Injury severity in polytrauma patients is underestimated using the injury severity score: a single-center correlation study in air rescue.

PURPOSE: Prehospital estimation of injury severity is essential for prehospital therapy, deciding on the destination hospital and the associated emergency room care. The aim of this study was to compare prehospital estimates of the abbreviated injury scale (AIS) and the Injury Severity Score (ISS) by emergency physicians with the values of AIS and ISS of injury severity determined at the conclusion of diagnostics. METHODS: In this prospective study, the ISS was determined prehospital by emergency physicians. The validated AIS and ISS were analyzed based on final diagnoses. A Bland-Altman plot was used in analyzing the agreement between two different assays as well as sensitivity and specificity were determined. Confidence intervals were calculated for a Wilson score. Significance level was set at p ≤ 0.05. RESULTS: The prehospital ISS was estimated at 26.0 ± 13.0 and was 34.7 ± 16.3 (p < 0.001) after in-hospital validation. In addition, most of the AIS subgroups were significantly higher in the final calculation than preclinically estimated (p < 0.05). When analyzing subgroups of trauma patients (ISS < 16 vs. ISS ≥ 16), we were able to demonstrate a sensitivity of > 90% to identify a multiple-trauma patient. Diagnosing a higher injury severity group (ISS ≥ 25), sensitivity dropped to 61.1%. The Bland-Altman plot demonstrates that injury severity is underestimated in higher injury levels. CONCLUSION: Multiple-trauma patients can be identified using the ISS. Anatomic scores might be used for transport decisions; however, an accurate estimation of the injury severity should also be based on other criteria such as patient status, mechanism of injury, and other triage criteria.

Kinetic therapy in multiple trauma patients with severe blunt chest trauma: an analysis at a level-1 trauma center.

BACKGROUND AND OBJECTIVES: Chest trauma is a relevant risk factor for mortality after multiple trauma. Kinetic therapy (KT) represents a potential treatment option in order to restore pulmonary function. Decision criteria for performing kinetic therapy are not fully elucidated. The purpose of this study was to investigate the decision making process to initiate kinetic therapy in a well defined multiple trauma cohort. METHODS: A retrospective analysis (2000-2009) of polytrauma patients (age > 16 years, ISS ⩾ 16) with severe chest trauma (AIS(Chest) ⩾ 3) was performed. Patients with AIS(Head) ⩾ 3 were excluded. Patients receiving either kinetic (KT+) or lung protective ventilation strategy (KT-) were compared. Chest trauma was classified according to the AIS(Chest), Pulmonary Contusion Score (PCS), Wagner Jamieson Score and Thoracic Trauma Severity Score (TTS). There were multiple outcome parameters investigated included mortality, posttraumatic complications and clinical data. A multivariate regression analysis was performed. RESULTS: Two hundred and eighty-three patients were included (KT+: n=160; KT-: n=123). AIS(Chest), age and gender were comparable in both groups. There were significant higher values of the ISS, PCS, Wagner Jamieson Score and TTS in group KT+. The incidence of posttraumatic complications and mortality was increased compared to group KT- (p< 0.05). Despite that, kinetic therapy failed to be an independent risk factor for mortality in multivariate logistic regression analysis. CONCLUSIONS: Kinetic therapy is an option in severely injured patients with severe chest trauma. Decision making is not only based on anatomical aspects such as the AIS(Chest), but on overall injury severity, pulmonary contusions and physiological deterioration. It could be assumed that the increased mortality in patients receiving KT is primarily caused by these factors and does not reflect an independent adverse effect of KT. Furthermore, KT was not shown to be an independent risk factor for mortality.

Effects of accidental hypothermia on posttraumatic complications and outcome in multiple trauma patients.

INTRODUCTION: Accidental hypothermia seems to predispose multiple trauma patients to the development of posttraumatic complications, such as Systemic Inflammatory Response Syndrome (SIRS), sepsis, Multiple Organ Dysfunction Syndrome (MODS), and increased mortality. However, the role of accidental hypothermia as an independent prognostic factor is controversially discussed. The aim of the present study was to evaluate the incidence of accidental hypothermia in multiple trauma patients and its effects on the development of posttraumatic complications and mortality. PATIENTS AND METHODS: Inclusion criteria for patients in this retrospective study (2005-2009) were an Injury Severity Score (ISS) ≥16, age ≥16 years, admission to our Level I trauma centre within 6h after the accident. Accidental hypothermia was defined as body temperature less than 35°C measured within 2 h after admission, but always before first surgical procedure in the operation theatre. The association between accidental hypothermia and the development of posttraumatic complications as well as mortality was investigated. Statistical analysis was performed with χ(2)-test, Student's t-test, ANOVA and logistic regression. Statistical significance was considered at p<0.05. RESULTS: 310 multiple trauma patients were enrolled in the present study. Patients' mean age was 41.9 (SD 17.5) years, the mean injury severity score was 29.7 (SD 10.2). The overall incidence of accidental hypothermia was 36.8%. The overall incidence of posttraumatic complications was 77.4% (SIRS), 42.9% (sepsis) and 7.4% (MODS), respectively. No association was shown between accidental hypothermia and the development of posttraumatic complications. Overall, 8.7% died during the posttraumatic course. Despite an increased mortality rate in hypothermic patients, hypothermia failed to be an independent risk factor for mortality in multivariate analysis. CONCLUSIONS: Accidental hypothermia is very common in multiply injured patients. However, it could be assumed that the increase of mortality in hypothermic patients is primarily caused by the injury severity and does not reflect an independent adverse effect of hypothermia. Furthermore, hypothermia was not shown to be an independent risk factor for posttraumatic complications.

Analytical method transfer: improving interpretability with ratio-based statistical approaches.

After assay validation in an originating laboratory, an analytical method needs to be transferred to one or several production laboratories, because measured outcomes among the laboratories must agree. To state agreement, the locations (e.g. means) must be equivalent and the production laboratory must be non-inferior to the originating one concerning scales (e.g. standard deviations). Here, parametric and non-parametric approaches based on marginal confidence intervals for the ratio of locations and the ratio of scales are presented. These intervals are appropriate for a matched pairs design without repeated measurements. Results of simulation studies investigating the power and the control of the type I error are shown and limits of the approaches are discussed. In addition, a Bland-Altman plot with tolerance intervals is proposed. As illustrated in the example proportional differences greatly improve the interpretation of the results compared to absolute differences.

[Postoperative hypoparathyroidism: risk factors and out-patient management following thyroid resections]. / Postoperativer Hypoparathyreoidismus: Risikofaktoren und ambulante Nachsorge nach Schilddrüsenresektionen.

BACKGROUND: Postoperative hypoparathryroidism is the most common complication following thyroid resection. Currently the data about the quality of out-patient management is inadequate. PATIENTS AND METHODS: Between 2003 and 2006 a total of 1,966 resections were performed and retrospectively analyzed. RESULTS: Of the patients 14% developed temporary hypoparathyroidism and permanent hypoparathyroidism was seen in 0.37%. The extent of resection and female sex were significant risk factors. The recommendation to wean calcium substitution was only performed in 18% of affected patients. CONCLUSION: The results demonstrated that the quality of out-patient management in cases of postoperative hypoparathyroidism after thyroid resection is insufficient.

Thyroid remnant dose: 124I-PET/CT dosimetric comparison of rhTSH versus thyroid hormone withholding before radioiodine remnant ablation in differentiated thyroid cancer.

AIM: Recombinant human thyroid-stimulating hormone (rhTSH) recently was approved as an alternative to thyroid hormone withholding (THW) to elevate TSH for thyroid remnant ablation in differentiated thyroid carcinoma patients. High ablation success rates are reported with diverse rhTSH-aided (131)I activities. Improved renal function causes approximately 50% faster radioiodine clearance under euthyroidism versus hypothyroidism. Knowledge of comparative remnant radioiodine kinetics, particularly the remnant radiation dose in Gy/GBq of administered (131)I activity (RDpA), could assist in choosing rhTSH-aided ablative activities. MATERIAL AND METHODS: To compare the RDpA, determined through (124)I-positron emission tomography/computed tomography (PET/CT), under the two stimulation methods, we retrospectively divided into two groups 55 consecutive totally-thyroidectomized, radioiodine-naïve patients. The rhTSH group (n=16) received (124)I on thyroid hormone, 24 h after two consecutive daily intramuscular injections of rhTSH, 0.9 mg. The THW group (n=39) received (124)I after weeks-long THW, when serum TSH first measured > or = 25 mIU/L. We performed PET investigations 4 h, 24 h, 48 h, 72 h and 96 h and PET/CT 25 h after (124)I administration. RESULTS: Median stimulated serum thyroglobulin was 15 times higher (p=0.023) and M1 disease almost twice as prevalent (p=0.05) in rhTSH versus THW patients. Mean+/-standard deviation RDpA was statistically equivalent between the groups: rhTSH, 461+/-600 Gy/GBq, THW, 302+/-329 Gy/GBq, two-sided p=0.258. CONCLUSIONS: rhTSH or THW deliver statistically equivalent radiation doses to thyroid remnant and may be chosen based on safety, quality-of-life, convenience and pharmacoeconomic factors. Institutional fixed radioiodine activities formulated for use with THW need not be adjusted for rhTSH-aided ablation.

[Midwife attendance during labour and its relation to interventions and outcome of birth]. / Zusammenhänge zwischen Anwesenheit der Hebamme, Interventionen und dem Outcome der Geburt.

BACKGROUND: Continuity of midwifery care during labour is beneficial. We investigated the relationship between midwife presence, interventions and outcome. PATIENTS AND METHODS: From the overall sample of singleton pregnancies in cephalic presentation (n=4 438) we selected 541 prospectively documented hospital-based birth processes occurring at term without antenatal risks and spontaneous mode of birth. Univariate and multivariate analyses were performed. RESULTS: Midwives were present for up to six hours in 66% of 247 births to primiparae, and for up to three hours in 61% of 294 births to multiparae. Midwives were present for more than 75% of the overall labour duration in 62% of all births in nulliparae and 63% in multiparae. Midwife presence for more than 75% of the total birth duration correlated positively to immersion in water (p<0.02), up to two CTG tracings (p<0.001), and up to three vaginal examinations (p<0.04). Midwives working in hospitals which contributed more than 50% of their eligible births were present for longer during labour than midwives in units with a lower participation rate (p<0.002). Multivariate regression revealed that up to two CTG tracings (p<0.001) and a participation rate of more than 50% (p<0.002) were significantly related to midwife presence. DISCUSSION: Intensive intrapartum midwife presence during spontaneous birth was associated neither with fetal outcome nor with interventions, except for up to two CTG tracings. This might be due to shorter labour or the later commencement of care. CONCLUSIONS: Intrapartum midwife presence covers a large portion of the birth process, but continues to be poorly understood.