Trauma triage criteria as predictors of severe injury - a Swedish multicenter cohort study.

BACKGROUND: Adequate performance of trauma team activation (TTA) criteria is important in order to accurately triage trauma patients. The Swedish National Trauma Triage Criteria (SNTTC) consists of 29 criteria that trigger either a Trauma Alert, the highest level of TTA, or a Trauma Response. This study aimed to evaluate the SNTTC and its accuracy in predicting a severely injured patient in a multicenter setting. METHODS: A cohort study in Sweden involving six trauma receiving hospitals. Data was collected from the Swedish Trauma Registry. Some 626 patients were analyzed with regard to the specific criteria used to initiate the TTA, injury severity with New Injury Severity Score (NISS) and emergency interventions. Sensitivity, specificity, positive predictive value (PPV) and positive likelihood ratio (LR+) of the criteria were calculated, as well as undertriage and overtriage. RESULTS: All 29 criteria of SNTTC had a sensitivity > 80% for identifying a severely injured patient. The 16 Trauma Alert Criteria had a lower sensitivity of 62.6% but higher LR+ (3.5 vs all criteria 1.4), specificity (82.3 vs 39.1%) and PPV (55.4 vs 37.6%) and the highest accuracy (AUC 0.724). When using only the six physiological criteria, sensitivity (44.8%) and accuracy (AUC 0.690) decreased while LR+ (6.7), specificity (93.3%) and PPV (70.2%) improved. CONCLUSION: SNTTC is efficient in identifying severely injured patients. The current set of criteria exhibits the best sensitivity compared to other examined combinations and no additional criterion was found to improve the protocol enough to promote a change.

Engagement under difficult conditions: Caring for patients with acute abdominal pain across the acute-care chain: A qualitative study.

BACKGROUND: Studies report that patients with acute abdominal pain do not always receive optimal care and can experience poor pain management, safety failures, and emotional harm. Deeper understanding of how health professionals experience care delivery is needed to improve care to patients with acute abdominal pain. AIM: To explore, from the perspective of registered nurses and physicians, how care is provided for patients with acute abdominal pain in the acute care chain, and to identify barriers that they describe in the delivery of care. METHOD: Registered nurses and physicians (n = 19) working in ambulance services, emergency departments, and surgical departments at five hospitals in Sweden were interviewed. A content analysis was performed. RESULTS: Five categories were identified; interaction: a decisive moment, competence and resources: not always available, guidelines: limited use, medical care: a main focus, and feedback and collaboration: limited across acute care chain. CONCLUSION: This study adds new insights relating to how health professionals reflect on patient needs and obstacles to satisfying them. To deliver high quality care and meet patients' fundamental needs, there is a need of general guidelines and close collaboration in the acute care chain.

Who is in charge of the care of patients with acute abdominal pain? An interview study with managers across the acute care chain.

AIM AND OBJECTIVES: To describe managers' perspectives on the care of patients with acute abdominal pain and explore how they influence the care. BACKGROUND: Patients with acute abdominal pain form a common group of patients who often report poor pain management. Managers are key actors in ensuring that patients receive high-quality care. This stresses the need to deepen the understanding of their perspectives on these patients, in order to provide high-quality fundamental care across the acute care chain. DESIGN: Qualitative descriptive semi-structured interview study, with an inductive approach. The Consolidated Criteria for Reporting Qualitative Research (COREQ) was used. METHODS: Individual interviews were conducted with managers (n = 17) from ambulance services, emergency departments and surgical departments at four hospitals in Sweden, representing managers at the micro- and macrolevels across the acute care chain. RESULTS: The patient group was described as a challenging heterogeneous group, with a focus on medical care, shaped by clinical practice guidelines, for which others were responsible. Managers with a physician background expressed that nursing care was important for the outcome of the care, while managers with a nursing background focused solely on the medical care. Additionally, the managers described that they affected the care by providing resources and serving as role models. CONCLUSIONS: The solely medical perspective is worrying. By being a stakeholder, the managers' responsibility should be to highlight the patient perspective in the care and promote and support all health professionals in redesigning the care, where achieving higher quality both in nursing and in medical care for patients with acute abdominal pain becomes a shared goal. RELEVANCE TO CLINICAL PRACTICE: Managers should use their leadership to bridge the gap between medicine and nursing care by highlighting patients' need for fundamental care, and to support health professionals in providing evidence-based and high-quality care.

A prospective stepped wedge cohort evaluation of the new national trauma team activation criteria in Sweden - the TRAUMALERT study.

BACKGROUND: Trauma triage based on prehospital information facilitates correct allocation of in-hospital resources. The Swedish national two-tier trauma team activation (TTA) criteria were revised in 2016. The current study aimed to evaluate the safety and efficacy of the new criteria. METHODS: Five centres covering trauma care for 1.2 million inhabitants registered all trauma patients prospectively in the Swedish trauma registry (SweTrau) prior to and after stepwise introduction of new TTA criteria within the cohort (a prospective stepped-wedge cohort study design; period August 2016-November 2017). Evaluation of full- and limited-TTA frequency, under- and overtriage were performed at equal duration before and after this change. RESULTS: The centres registered 1948 patients, 1882 (96.6%) of which were included in the study. With new criteria, frequency of full-TTA was unchanged, while limited-TTA decreased with 46.3% (from 988 to 531). 30-day trauma mortality was unchanged. The overtriage was 107/150 (71.3%) with former criteria, and 104/144 (72.2%) with new criteria, p = 0.866. Undertriage was 50/1037 (4.8%) versus 39/551 (7.1%), p = 0.063. Undertriage was consistently > 20% in patients with fall injury. Among patients with Injury Severity Score (ISS) > 15, 50/93 (53.8%) did not initiate full-TTA with former, vs 39/79 (49.4%) with new criteria, p = 0.565. Age > 60-years was a risk factor for undertriage (OR 2.89, p < 0.001), while low fall injuries indicated a trend (OR 2.70, p = 0.051). CONCLUSIONS: The newly implemented Swedish TTA criteria result in a reduction in limited TTA frequency, indicating an increased efficiency in use of resources. The over- and undertriage is unchanged compared to former criteria, thus upholding patient safety.

Better compliance with triage criteria in trauma would reduce costs with maintained patient safety.

OBJECTIVE: To evaluate trauma triage criteria in terms of compliance, undertriage, and overtriage and identify risk factors for mistriage. METHODS: In a retrospective cohort study, all consecutive trauma patients at a University Hospital in Sweden in 2012 were included. Patients were stratified into three groups on the basis of trauma team activation (full trauma team, limited trauma team, and no trauma team). Case records were reviewed for mechanism of injury, vital signs, and injuries. Compliance with alert criteria was evaluated and injury severity score combined with the Matrix method was used for assessment of overtriage and undertriage. RESULTS: A total of 1424 trauma patients were included in the study. Seventy-three (5.1%) patients activated a full trauma team, 732 (51.4%) a limited trauma team, and 619 (43.5%) did not activate any trauma team. Undertriage was 2.7% [95% confidence interval (CI): 1.9-3.8%] and overtriage was 34.2% (95% CI: 23.5-46.3%) in the complete cohort. Compliance with 'trauma triage criteria' was assessed by comparing actual alerts with what was estimated to be the correct alert levels on the basis of prehospital case records. Compliance with full trauma team criteria was 80% (68-88%), limited trauma team was 54% (51-58%), and no trauma team was 79% (76-82%). Assuming full compliance with trauma criteria, the Matrix method resulted in an undertriage of 2.3% (95% CI: 1.6-3.3%) and an overtriage of 42.6% (95% CI: 32.4-53.2%). CONCLUSION: The overtriage and undertriage in this study is in line with the recommendations of the American College of Surgeons Committee on Trauma. However, better compliance with trauma alert criteria would result in fewer trauma team activations without affecting patient safety.

Lack of existing guidelines for a large group of patients in Sweden: a national survey across the acute surgical care delivery chain.

RATIONALE, AIMS AND OBJECTIVES: Evidence-informed healthcare is the fundament for practice, whereby guidelines based on the best available evidence should assist health professionals in managing patients. Patients seeking care for acute abdominal pain form a common group in acute care settings worldwide, for whom decision-making and timely treatment are of paramount importance. There is ambiguity about the existence, use and content of guidelines for patients with acute abdomen. The objective was to describe and compare guidelines and management of patients with acute abdomen in different settings across the acute care delivery chain in Sweden. METHOD: A national cross-sectional design was used. Twenty-nine ambulance stations, 17 emergency departments and 33 surgical wards covering all six Swedish health regions were included, and 23 guidelines were quality appraised using the validated Appraisal of Guidelines for Research & Evaluation II tool. RESULTS: There is a lack of guidelines in use for the management of this large group of patients between and within different healthcare areas across the acute care delivery chain. The quality appraisal identified that several guidelines were of poor quality, especially the in-hospital ones. Further, range orders for analgesics are common in the ambulance services and the surgical wards, but are seldom present in the emergency departments. Also, education in pain management is more common in the ambulance services. These findings are noteworthy as, hypothetically, the same patient could be treated in three different ways during the same care episode. CONCLUSIONS: There is an urgent need to develop high-quality evidence-based clinical guidelines for this patient group, with the entire care process in focus.

Routine whole body CT of high energy trauma patients leads to excessive radiation exposure.

BACKGROUND: Whole body computed tomography (WBCT) is an important adjunct in trauma care, which is often part of standard protocol in initial management of trauma patients. However, WBCT exposes patients to a significant dose of radiation. The use of WBCT was assessed in a modern trauma cohort in Sweden. METHODS: A two-center retrospective cohort study was performed. All consecutive trauma alert patients at a university hospital (July-December 2008), and a rural county hospital (January 2009- December 2010) were included. Patients were stratified into three groups (high, intermediate and low risk) based on documented suspected injuries at primary survey at the site of accident or at the emergency department. Injury severity score (ISS) was calculated. Case records were reviewed for clinical and radiological findings at the time of trauma, and during a ≥36 months of follow-up period to identify possible missed injuries. RESULTS: A total of 523 patients were included in the study (university hospital n = 273; rural county hospital n = 250), out of which 475 patients (91.0 %) underwent radiological examinations, 290 patients (55.4 %) underwent WBCT, which identified trauma related findings in 125 patients (43.1 % of those examined). The high-risk group (n = 62) had a mean age of 38.5 years (21.1 SD). Mean ISS was 16.48 (18.14 SD). In this group, WBCT resulted in a positive finding in 38 (74.5 %) patients. In the intermediate-risk group (n = 322; mean age 37.66, 20.24 SD) ISS was 4.42 (6.30 SD). A positive finding on WBCT was found in 87 of the intermediate group patients (44.8 %). The low-risk group (n = 139; mean age 32.5 years; 21.4 SD) had a mean ISS of 0.84 (1.57 SD) with no positive findings on WBCT and no missed injuries in medical records at ≥36 months. DISCUSSION: The risk of developing radiation induced cancer is significant for young people if exposed to relatively high dose radiation as is the case in WBCT. WBCT in high-energy trauma is important for planning of treatment in severely injured patients while it can be questioned in the seemingly not injured where it is used mainly to permit early discharge from the ED. CONCLUSIONS: Risk stratification criteria could in this retrospective study identify high energy trauma patients not in need of radiological imaging. WBCT in high-energy trauma does not affect patient care if the patient is mentally alert, not intoxicated nor shows signs of other than minor injuries when evaluated by a trauma-team. The risk of missing important traumatic findings in these patients is very low. Observation of the patient with reexamination instead of imaging may be considered in this group of often young patients where radiation dose is an issue.

Super-selective venous sampling in conjunction with quickPTH for patients with persistent primary hyperparathyroidism: report of five cases.

Selective venous sampling (SVS) helps to interpret imaging results in patients with persistent primary hyperparathyroidism (pHPT). However, one of the drawbacks of conventional SVS may be low "spatial resolution", depending on the sample size. We modified SVS in the following way: first, patients underwent conventional SVS with up to 11 parathyroid hormone (PTH) samples taken. The quickPTH assay was used to measure PTH levels. The patients subsequently underwent super-selective venous sampling (super-SVS) in the region with the highest quickPTH level in the same session. The subjects were five consecutive patients with persistent pHPT investigated by various imaging techniques, none of which was considered conclusive. Therefore, all five patients underwent super-SVS, which was done successfully in four. Re-evaluation of the imaging results of these four patients resulted in localization of the parathyroid adenoma. Curative surgery was performed successfully in all four patients during the study period. Super-SVS increases the "spatial resolution" of conventional SVS and may have advantages when imaging results of patients with persistent pHPT are interpreted. Its true value must be analyzed in larger studies.

Adrenal incidentaloma - follow-up results from a Swedish prospective study.

OBJECTIVES: To examine the risk of developing adrenal carcinomas and clinically overt hypersecreting tumours during short-term follow-up in patients with adrenal incidentalomas. DESIGN: 229 (98 males and 131 females) patients with adrenal incidentalomas were investigated in a prospective follow-up study (median time 25 months; range 3-108 months). The patients were registered between January 1996 and July 2001 and followed until December 2004. Twenty-seven Swedish hospitals contributed with follow-up results. METHODS: Diagnostic procedures were undertaken according to a protocol including reinvestigation with computed tomography scans after 3-6 months, 15-18 months and 27-30 months, as well as hormonal evaluation at baseline and after 27-30 months of follow-up. Operation was recommended when the incidentaloma size increased or if there was a suspicion of a hypersecreting tumour. RESULTS: The median age at diagnosis of the 229 patients included in the follow-up study was 64 years (range 28-84 years) and the median size of the adrenal incidentalomas when discovered was 2.5 cm (range 1-8 cm). During the follow-up period, an increase in incidentaloma size of > or =0.5 cm was reported in 17 (7.4%) and of > or =1.0 cm was reported in 12 (5.2%) of the 229 patients. A decrease in size was seen in 12 patients (5.2%). A hypersecreting tumour was found in 2% of the hormonally investigated patients: Cushing's syndrome (n = 2) and phaeochromocytoma (n = 1). Eleven patients underwent adrenalectomy, but no cases of primary adrenal malignancy were observed. CONCLUSIONS: Patients with adrenal incidentaloma had a low risk of developing malignancy or hormonal hypersecretion during a short-term follow-up period.

Vincristine, cisplatin, teniposide, and cyclophosphamide combination in the treatment of recurrent or metastatic adrenocortical cancer.

The efficacy and tolerability of a combination of vincristine, cisplatin, teniposide, and cyclophosphamide (OPEC) in 11 patients (median age, 45 yr) with recurrent and/or metastatic adrenocortical cancer (ACC) (seven functional and four nonfunctional) were evaluated. All patients received this regimen after the failure of streptozocin and o,p'-DDD (SO) combination therapy. The regimen comprised cyclophosphamide, 600 mg/m2, and vincristine, 1.5 mg/m2, maximum dose 2.0 mg (d 1); cisplatin, 100 mg/m2 (d 2) and teniposide, 150 mg/m2 (d 4). Cycles were repeated every 4 wk. One to eight cycles (median, six cycles) of OPEC were administered to each patient. The median duration of treatment was 6 mo. The overall 2-yr survival rate was 82% and the median survival since diagnosis was 44 mo while it was 21 mo since start of OPEC therapy. Responses were obtained in nine patients: partial response in two patients, and stable disease in seven patients. The median duration of response was 6.75 mo. A total of 60 cycles of chemotherapy were given to all patients; grade 1-2 toxicity occurred in 57 cycles, while grade 3 toxicity was observed only in two cycles, according to NCI's Common Toxicity Criteria. We conclude that the OPEC regimen may be considered in recurrent or metastatic ACC as a second-line medical treatment. However, the combination is accompanied by considerable side effects and dose modifications are necessary in order to be able to recommend the treatment. This regimen needs further evaluation compared with SO therapy preferably in a randomized multicenter trial.

Pheochromocytomas: detection with 11C hydroxyephedrine PET.

PURPOSE: To evaluate the accuracy of carbon 11 (11C) hydroxyephedrine (HED) positron emission tomography (PET) in the detection of pheochromocytomas. MATERIALS AND METHODS: Nineteen patients (12 women, seven men; mean age, 53 years) suspected of having pheochromocytoma were evaluated. Patients had enlarged adrenal glands at computed tomography and either increased urinary catecholamine levels (n = 18) or normal biochemistry (n = 1). Dynamic PET examination in the adrenal region was performed after injection of 800 MBq 11C HED. PET data were analyzed visually and semiquantitatively. Time-activity curves were generated for different organs. PET results were validated with histologic evaluation (n = 16) or clinical follow-up (n = 3). The diagnostic value of HED PET was evaluated by calculating the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. RESULTS: In 12 patients, 13 pheochromocytomas were verified at surgery and histologic evaluation. All but one of the pheochromocytomas were detected with HED PET, which demonstrated elevated uptake. The rest of the patients (n = 7) did not have pheochromocytomas. In these patients, HED PET did not show any abnormal uptake in the suspicious tumors (confirmed at surgery in four patients and at clinical follow-up in three). Mean standardized uptake value of the tumors was 21.4 (range, 11.1-40.9). The time-activity curves for pheochromocytomas showed early uptake after injection, and the activity increased with the time of examination. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of HED PET in the detection of pheochromocytomas were 92% (12 of 13), 100% (seven of seven), 100% (12 of 12), 87.5% (seven of eight), and 95% (19 of 20), respectively. CONCLUSION: HED PET is useful in the detection of pheochromocytomas, providing a high level of accuracy.

Fourth branchial pouch sinus with recurrent deep cervical abscesses successfully treated with trichloroacetic acid cauterization.

A previously healthy 13-year-old girl presented with a left-sided deep cervical abscess. A CT scan demonstrated an abscess in the lower neck, anterior to the common carotid artery. Treatment with i.v. antibiotics and incision drainage resolved the condition. A recurrence of the abscess 7 months later was treated identically. Further investigations with MRI showed a 2-3-mm wide, 10-mm long structure in the lateral aspect of the left thyroid lobe. A barium radiograph depicted a narrow, 20-mm long fistula originating from the left pharynx. At endoscopy a 2-3-mm wide opening was found at the left pyriform sinus apex. This, together with the radiological findings, verified the diagnosis of a 4th branchial pouch sinus. The recurrence of the abscess may have been due to contamination by infectious pharyngeal secretions. Although radical surgical excision is traditionally recommended for this condition a non-invasive treatment, namely chemocauterization with 40% trichloroacetic acid (TCA), was chosen in this case. Three cauterizations were needed to close the pyriform sinus opening. To date (Month 14) there has been no recurrence of the cervical abscesses. TCA chemocauterization seems to be a safe first-line treatment for patients with a pyriform sinus fistula.

[A case report: anomaly of the fourth branchial pouch with recurring cervical abscesses. Cauterization with trichloroacetic acid closed the fistula opening and cured the patient]. / Fallbeskrivning: anomali i fjärde gälfickan med recidiverande halsabscesser. Etsning med triklorättiksyra tillslöt fistelmynning och botade patienten.

A fourth branchial pouch sinus is a rare congenital anomaly, which in a 13-year-old girl presented clinically as recurrent deep cervical abscesses. The location of the majority of these anomalies is the left side of the neck (90%). Radiological and endoscopic investigations verified the diagnosis. The internal orifice located at the apex of the pyriform sinus could facilitate contamination by infectious pharyngeal secretions and lead to abscess recurrence. Traditionally, the recommended treatment is radical surgery. It can, however, be technically difficult to excise the whole fistula tract. In this patient we used a non-invasive treatment modality; chemocauterization with 40% trichloroacetic acid (TCA). After three treatments the fistula was closed. To date (month no. 15) there has been no abscess recurrence. TCA chemocauterization seems to be a safe first-line treatment for patients with pyriform sinus fistulas.

11C-metomidate PET imaging of adrenocortical cancer.

The diagnostic potential of positron emission tomography (PET) with carbon-11 metomidate in patients with adrenocortical cancer (ACC) was evaluated. Thirteen PET examinations were performed in 11 patients with CT-detected primary tumours or recurrence and/or metastases from a previously histopathologically proven ACC. The findings at PET were compared with those at CT and verified by histopathology. Six studies (group A) were performed in patients who at the time of imaging were free of medication that could interfere with 11beta-hydroxylase activity and thereby tracer uptake at PET, such as adrenal steroid inhibitors or chemotherapy. The remaining seven studies (group B) were carried out in patients who were monitored during treatment with one or a combination of these drugs. PET visualised all viable tumours with high tracer uptake, and revealed two more lesions than were seen on CT. Three necrotic tumours were detected as false negative observations, as confirmed at surgery and histopathological examination. A true negative observation was obtained at PET in the case of a suspected liver metastasis on CT that was found to have fat vacuolation at histopathological examination of an ultrasonically guided core biopsy specimen. Group A showed apparently higher uptake in normal tissues than group B (adrenal, P=0.03; liver, P=0.01). The metomidate uptake was increased in tumour lesions as compared with normal tissues (adrenal, P=0.02; liver, P=0.005). ACC could be clearly visualised with (11)C-metomidate PET except when the tumour was necrotic. Medication with adrenal steroid inhibitors and chemotherapy decreased the tracer uptake.

The role of PET in localization of neuroendocrine and adrenocortical tumors.

Positron emission tomography (PET) supplies a range of labeled compounds to be used for the characterization of tumor biochemistry. Some of these have proved to be of value for clinical diagnosis, treatment follow up, and clinical research. The first routinely used PET tracer in oncology, (18)F-labeled deoxyglucose (FDG), was successfully used for diagnosis of cancer, reflecting increased expression of glucose transporter in cancerous tissue. This tracer, however, usually does not show sufficient uptake in well-differentiated tumors such as neuroendocrine tumors. We developed a tracer more specific to neuroendocrine tumors-the serotonin precursor 5-hydroxytryptophan (5-HTP) labeled with (11)C-and demonstrated increased uptake and irreversible trapping of this tracer in carcinoid tumors. The uptake was so selective and the resolution was so high that we could detect more liver and lymph node metastases with PET than with CT or octreotide scintigraphy. To further improve the method, especially to reduce the high renal excretion of the tracer producing streaky artifacts in the area of interest, we introduced premedication by the decarboxylase inhibitor carbidopa, leading to a six-fold decreased renal excretion while the tumor uptake increased three-fold, hence improving the visualization of the tumors. (11)C-labeled l-DOPA was evaluated as an alternative tracer, especially for endocrine pancreatic tumors, which usually do not demonstrate enhanced urinary serotonin metabolites. However, only half of the EPTs, mainly functioning tumors, could be detected with l-DOPA. Instead 5-HTP seems to be a universal tracer for EPT and foregut carcinoids. With new, more sensitive PET cameras, larger field of view and procedures for whole-body coverage, the PET examination with 5-HTP is now routinely performed as reduced whole-body PET examinations with coverage of the thorax and abdomen. With this method we have been able to visualize small neuroendocrine lesions in the pancreas and thorax (e.g., ACTH-producing bronchial carcinoids) not detectable by any other method, including octreotide scintigraphy, MRI, and CT. Another tracer, the 11beta-hydroxylase inhibitor, metomidate labeled with (11)C, was developed to simplify diagnosis and follow-up of patients with incidentalomas. A large series of patients with incidentally found adrenal masses have been investigated and so far all lesions of adrenocortical origin have been easily identified because of exceedingly high uptake of (11)C-metomidate, whereas noncortical lesions showed very low uptake. In addition, adrenocortical cancer shows high uptake, suggesting that this PET tracer can be used for staging purposes.

Involvement of the MEN1 gene locus in familial isolated hyperparathyroidism.

BACKGROUND: Familial isolated hyperparathyroidism (FIHP) is a hereditary disorder characterised by uni- or multiglandular parathyroid disease. A subset of families are likely to be genetic variants of other familial tumour syndromes in which PHPT is the main feature, for example multiple endocrine neoplasia type 1 (MEN 1) and the hyperparathyroidism-jaw tumour syndrome (HPT-JT). OBJECTIVE: To investigate seven families diagnosed with FIHP, each with two to eight affected family members, to clarify the underlying genetic mechanism. METHODS: The entire MEN1 gene was sequenced for germline mutations and, in addition, tumour specimens were analysed in comparative genomic hybridisation and loss of heterozygosity studies. RESULTS: Two families exhibited MEN1 mutations, L112V and 1658delG, which were associated with loss of the wild-type 11q13 alleles in all tumours analysed. In the remaining five families, no MEN1 mutation was identified. CONCLUSION: These results support the involvement of the MEN1 tumour suppressor gene in the pathogenesis of some of the FIHP kindreds. However, loss on chromosome 11 was seen in all tumours exhibiting somatic deletions, although in two families the tumour deletions involved 11q distal to MEN1. We conclude that the altered MEN1 gene function is of importance in the development of FIHP.