insured patients were done in the USA. We sought to gain further insights into differences in the outcomes of trauma patients in a healthcare system with mandatory public health coverage by comparing publicly versus privately insured patients. METHODS: We used a prospective national quality assessment database from the Arbeitsgemeinschaft für Qualitätssicherung in der Chirurgie (AQC). More than 80 surgical departments in Switzerland are part of this quality program. We included all patients in the AQC database with any S- or T-code diagnosis according to the International Classification of Diseases ICD-10 (any injuries) who were treated during the 11-year period of 2004-2014. Missing insurance status information was an exclusion criterion. In total, 30,175 patients were included for analysis. The primary outcome was in-hospital mortality. Secondary outcomes included overall and intra- and postoperative complications. Bi- and multivariate analyses were performed, adjusted for insurance status, age, sex, American Society of Anesthesiologists (ASA) physical status category, type of injury, and surgeon's level of experience. RESULTS: In total, 76.8% (n = 23,196) of the patients were publicly insured. Patients with public insurance were significantly younger (p < 0.001), more often male (p < 0.001), and in better general health according to the ASA physical status category (p < 0.001). Length of pre- and postoperative stay and the number of operations per case were similar in the two groups. Patients with public insurance had a lower mortality rate (1.3% vs. 1.9%, p < 0.001), but after adjusting for confounders, insurance status was not a predictor of mortality. Overall complication rates were significantly higher for publicly insured patients (8.4% vs. 6.2%, p < 0.001), and after adjusting for confounders, insurance status was identified as an independent risk factor for overall complications (p < 0.001). CONCLUSION: Differences exist with respect to patient and procedural characteristics: publicly insured patients were younger, more often male, and scored better on ASA physical status. Insurance status seems not to be a predictor for fatal outcome after trauma, although it is associated with complications.

The GERtality Score: The Development of a Simple Tool to Help Predict in-Hospital Mortality in Geriatric Trauma Patients.

Feasible and predictive scoring systems for severely injured geriatric patients are lacking. Therefore, the aim of this study was to develop a scoring system for the prediction of in-hospital mortality in severely injured geriatric trauma patients. The TraumaRegister DGU® (TR-DGU) was utilized. European geriatric patients (≥65 years) admitted between 2008 and 2017 were included. Relevant patient variables were implemented in the GERtality score. By conducting a receiver operating characteristic (ROC) analysis, a comparison with the Geriatric Trauma Outcome Score (GTOS) and the Revised Injury Severity Classification II (RISC-II) Score was performed. A total of 58,055 geriatric trauma patients (mean age: 77 years) were included. Univariable analysis led to the following variables: age ≥ 80 years, need for packed red blood cells (PRBC) transfusion prior to intensive care unit (ICU), American Society of Anesthesiologists (ASA) score ≥ 3, Glasgow Coma Scale (GCS) ≤ 13, Abbreviated Injury Scale (AIS) in any body region ≥ 4. The maximum GERtality score was 5 points. A mortality rate of 72.4% was calculated in patients with the maximum GERtality score. Mortality rates of 65.1 and 47.5% were encountered in patients with GERtality scores of 4 and 3 points, respectively. The area under the curve (AUC) of the novel GERtality score was 0.803 (GTOS: 0.784; RISC-II: 0.879). The novel GERtality score is a simple and feasible score that enables an adequate prediction of the probability of mortality in polytraumatized geriatric patients by using only five specific parameters.

Age-Dependent Patient and Trauma Characteristics and Hospital Resource Requirements-Can Improvement Be Made? An Analysis from the German Trauma Registry.

Background and objectives: The burden of geriatric trauma patients continues to rise in Western society. Injury patterns and outcomes differ from those seen in younger adults. Getting a better understanding of these differences helps medical staff to provide a better care for the elderly. The aim of this study was to determine epidemiological differences between geriatric trauma patients and their younger counterparts. To do so, we used data of polytraumatized patients from the TraumaRegister DGU®. Materials and Methods: All adult patients that were admitted between 1 January 2013 and 31 December 2017 were included from the TraumaRegister DGU®. Patients aged 55 and above were defined as the elderly patient group. Patients aged 18-54 were included as control group. Patient and trauma characteristics, as well as treatment and outcome were compared between groups. Results: A total of 114,169 severely injured trauma patients were included, of whom 55,404 were considered as elderly patients and 58,765 younger patients were selected for group 2. Older patients were more likely to be admitted to a Level II or III trauma center. Older age was associated with a higher occurrence of low energy trauma and isolated traumatic brain injury. More restricted utilization of CT-imaging at admission was observed in older patients. While the mean Injury Severity Score (ISS) throughout the age groups stayed consistent, mortality rates increased with age: the overall mortality in young trauma patients was 7.0%, and a mortality rate of 40.2% was found in patients >90 years of age. Conclusions: This study shows that geriatric trauma patients are more frequently injured due to low energy trauma, and more often diagnosed with isolated craniocerebral injuries than younger patients. Furthermore, utilization of diagnostic tools as well as outcome differ between both groups. Given the aging society in Western Europe, upcoming studies should focus on the right application of resources and optimizing trauma care for the geriatric trauma patient.

Bioactive glass in the treatment of chronic osteomyelitis-a valid option?

Chronic osteomyelitis continues to represent a challenge both for patients and the treating physician, especially in the presence of multiple germs. We performed a literature review assessing the current role of the indications of bioactive glass. We included studies about patients with chronic osteomyelitis that were treated with S53P4. A literature review of Medline via PubMed was performed. After the exclusion of case reports, 7 studies were included in the narrative review. Recurrence of infection was defined as the main outcome parameter. Six of 7 studies were retrospective, or case studies with a relatively small sample size (total patient number N = 274). The overall recurrence rate was 10.6%. Studies that compared the outcome of the treatment with S53P4 versus antibiotic-loaded polymethyl methacrylate (PMMA) revealed no significant difference. The data reviewed indicate that in cases of multiple bacteria and resistance to antibiotic treatment, bioglass may be a valuable treatment alternative to other forms of spacers (e.g., PMMA). This statement is limited by the fact that the number of described cases is very low. Therefore, a definitive statement of its effectiveness cannot be made at this point.

Establishment of Submillisievert Abdominal CT Protocols With an In Vivo Swine Model and an Anthropomorphic Phantom.

OBJECTIVE. The purpose of this study was to evaluate radiation dose, effective dose, and image quality of different low-dose abdominal CT protocols in a swine model and an anthropomorphic phantom using a third-generation dual-source CT scanner. MATERIALS AND METHODS. Four different abdominal low-dose protocols were established using a swine model and were regarded as diagnostic by two experienced radiologists on the basis of clarity and sharpness of anatomic structures. General image conditions such as noise and spatial resolution as well as diagnostic acceptability and artifacts were evaluated. Objective image quality was determined by measuring signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) in different anatomic locations. To evaluate the effective dose, thermoluminescent dosimeter (TLD) measurements were repeated in a phantom. RESULTS. Diagnostic acceptability, spatial resolution, and noise were rated as optimal in all four protocols, which were therefore regarded as diagnostic. We found no statistically significant differences in SNR or CNR for the four low-dose protocols. Effective dose determined from the phantom measurements did not exceed 0.33 mSv for any protocol. Overall evaluation of the 86 TLD measurements for the four low-dose protocols revealed a statistically significant difference in radiation dose (p < 0.0001), showing that the dual-source protocol had the lowest radiation dose. CONCLUSION. Submillisievert abdominal CT is feasible with good image quality and doses even lower than conventional abdominal radiography. Our dual-source protocol achieved the lowest dose, which further shows that dual-source imaging is possible in the submillisievert range without additional dose.

Abdominal imaging dose in radiology and radiotherapy - Phantom point dose measurements, effective dose and secondary cancer risk.

PURPOSE: To compare abdominal imaging dose from 3D imaging in radiology (standard/low-dose/dual-energy CT) and radiotherapy (planning CT, kV cone-beam CT (CBCT)). METHODS: Dose was measured by thermoluminescent dosimeters (TLD's) placed at 86 positions in an anthropomorphic phantom. Point, organ and effective dose were assessed, and secondary cancer risk from imaging was estimated. RESULTS: Overall dose and mean organ dose comparisons yield significantly lower dose for the optimized radiology protocols (dual-source and care kV), with an average dose of 0.34±0.01 mGy and 0.54±0.01 mGy (average ±â€¯standard deviation), respectively. Standard abdominal CT and planning CT involve considerably higher dose (13.58 ±â€¯0.18 mGy and 18.78±0.27 mGy, respectively). The CBCT dose show a dose fall-off near the field edges. On average, dose is reduced as compared with the planning or standard CT (3.79 ±â€¯0.21 mGy for 220° rotation and 7.76 ±â€¯0.37 mGy for 360°), unless the high-quality setting is chosen (20.30 ±â€¯0.96 mGy). The mean organ doses show a similar behavior, which translates to the estimated secondary cancer risk. The modelled risk is in the range between 0.4 cases per million patient years (PY) for the radiological scans dual-energy and care kV, and 300 cases per million PY for the high-quality CBCT setting. CONCLUSIONS: Modern radiotherapy imaging techniques (while much lower in dose than radiotherapy), involve considerably more dose to the patient than modern radiology techniques. Given the frequency of radiotherapy imaging, a further reduction in radiotherapy imaging dose appears to be both desirable and technically feasible.