[Challenges of digitalization in trauma care]. / Herausforderungen der Digitalisierung in der Traumaversorgung.

The increasing digitalization of social life opens up new possibilities for modern health care. This article describes innovative application possibilities that could help to sustainably improve the treatment of severe injuries in the future with the help of methods such as big data, artificial intelligence, intelligence augmentation, and machine learning. For the successful application of these methods, suitable data sources must be available. The TraumaRegister DGU® (TR-DGU) currently represents the largest database in Germany in the field of care for severely injured patients that could potentially be used for digital innovations. In this context, it is a good example of the problem areas such as data transfer, interoperability, standardization of data sets, parameter definitions, and ensuring data protection, which still represent major challenges for the digitization of trauma care. In addition to the further development of new analysis methods, solutions must also continue to be sought to the question of how best to intelligently link the relevant data from the various data sources.

[Future perspective of the TraumaRegister DGU® : Further development, additional modules and potential limits]. / Zukunftsperspektiven des TraumaRegister DGU® : Weiterentwicklung, Zusatzmodule und potenzielle Grenzen.

Since its founding in 1993 the TraumaRegister DGU® has become one of the largest registries especially in terms of data diversity. Since the introduction of the TraumaNetzwerk DGU®, the TraumaRegister DGU® has enabled a quasi-nationwide picture of the quality of care of severely injured patients in Germany. The register is subject to constant development, under the guidance of the working groups of the German Society for Trauma Surgery (DGU). The first modular expansion of special injury entities (craniocerebral trauma and complex hand injuries) is currently taking place. The future developments will involve the extension of the register to certain injury patterns. The existing registry will also be supplemented with other recorded qualities (from the supplementary serum database up to the quality of life). This makes the TraumaRegister DGU® a tool for quality assurance and science which is well prepared for the future.

[Data content of the TraumaRegister DGU® : Results of a random sample control]. / Datengüte des TraumaRegister DGU® : Ergebnisse einer Stichprobenkontrolle.

BACKGROUND: Registries are becoming increasingly more important in clinical research. The TraumaRegister DGU® of the German Society for Trauma Surgery plays an excellent role with respect to the care of severely injured patients. AIM: Within the framework of this investigation the quality of data provided by this registry was to be verified. MATERIAL AND METHODS: Certified hospitals participating in the TraumaNetzwerk DGU® of the German Society for Trauma Surgery are obliged to submit data of treated severely injured patients to the TraumaRegister DGU®. Participating hospitals have to undergo a re-certification process every 3 years. Within the framework of this re-audit, data from 5 out of 8 randomly chosen patient cases included in the registry are controlled and compared to the patient files of the certified hospital. In the present investigation discrepancies concerning data provided were documented and the pattern of deviation was analyzed. RESULTS: The results of 1075 re-certification processes carried out in 631 hospitals including the documentation of 5409 checked patient cases from 2012-2017 were analyzed. The highest number of discrepancies detected concerned the documented time until initial CT (15.8%) and the lowest concerned the discharge site (3.2%). The majority of data sheets with discrepancies showed deviations in only one out of seven checked parameters. Interestingly, large trauma centers with a high throughput of severely injured patients showed the most deviations. CONCLUSION: The present investigation underlines the importance of standardized checks concerning data provided for registries in order to be able to guarantee an improvement in entering data.

[The TraumaRegister DGU® dataset, its development over 25 years and advances in the care of severely injured patients]. / Der Datensatz des TraumaRegister DGU®, seine Entwicklung über 25 Jahre und Fortschritte in der Schwerverletzenversorgung.

BACKGROUND: Since the publication in 1993, the dataset and documentation form of the TraumaRegister DGU® (TR-DGU) have continuously evolved. On the occasion of the 25th anniversary the authors have analyzed this evolution in order to reflect it in the light of medical progress in the treatment of the severely injured. MATERIAL AND METHODS: Enrolled in the study were 5 reference data entry sheets from the years 1993, 1996, 2002, 2009 and 2016. Every piece of information (item) queried therein was entered into the study database, was categorized by topic and counted for further analysis. RESULTS: The arrangement of the 4­page data entry form has remained practically unchanged since 1993 and includes an average of 212 items. A total of 491 items were identified of which 64 were present throughout every dataset. Based on the average extent of the form this equals a proportion of approximately 30%. The dataset actually shows much more consistency than this number suggests because many changes can be traced back to a smarter design of the data entry form. Most items fell into the categories "results/diagnosis" (143 items/29.1%), "coagulation" (104/21.2%) and "surgical approach" (40/8.1%). Many items serve as raw data for the calculation of prognostic risk scores, such as the trauma and injury severity score (TRISS), the revised injury severity classification II (RISC II) and the trauma associated severe hemorrhage (TASH) score. Currently, nine scores can be calculated from the dataset. CONCLUSION: The members of the working group TraumaRegister all actively participate in the treatment of severely injured patients. For 25 years this group has managed to unify the latest medical developments and well-established parameters within the TR-DGU dataset at a relatively constant degree of effort for documentation. Practice in place of theory is the driving force behind this development that serves quality assurance and research in the treatment of severely injured patients.

[Complex pelvic traumas : data linkage of the German Pelvic Injury Register and the TraumaRegister DGU®]. / Das komplexe Beckentrauma : Matching des Beckenregisters DGU mit dem TraumaRegister DGU®.

BACKGROUND: Complex pelvic traumas, i.e., pelvic fractures accompanied by pelvic soft tissue injuries, still have an unacceptably high mortality rate of about 18 %. PATIENTS AND METHODS: We retrospectively evaluated an intersection set of data from the TraumaRegister DGU® and the German Pelvic Injury Register from 2004-2009. Patients with complex and noncomplex pelvic traumas were compared regarding their vital parameters, emergency management, stay in the ICU, and outcome. RESULTS: From a total of 344 patients with pelvic injuries, 21 % of patients had a complex and 79 % a noncomplex trauma. Complex traumas were significantly less likely to survive (16.7 % vs. 5.9 %). Whereas vital parameters and emergency treatment in the preclinical setting did not differ substantially, patients with complex traumas were more often in shock and showed acute traumatic coagulopathy on hospital arrival, which resulted in more fluid volumes and transfusions when compared to patients with noncomplex traumas. Furthermore, patients with complex traumas had more complications and longer ICU stays. CONCLUSION: Prevention of exsanguination and complications like multiple organ dysfunction syndrome still pose a major challenge in the management of complex pelvic traumas.

Female sex protects from organ failure and sepsis after major trauma haemorrhage.

INTRODUCTION: Biological sex is considered a risk factor for adverse outcome after major trauma. We hypothesized that female sex is protective against organ failure, sepsis and mortality in patients with traumatic haemorrhage. PATIENTS AND METHODS: We selected patients from TraumaRegister DGU(®) (TR-DGU) with primary admission for blunt trauma with an injury severity score ≥ 16 and an ICU stay ≥ 3 days that presented with relevant bleeding in the years 2007-2012. Relevant bleeding was defined as Abbreviated Injury Scale (AIS) ≥ 3 with an estimated blood loss exceeding 20%, any femoral shaft fracture, any pelvic clamp as surrogate for unstable pelvic fracture or the presence of at least one criteria of haemorrhagic shock: shock index of 0.8-1.4; base excess of -2.0 to -10.0 mmol/L; body temperature ≤ 34°C; transfusion of ≥ 4 units of packed red blood cells; application of recombinant activated factor VII; any embolization during trauma room phase and pre-hospital resuscitation volume ≥ 3000 ml or any catecholamine use during pre-hospital care in the absence of cardiopulmonary resuscitation. A total of 7560 males and 2774 females were selected and analyzed for sex differences. RESULTS: Higher rates of multiple organ failure (24.4 vs. 21.3%, Odds ratio [OR] 1.19 (95% confidence interval [95%CI] 1.07-1.33), p=0.001*) and sepsis (16.5 vs. 11.3%, OR 1.55 (95%CI 1.35-1.77), p<0.001*) were observed in males. Organ function of lung, cardio-circulatory system, liver and kidney were better in females, however, there was no difference in mortality. Stratification by age group revealed that in particular age-group 16-44 years was related to improved organ function which may indicate effects of sex hormones in females at reproductive age. Increased rates of sepsis in males were observed throughout virtually all age groups starting at 16 years of age, except in age group 54-64 years. This may suggest suppressive effect of testosterone on immune function. CONCLUSIONS: Our study supports the hypothesis that female sex is associated with improved organ function following traumatic injury and haemorrhagic shock, in particular in age groups that are at reproductive age. However, further studies are warranted before sex steroids can be deployed as therapeutic intervention in critically ill trauma patients.

The ATLS(®) classification of hypovolaemic shock: a well established teaching tool on the edge?

Uncontrolled bleeding is the leading cause of shock in trauma patients and delays in recognition and treatment have been linked to adverse outcomes. For prompt detection and management of hypovolaemic shock, ATLS(®) suggests four shock classes based upon vital signs and an estimated blood loss in percent. Although this classification has been widely implemented over the past decades, there is still no clear prospective evidence to fully support this classification. In contrast, it has recently been shown that this classification may be associated with substantial deficits. A retrospective analysis of data derived from the TraumaRegister DGU(®) indicated that only 9.3% of all trauma patients could be allocated into one of the ATLS(®) shock classes when a combination of the three vital signs heart rate, systolic blood pressure and Glasgow Coma Scale was assessed. Consequently, more than 90% of all trauma patients could not be classified according to the ATLS(®) classification of hypovolaemic shock. Further analyses including also data from the UK-based TARN registry suggested that ATLS(®) may overestimate the degree of tachycardia associated with hypotension and underestimate mental disability in the presence of hypovolaemic shock. This finding was independent from pre-hospital treatment as well as from the presence or absence of a severe traumatic brain injury. Interestingly, even the underlying trauma mechanism (blunt or penetrating) had no influence on the number of patients who could be allocated adequately. Considering these potential deficits associated with the ATLS(®) classification of hypovolaemic shock, an online survey among 383 European ATLS(®) course instructors and directors was performed to assess the actual appreciation and confidence in this tool during daily clinical trauma care. Interestingly, less than half (48%) of all respondents declared that they would assess a potential circulatory depletion within the primary survey according to the ATLS(®) classification of hypovolaemic shock. Based on these observations, a critical reappraisal of the current ATLS(®) classification of hypovolaemic seems warranted.

[The TraumaRegister DGU® as data source for monitoring severe injuries]. / Das TraumaRegister DGU® als Datenquelle für das Monitoring schwerer Unfallverletzungen.

BACKGROUND: The TraumaRegister DGU® of the German Society for Trauma Surgery (TR-DGU) has collected data on the treatment of severely injured accident victims in Germany since 1993. Due to the current number of more than 600 participating clinics which regularly receive quality comparison reports, these register data are becoming an increasingly more valuable source for healthcare research. OBJECTIVES: The aims of this article are to describe the potential of the TR-DGU for dealing with epidemiological questions and for describing the quality of the process and results for treatment of severely injured patients. MATERIAL AND METHODS: The TR-DGU includes approximately 100 details per patient on the person, the circumstances of the accident, the injury pattern, the preclinical and hospital treatment, the condition of the patient and the outcome. Using comparative analyses the observed mortality is adjusted by considering prognostically relevant findings. Some key features of the register are reported for patients who were treated in German hospitals between 2002 and 2012 with an injury severity score (ISS) of ≥9 points. RESULTS: Since 1993 more than 122,000 patients have been included in the register. The majority are traffic accident victims (57 %), followed by patients with falls from low heights (< 3 m, 17 %) or greater heights (> 3 m, 16 %). Among the traffic accident victims approximately one half are car drivers or passengers (46 %), one quarter are motorbike drivers (25 %) and the rest are cyclists (14 %) and pedestrians (13 %). The mortality of patients with an ISS ³ 9 is 12.8 %. This value is approximately 1-2 % below the expected prognosis based on data from the 1990s. DISCUSSION: The TR-DGU is not only a successful instrument for external quality assurance of the treatment of severely injured patients but also an increasingly more valuable source for scientific evaluation within the framework of healthcare research. The introduction of regional trauma networks by the DGU has made a substantial contribution to the comprehensive compilation of severely injured patients and allows increasingly more detailed information on the epidemiology of severe injuries in Germany to be compiled.

A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality?

AIM: The aim of this study was to validate the classification of hypovolaemic shock given by the Advanced Trauma Life Support (ATLS). METHODS: Patients derived from the TraumaRegister DGU(®) database between 2002 and 2010 were analyzed. First, patients were allocated into the four classes of hypovolaemic shock by matching the combination of heart rate (HR), systolic blood pressure (SBP) and Glasgow Coma Scale (GCS) according to ATLS. Second, patients were classified by only one parameter (HR, SBP or GCS) according to the ATLS classification and the corresponding changes of the remaining two parameters were assessed within these four groups. Analyses of demographic, injury and therapy characteristics were performed as well. RESULTS: 36,504 patients were identified for further analysis. Only 3411 patients (9.3%) could be adequately classified according to ATLS, whereas 33,093 did not match the combination of all three criteria given by ATLS. When patients were grouped by HR, there was only a slight reduction of SBP associated with tachycardia. The median GCS declined from 12 to 3. When grouped by SBP, GCS dropped from 13 to 3 while there was no relevant tachycardia observed in any group. Patients with a GCS=15 presented normotensive and with a HR of 88/min, whereas patients with a GCS<12 showed a slight reduced SBP of 117mmHg and HR was unaltered. CONCLUSION: This study indicates that the ATLS classification of hypovolaemic shock does not seem to reflect clinical reality accurately.

[Standardized documentation in emergency departments with the core dataset of the DIVI]. / Standardisierte Dokumentation im Schockraum mit dem Kerndatensatz "Notaufnahme" der DIVI.

In Germany the documentation of every prehospital emergency medical treatment has been standardized since 1997 based on the core data-set MIND (minimal emergency physician data-set). Against this background it is very surprising that there is still no standardized data-set implemented for the documentation of early inhospital emergency care. In order to create such a data-set the current state of documentation in many different hospitals all over the country was scrutinized. In addition existing registries and international requirements were taken into consideration. Finally, a modular data-set was created using a Delphi process. This data-set was tested, clinically validated and finally ratified by the executive committee of the DIVI (German Interdisciplinary Association of Critical Care Medicine). The modular data-set was designed in such a way that a basic module forms the foundation for every patient. Process-oriented modules (e.g. surveillance) and symptom-oriented modules (e.g. trauma, neurology) were added if necessary. Along with this data-set a set of six modules was created for graphical representation when required. This high level of standardization not only allows an internal and external quality assessment but also provides a sophisticated documentation system especially to the trauma team in the emergency department. In terms of content major parameters of interhospital quality management are recorded and important factors of process management, such as MTS (Manchester triage system), ATLS (advanced trauma life support) and EWS (early warning score) have been implemented. The data-set includes all necessary information for transfers between physicians and non-academic staff as well as between physicians and could also be used as a fundamental discharge letter. Moreover, this new core data-set is the implementation of items required by existing registries into the daily routine documentation in order to reduce unnecessarily time-consuming and error-prone secondary data acquisition. For example, all items of the preclinical and emergency room documentation for the TraumaRegister DGU® (documentation phase S, A and B of the standard and QM form) have been included. This is sufficient for participation as a TraumaNetzwerk DGU® member as far as the early clinical treatment of multiple injured patients is concerned.

Epidemiology of in-hospital trauma deaths.

PURPOSE: About half of all trauma-related deaths occur after hospital admission. The present study tries to characterize trauma deaths according to the time of death, and, thereby, contributes to the discussion about factors considered as the cause of death. METHODS: Data from two large European trauma registries (Trauma Registry of the German Society of Trauma Surgery, TR-DGU, and the Trauma Audit and Research Network, TARN) were analyzed in parallel. All hospital deaths with Injury Severity Score (ISS) > 9 documented between 2000 and 2010 were considered. Patients were categorized into five subgroups according to the time to death (0-6 h; 7-24 h; day 1-6; day 7-30; beyond day 30). Surviving patients from the same time period served as a control group. RESULTS: In total, 6,685 and 6,867 non-survivors were included from the TR-DGU and TARN, respectively. The hospital mortality rate was between 15 and 17%. About half of all deaths occurred within the first 24 h after admission (TR-DGU: 54%; TARN: 45%). The earliest subgroup of trauma deaths showed the highest mean ISS and the highest rate of mass transfusions. Severe head injury was most frequently observed in the subgroup of day 1-6. Late deaths are associated with higher age and more complications (sepsis, multiple organ failure). CONCLUSIONS: The time to death after severe trauma does not follow a trimodal distribution but shows a constantly decreasing incidence.

Green plants in starling nests: effects on nestlings.

European starlings, Sturnus vulgaris, intermingle fresh herbs, especially species rich in volatile compounds, with their otherwise dry nest material. In this field study we investigated whether these herbs reduce ectoparasites and thereby protect nestlings (the nest protection hypothesis). We also considered whether volatile compounds in herbs improve the condition of nestlings (the drug hypothesis). As measures of condition we used body mass, haematocrit levels and immunological parameters. We replaced 148 natural starling nests with artificial ones: half contained herbs and half (controls) contained grass. The ectoparasite loads (mites, lice, fleas) in herb and control nests were indistinguishable. However, nestlings in herb nests weighed more and had higher haematocrit levels at fledging than nestlings in control nests. Fledging success was similar in herb and control nests, but more yearlings from herb nests were identified in the colony the year after hatching. The response of the immune system when challenged with phytohaemagglutinin did not differ in nestlings from herb and control nests. Nestlings from herb nests had more basophils and fewer lymphocytes in their blood than those from control nests, while the eosinophil and heterophil counts did not differ. We conclude that herbs do not reduce the number of ectoparasites, but they improve the condition of nestlings, perhaps by stimulating elements of the immune system that help them to cope better with the harmful activities of ectoparasites. Copyright 2000 The Association for the Study of Animal Behaviour.

Paprika (Capsicum annuum) oleoresin extraction with supercritical carbon dioxide.

Paprika oleoresin was fractionated by extraction with supercritical carbon dioxide (SCF-CO(2)). Higher extraction volumes, increasing extraction pressures, and similarly, the use of cosolvents such as 1% ethanol or acetone resulted in higher pigment yields. Within the 2000-7000 psi range, total oleoresin yield always approached 100%. Pigments isolated at lower pressures consisted almost exclusively of beta-carotene, while pigments obtained at higher pressures contained a greater proportion of red carotenoids (capsorubin, capsanthin, zeaxanthin, beta-cryptoxanthin) and small amounts of beta-carotene. The varying solubility of oil and pigments in SCF-CO(2) was optimized to obtain enriched and concentrated oleoresins through a two-stage extraction at 2000 and 6000 psi. This technique removes the paprika oil and beta-carotene during the first extraction step, allowing for second-stage oleoresin extracts with a high pigment concentration (200% relative to the reference) and a red:yellow pigment ratio of 1.8 (as compared to 1.3 in the reference).

Various dietary fibers have different effects on lipase-catalyzed hydrolysis of tributyrin in vitro.

The ability of various dietary fibers to impede lipase-catalyzed hydrolysis of tributyrin was studied in vitro. Conditions (temperature, kind and concentration of constituents, pH, agitation) were chosen to mimic, as closely as possible, those prevailing in the human duodenum. Lipolysis was monitored at pH 6.0 and 37 degrees C using a constant pH titrimeter. Some fibers inhibited lipolysis (red wheat bran, white wheat bran, oat bran and sugarbeet fiber), whereas most did not (psyllium seed, pectin LM 12CG, carrageenan, carboxymethylcellulose, gum arabic, and pectin slow set). Water extracts of the fibers accounted for 32-41% of the inhibitory effect of the two wheat brans on lipolysis and 100% of the inhibitory effect of oat bran.