Mortality after hospital admission for trauma in Norway: A retrospective observational national cohort study.

BACKGROUND: National quality data for trauma care in Norway have not previously been reported. We have therefore assessed crude and risk-adjusted 30-day mortality in trauma cases after primary hospital admission on national and regional levels for 36 acute care hospitals and four regional trauma centres. METHODS: All patients in the Norwegian Trauma Registry in 2015-2018 were included. Crude and risk-adjusted 30-day mortality was assessed for the total cohort and for severe injuries (Injury Severity Score ≥16), and individual and combined effects of health region, hospital level, and hospital size were studied. RESULTS: 28,415 trauma cases were included. Crude mortality was 3.1% for the total cohort and 14.5% for severe injuries, with no statistically significant difference between regions. Risk-adjusted survival was lower in acute care hospitals than in trauma centres (0.48 fewer excess survivors per 100 patients, P<0.0001), amongst severely injured patients in the Northern health region (4.80 fewer excess survivors per 100 patients, P = 0.004), and in hospitals with <100 trauma admissions per year (0.65 fewer excess survivors than in hospitals with ≥100 admissions, P = 0.01). However, the only statistically significant effects in a multivariable logistic case mix-adjusted descriptive model were hospital level and health region. Case-mix adjusted odds ratio for survival for severely injured patients directly admitted to a trauma centre vs. an acute care hospital was 2.04 (95% CI 1.04-4.00, P = 0.04), and if admitted in the Northern health region vs. all other health regions was 0.47 (95% CI 0.27-0.84, P = 0.01). The proportion of cases admitted directly to the regional trauma centre in the sparsely populated Northern health region was half of that in the other regions (18.4% vs. 37.6%, P<0.0001). CONCLUSION: Differences in risk-adjusted survival for severe injuries can to a large extent be attributed to whether patients are directly admitted to a trauma centre. This should have implications for planning of transport capacity in remote areas.

Endoscopic full-thickness dissection (EFTD) in the rectum: a case series.

BACKGROUND: Rectal endoscopic full- thickness dissection (EFTD) using a flexible colonoscope is an alternative to the well-established trans-anal endoscopic microsurgery (TEM) and the trans-anal minimally invasive surgery (TAMIS) techniques for resecting dysplastic or malignant rectal lesions. This study evaluated EFTD safety by analyzing outcomes of the first patients to undergo rectal EFTD at the University Hospital of North-Norway. METHODS: The first 10 patients to undergo rectal EFTD at the University Hospital of North-Norway April, 2016 and January, 2021, were included in the study. The procedural indications for EFTD were therapeutic resection of non-lifting adenoma, T1 adenocarcinoma (AC), recurrent neuroendocrine tumor (NET) and re-excision of a T1-2 AC. RESULTS: EFTD rectal specimen histopathology revealed three ACs, five adenomas with high-grade dysplasia (HGD), one NET and one benign lesion. Six procedures had negative lateral and vertical resection margins and in three cases lateral margins could not be evaluated due to piece-meal dissection or heat damaged tissue. Two patients experienced delayed post-procedural hemorrhage, one of whom also presented with a concurrent post-procedural infection. No serious complications occurred. CONCLUSION: Preliminary results from this introductory trial indicate that EFTD in the rectum can be conducted with satisfactory perioperative results and low risk of serious complications.

Are severely injured trauma victims in Norway offered advanced pre-hospital care? National, retrospective, observational cohort.

BACKGROUND: Studies of severely injured patients suggest that advanced pre-hospital care and/or rapid transportation provides a survival benefit. This benefit depends on the disposition of resources to patients with the greatest need. Norway has 19 Emergency Helicopters (HEMS) staffed by anaesthesiologists on duty 24/7/365. National regulations describe indications for their use, and the use of the national emergency medical dispatch guideline is recommended. We assessed whether severely injured patients had been treated or transported by advanced resources on a national scale. METHODS: A national survey was conducted collecting data for 2013 from local trauma registries at all hospitals caring for severely injured patients. Patients were analysed according to hospital level; trauma centres or acute care hospitals with trauma functions. Patients with an Injury Severity Score (ISS) > 15 were considered severely injured. RESULTS: Three trauma centres (75%) and 17 acute care hospitals (53%) had data for trauma patients from 2013, a total of 3535 trauma registry entries (primary admissions only), including 604 victims with an ISS > 15. Of these 604 victims, advanced resources were treating and/or transporting 51%. Sixty percent of the severely injured admitted directly to trauma centres received advanced services, while only 37% of the severely injured admitted primarily to acute care hospitals received these services. CONCLUSION: A highly developed and widely distributed HEMS system reached only half of severely injured trauma victims in Norway in 2013.

Sacral neuromodulation compared with injection of bulking agents for faecal incontinence following obstetric anal sphincter injury - a randomized controlled trial.

AIM: The purpose of this trial was to compare the effectiveness of sacral neuromodulation (SNM) with a submucosal injection of collagen (Permacol®) in women with faecal incontinence following obstetric anal sphincter injury (OASIS). METHOD: This single-blinded randomized controlled trial at two hospital units in Norway included women with faecal incontinence following OASIS. Eligible women who had had a successful percutaneous nerve evaluation were randomly assigned to SNM or Permacol®. The primary outcome was the difference in the St Mark's incontinence score between baseline and 6 months. Secondary outcomes were changes in the disease-specific quality of life (FIQL) and urinary incontinence (ICIQ-UI-SF) scores. RESULTS: Fifty-eight women were randomly assigned to SNM (n = 30) and Permacol® (n = 28). The reduction in the St Mark's score between baseline and 6 months was 11.2 (SD 5.3) in the SNM group vs 2.3 (SD 5.0) in the Permacol® group, resulting in a difference of 8.9 (95% CI: 6.1-11.7, P < 0.0001). The differences in the four scales of FIQL (lifestyle, coping, depression, embarrassment) were 0.90 (95% CI: 0.50-1.30, P < 0.001), 1.05 (0.62-1.47, P < 0.001), 0.52 (95% CI: 0.16-0.87, P = 0.005) and 0.95 (95% CI: 0.50-1.40, P < 0.001), respectively, in favour of SNM. The difference in the ICIQ-UI-SF was 5.0 (95% CI: 1.97-8.02, P = 0.002) in favour of SNM. There were nine minor adverse events in the SNM group compared with seven in the Permacol® group (P = 0.77). CONCLUSION: SNM was superior to Permacol® in terms of reduction of St Mark's score, ICIQ-UI-SF and the change of the FIQL in women with faecal incontinence following OASIS.

Sacral neuromodulation for faecal incontinence following obstetric sphincter injury - outcome of percutaneous nerve evaluation.

AIM: The purpose of this study was to assess the efficacy of percutaneous nerve evaluation (PNE) in women with faecal incontinence (FI) following obstetric anal sphincter injury and to relate the outcomes to baseline factors, with special emphasis on the extent of the sphincter defect. METHOD: This was a prospective study at a tertiary colorectal referral unit at the University Hospital of North Norway conducted from 2012 to 2014. Sixty-three women underwent a 3-week PNE using a tined lead and the Verify® external neurostimulator. The primary outcome was efficacy, defined as the percentage reduction in weekly FI episodes, and patients with a reduction of 50% or more were defined as responders. Baseline factors affecting the primary outcome were explored. Sphincter defects were classified with a validated three-dimensional endoanal ultrasound defect score. RESULTS: Fifty-six (89%) of the 63 women were responders with a reduction in weekly FI episodes of 94.5%, from a median (interquartile range) of 4.8 (2.0-11.0) to 0.5 (0-2.0) (P < 0.001). Twenty-nine (52%) reported no weekly FI episodes, and urgency episodes disappeared in 18 (32%). In the multivariable linear regression model, efficacy was related to concomitant urinary incontinence (P = 0.04), body mass index (BMI) (P = 0.03) and pain during PNE (P = 0.046) but not to the extent of the sphincter defect (P = 0.1). Responders had a higher St Mark's score than nonresponders (P = 0.046). CONCLUSIONS: The vast majority of women had successful PNE tests. Responders had higher baseline St Mark's scores than nonresponders. Efficacy was related to concomitant urinary incontinence, BMI and pain, not to the extent of the sphincter defect.

Fatal injuries in rural and urban areas in northern Finland: a 5-year retrospective study.

BACKGROUND: Finland has the fourth highest injury mortality rate in the European Union. To better understand the causes of the high injury rate, and prevent these fatal injuries, studies are needed. Therefore, we set out to complete an analysis of the epidemiology of fatal trauma, and any contributory role for alcohol, long suspected to promote fatal injuries. As a study area, we chose the four northernmost counties of Finland; their mix of remote rural areas and urban centres allowed us to correlate mortality rates with 'rurality'. METHODS: The Causes of Death Register was consulted to identify deaths from external causes over a 5-year time period. Data were retrieved from death certificates, autopsy reports and medical records. The municipalities studied were classified as either rural or urban. RESULTS: Of 2915 deaths categorized as occurring from external causes during our study period, 1959 were eligible for inclusion in our study. The annual crude mortality rate was 54 per 100,000 inhabitants; this rate was higher in rural vs. urban municipalities (65 vs. 45 per 100,000 inhabitants/year). Additionally, a greater number of pre-hospital deaths from accidental high-energy trauma occurred in rural areas (78 vs. 69%). 42% of all pre-hospital deaths occurred under the influence of alcohol. CONCLUSION: The crude mortality rate for fatal injuries was high overall as compared to other studies, and elevated in rural areas, where pre-hospital deaths were more common. Almost half of pre-hospital deaths occurred under the influence of alcohol.

Implementation of a trauma system in Norway: a national survey.

BACKGROUND: Trauma systems have improved outcomes for injured patients, but might be challenging to implement. We assessed the implementation of a trauma system in Norway after recommendations for a national trauma system were published in 2007, with a focus on elements in acute care hospitals. METHODS: All hospitals in Norway, except for the four regional trauma centres, admitting injured patients at the time of the study were included in a telephone survey. The questionnaire was administered during May 2013 by the regional trauma coordinators who interviewed the local trauma coordinator and/or the local doctor responsible for trauma care in all the acute care hospitals. The main categories were availability of the trauma team and team training, written procedures, preparedness and training of personnel. The compliance to a set of 17 predefined trauma system criteria was evaluated at each institution. RESULTS: Of the 35 acute care hospitals in Norway admitting trauma patients at the time of the survey, all were included. The median number of fulfilled criteria was 14. Major deficiencies were found in fulfilling competence criteria, maintaining a local trauma registry, and trauma audits. The number of fulfilled criteria correlated strongly with the size of the hospital and the frequency of trauma team activation. CONCLUSIONS: Shortcomings in requirements for lower-level trauma care hospitals correlate to hospital size and frequency with which the trauma team is activated. In order to fulfill the minimum requirements, smaller hospitals should receive more attention.

Fatal injury caused by low-energy trauma - a 10-year rural cohort.

BACKGROUND: Death after injury with low energy has gained increasing focus lately, and seems to constitute a significant amount of trauma-related death. The aim of this study was to describe the epidemiology of deaths from low-energy trauma in a rural Norwegian cohort. METHODS: All deaths from external causes in Finnmark County, Norway, from 1995 to 2004 were identified retrospectively through the Norwegian Cause of Death Registry. Deaths caused by hanging, drowning, suffocation, poisoning, and electrocution were excluded. Trauma was categorised as high energy or low energy based on mechanism of injury. All low-energy trauma deaths were then reviewed. RESULTS: There were 262 cases of trauma death during the period. Low-energy trauma counted for 43% of the trauma deaths, with an annual crude death rate of 13 per 100,000 inhabitants. Low falls accounted for 99% of the injuries. Fractures were sustained in 89% of cases and head injuries in 11%. Ninety per cent of patients had pre-existing medical conditions, and the median age was 82 years. Death was caused by a medical condition in 85% of cases. Fifty-two per cent of the patients died after discharge from the hospital. CONCLUSION: In this cohort, low-energy trauma was a significant contributor to trauma related death, especially among elderly and patients with pre-existing medical conditions.

Translation and validation of the Norwegian version of the fecal incontinence quality-of-life scale.

BACKGROUND AND AIM: Fecal incontinence quality-of-life scale (FIQLS) is a condition-specific health-related quality-of-life questionnaire composed of four scales: lifestyle, coping/behaviour, depression/self-perception and embarrassment. It has been widely translated and used as an evaluation tool for patients with fecal incontinence. Our aim was to translate the FIQLS, and to test some of the psychometric properties of the Norwegian version of the questionnaire. MATERIAL AND METHODS: The FIQLS was translated to Norwegian, and administered to a sample of 76 patients (73 women) who completed the questionnaire at baseline and again after three weeks. In addition, the severity of incontinence was assessed by phone-interviews (St. Mark's score). RESULTS: Three of four domains had good internal consistency in terms of Cronbach's alpha (.83-.91), the fourth (embarrassment) somewhat lower (.64). Stability over time was acceptable for all domains with ICC ranging from .74 to .86. Correlation with severity of incontinence (St. Mark's score) was medium to large for all four domains (-.46 to -.63) supporting the construct validity of the Norwegian FIQLS. CONCLUSION: The Norwegian version of fecal incontinence quality-of-life scale has been successfully translated and tested.

Three-dimensional endoanal ultrasonography: intraobserver and interobserver agreement using scoring systems for classification of anal sphincter defects.

OBJECTIVES: To determine the degree of intraobserver and interobserver agreement for an experienced and an inexperienced sonologist using two scoring systems for ultrasonographic assessment of anal sphincter defects. METHODS: The study sample comprised the datasets of all women aged between 20 and 40 years who had attended our outpatient clinic and undergone a complete three-dimensional (3D) endoanal ultrasound (EAUS) examination in the period from January 2003 to December 2005. The EAUS datasets were assessed twice independently by two sonologists: one with experience of > 400 3D EAUS assessments and one inexperienced sonologist who had performed approximately 50 assessments before the study. Cases with intraobserver disagreement were resolved by a third (final) assessment. The final assessment from each observer was used to determine the degree of interobserver agreement. Sphincter defects were classified according to our EAUS defect score and the Starck score. RESULTS: EAUS datasets of 55 women were included. Based on first vs. second assessments, intraobserver agreement for the experienced sonologist was good for our EAUS defect score (weighted kappa, 0.75) and the Starck score (weighted kappa, 0.73). Intraobserver agreement for the inexperienced sonologist was moderate for our EAUS defect score (weighted kappa, 0.58) and good for the Starck score (weighted kappa, 0.62). Interobserver agreement was good for both our EAUS defect score (weighted kappa, 0.65) and the Starck score (weighted kappa, 0.74). CONCLUSIONS: Intraobserver and interobserver agreement was acceptable for both scoring systems. The experienced sonologist obtained a higher degree of intraobserver agreement than did the inexperienced sonologist.