Increased Age, Cardiovascular Comorbidities, COPD, and Diabetes mellitus Determine Excess Mortality in Trauma Patients with SSI or Chronic Wounds. / Erhöhtes Alter, kardiovaskuläre Nebenerkrankungen, COPD und Diabetes mellitus bedingen eine Übersterblichkeit in der septischen Unfallchirurgie.

BACKGROUND: The constant aging of the German population leads, among other things, to an increase in the average age of hospitalised patients. In association with the reduced physiological reserve and the endogenous defence mechanism, this results in an increased susceptibility to infections and complications. Compared with that in trauma patients, the age distribution in patients with surgical site infections (SSI) has been poorly studied. Studies on the impact of age, diverse underlying diseases and influence of alcohol and nicotine consumption on the mortality risk in patients with SSI are limited. METHODS: In 2014/15 (Exam 1), 345 patients with SSI were included in this study. The 3-year follow-up examination was performed in 2017/18 (Exam 2). The questionnaires (Exams 1 and 2) assessed demographic parameters, comorbidities, medication use, alcohol and nicotine consumption, and different risk factors related to morbidity. The mortality risk in patients with SSI was calculated as a function of various risk factors (age, comorbidities, medication intake, and noxious agents). Furthermore, the development of the patients' age in the trauma department, especially of those with SSI, were evaluated between 2010 and 2019. RESULTS: In 2014/15 (Exam 1), 345 patients were included in the study. Of these, 274 (79.4%) were contacted by telephone in 2017/18. Thirty-six (10.4%) declined to be questioned again. Twenty (8.4%) of the 238 remaining participants had already died, resulting in 218 patients (63.2%) re-participating. From 2010 (n = 492) to 2019 (n = 885), the number of patients with SSI increased by 79.9%, especially those aged < 65 years. After the age of 60 years, the mortality risk increased rapidly (60 years: 0.0377 vs 70 years: 0.1395); the mortality risk of a 60-year-old patient with SSI was equal to that of an 80-year-old in the general population. Nicotine (p = 0.93) and alcohol consumption (p = 0.344) had no significant effect on mortality, whereas history of cardiac disease (p = 0.01), chronic obstructive pulmonary disease (COPD) (p = 0.01), diabetes mellitus (p = 0.05) and peripheral artery disease (p = 0.01) were associated with a significant increase in the mortality risk. CONCLUSION: Age, pre-existing cardiac conditions, as well as COPD, diabetes mellitus and peripheral artery disease are associated with a significantly increased mortality risk in patients with SSI. Thus, an exponential increase in mortality risk was found between the ages of 50 and 60 years, with the mortality risk of a 60-year-old patient with SSI being equivalent to that of an 80-year-old in the general population.

Comparability of Patient-reported Outcome Measures and Clinical Assessment Tools for Shoulder Function in Patients with Proximal Humeral Fracture. / Vergleichbarkeit subjektiver, durch den Patienten beantworteter Feedbackfragebögen und klinischer Fragebögen zur Beurteilung der Schulterfunktion bei Patienten mit proximaler Humerusfraktur.

BACKGROUND: Patient-reported outcome measures (PROMs) are gaining increasing importance in the context of quality management. Different PROMs and scoring tools are available to assess shoulder function after proximal humeral fracture (PHFx). In Europe, these include the Constant-Murley Score (CS), Neer Score (NS), Oxford Shoulder Score (OSS), University of California at Los Angeles Score (UCLA) and Disabilities of the Arm, Shoulder and Hands Score (DASH). In addition, the health-related quality of life can be assessed by the PROMs Short Form 36 (SF-36) and EuroQol (EQ-5D). Although all these test instruments assess shoulder function, the components to be answered objectively and subjectively vary and thus the possibility of independent assessment. The aim of the present study is to compare the correlation between the results of the different PROMs and the clinical screening tools in patients with PHFx. METHODS: 76 patients who were treated with angular stable plate osteosynthesis for a proximal humeral fracture between 01/2001 and 12/2005 were included in this trial. The outcome was measured with PROMs or clinical scoring tools such as CS, NS, OSS, UCLA, DASH, SF-36 and EQ-5D and a correlation coefficient between those evaluation tools was calculated. In addition, a distinction was made between the two force measurement methods (wrist [HG] vs. deltoid muscle [DM]) for CS. RESULTS: The correlation of the results of CS and NS (HG: r = 0.85; p < 0.001/DM: r = 0.93; p < 0.001), CS and UCLA (HG: r = 0.83; p < 0.001/DM: r = 0.86; p < 0.001), NS and UCLA (r = 0.91; p < 0.001) as well as DASH and OSS (r = 0.88; p < 0.001) was strongly expressed. A good comparability of the results was demonstrated between CS and OSS (HG: r = 0.63; p < 0.001/DM: r = 0.66; p < 0.001) and between CS and DASH (HG: r = 0.62; p < 0.001/DM: r = 0.61; p < 0.001). The correlation of CS (HG/DM) and UCLA with the EQ-5D index was also good. Assessment of the physical components of SF-36 with CS, NS, OSS, UCLA and DASH showed a moderate to good association, while the mental components of SF-36 showed a low correlation (p > 0.05). CONCLUSION: The assessment of shoulder function after proximal humerus fracture showed a very strong correlation within the clinical questionnaires (CS/NS/UCLA) and the PROMs (OSS/DASH). A strong correlation also exists between the clinical questionnaires and the PROMs. There was only a moderate correlation with the EQ-5D. The moderate to strong correlation between the physical components of SF-36, with almost no correlation between the mental components of SF-36, indicates that the quality of life restriction is based on a physical, but not on a mental impairment.

Risk of malnutrition in orthopedic trauma patients with surgical site infections is associated with increased morbidity and mortality - a 3-year follow-up study.

BACKGROUND: Malnutrition is a worldwide problem which can result in prolonged hospitalization from complications such as poor wound healing and increased morbidity. There is increasing evidence of the effect of risk of malnutrition (ROM) on outcomes in orthopedic surgical patients. However, there is little data on the effect of nutritional status on clinical outcomes in orthopedic trauma patients with surgical site infections (SSI). Therefore, our aim was to investigate how malnutrition risk affects clinical outcomes in a prospective cohort of orthopedic trauma patients with SSI. METHODS: The study included 345 patients who underwent surgery due to SSI at a level 1 trauma center. All patients were evaluated on their nutritional status as assessed by the Nutritional Risk Screening in 2014/15 and 2017/18. 238 (69.0%) datasets were available for the follow-up analysis. Twenty patients (8.4%) had died, resulting in 218 patients. Outcomes investigated included comorbidities, medication intake, destination of discharge, degree of mobility, support for procuring food, mortality risk and quality of life. RESULTS: 32.8% were at risk of malnutrition (ROM) at EXAM1. Female patients had a higher ROM than males (p < 0.05). Patients with ROM had more comorbidities (p < 0.001), an increased need for medication intake (p < 0.001), a decreased level of mobility (p < 0.001) and increased need of support in procuring food (p < 0.001). The destination of discharge was independent of the nutritional status (p = 0.641). Twenty (8.4%) of the available 238 patients had died during follow-up time period, resulting in a 6.2-times higher risk of mortality in patients with ROM. EQ-5D revealed that mobility, self-supply and usual activities of daily living were increased in well-nourished patients (p < 0.001). CONCLUSION: ROM in orthopedic trauma patients with SSI is associated with an increased number of comorbidities and need for medication intake, a decrease in mobility and a higher dependency for food acquisition. Patients at ROM exhibited a 6.2-times higher mortality rate than well-nourished patients. EQ-5D evaluation showed better mobility, self-supply, and activity of daily living in well-nourished patients. We therefore strongly recommend supplementing patients with ROM with a specific diet during and after discharge from the hospital in order to reduce postoperative complications and long-term mortality.

S100B Serum Level is Independent of Moderate Alcohol Intoxication. / S100B-Serumniveau ist unabhängig von moderatem Alkoholkonsum.

OBJECTIVE: In Germany, among patients with minor head injury (MHI), the incidence of coexisting alcohol intoxication is indicated up to 50%. The neurological symptoms of patients with MHI may be caused or altered by alcohol intoxication, this could mislead to further, potential harmful, diagnostic steps or to misinterpretation of the symptoms and to non-execution of necessary treatments. In order to decide which patients need further diagnostics by CCT, S100B has been proposed as a potential selection criterion. On the other hand, studies have hypothesized that alcohol intoxication may lead to elevated S100B serum levels. Therefore, the present study aims to investigate the relationship between the blood ethyl alcohol concentration and the S100B serum concentration in an experimental setting in young human adult volunteers. METHODS: In a cohort of 58 healthy volunteers, serum S100B concentration and blood ethyl alcohol concentration were measured before and after liberately drinking alcohol. The study was approved by the local Ethics Committee of the Medical Faculty Mannheim (Ethics Committee II, AZ 2012-272 N-MA). Instantaneous analysis of the samples was carried out using state-of-the art automated measuring systems. (Analyzer Cobas e411, Roche and Analyzer Dimension Vista 1500, Siemens). RESULTS: After drinking, alcohol levels ranged from 0,23 to 1,92 g/l. The S100B value ranged from to 0,021 to 0,115 µg/l after alcohol consumption (S100B standard value < 0,11 µg/l). By calculating the Pearson correlation of empirical correlation after drinking alcohol with r = 0.01181, a correlation between serum S100B concentration and ethyl alcohol concentration is not probable. The S100B concentrations were independent on the alcohol intake in low to medium alcohol levels. CONCLUSION: A relevant alcohol blood concentration (~ 1 g/l), in otherwise healthy volunteers, does not affect the serum concentration of S100B. S100B may be a useful brain injury marker in low to moderate drunken patients.

Evaluation of the Constant score: which is the method to assess the objective strength?

BACKGROUND: The Constant score (CS) is one of the most frequently applied tools for the assessment of the shoulder joint. However, evaluation of strength is not standardized leading to potential bias when comparing different studies. METHODS: Seventy-six patients with fractures of the proximal humerus undergoing open reduction and internal fixation (ORIF) were assessed using standardized CS strength measurements at the deltoid muscle insertion and at the wrist in three different arm positions. Variation coefficients were evaluated for each patient and position. RESULTS: Forty women (57%) and 36 men (43%) were examined 96 months in mean after ORIF. We could state a maximum of 105.3 N difference if measurements were performed at the wrist or the insertion of the deltoid muscle in 90° forward flexion on the injured arm (167.9 ± 83.1 N; 62.6 ± 29.4 N). The lowest variation coefficient of the three performed measurements could be stated at the deltoid muscle insertion in a 90° abduction position in the scapula plane (6.94 ± 5.5). CONCLUSION: Following our study results, different positions of force measurement can change the total CS by a whole category (e.g. "very good" to "good"). We recommend performing the measurement at the insertion of the deltoid muscle in a 90° abduction position in the scapula plane. Otherwise, even in the non-injured, it is hard to reach a "normal" shoulder function, based on the CS. When using the CS as outcome parameter, authors must give detailed information about the force measuring and use an exact measuring device.

The continuous downgrading of malnutrition in the German DRG system: possible effects on the treatment of patients at risk for malnutrition.

It has been internationally recognized that malnutrition is an independent risk factor for patients' clinical outcome. A new mandatory fixed price payment system based on diagnosis-related groups (G-DRG) went into effect in 2004. The aim of our study was to demonstrate the importance of carefully coding the secondary diagnosis of "malnutrition" in the G-DRG system and to highlight how the economic relevance of malnutrition in the G-DRG system has changed from 2014 to 2016. 1372 inpatients at the Berufsgenossenschaftliche Unfallklinik (Trauma Center) in Tübingen were screened for the risk of malnutrition using Nutritional Risk Screening (NRS-2002). Patient data were compared with the NRS values collected during the study and a case simulation was carried out separately for each year. We used the codes E44.0 for NRS = 3 and E43.0 for NRS > 3. The ICD codes were entered as an additional secondary diagnosis in the internal hospital accounting system DIACOS to determine possible changes in the effective weight. In 2014 the highest additional revenue by far was calculated by coding malnutrition. For the 638 patients enrolled in the study in 2014, we were able to calculate an average additional revenue per patient coded with malnourishment of €107. In 2016, we were unable to calculate any additional revenue for the 149 patients enrolled. Although it is well known that malnutrition is an independent risk factor for poor patient outcomes, nationwide screening for a risk of malnutrition when patients are admitted to a hospital is still not required. For this reason, malnutrition in German hospitals continues to be insufficiently documented. Due to the continuous downgrading of diagnosis-related severity (CCL) of malnutrition in the G-DRG system in trauma surgery patients, it is no longer possible to refinance the costs incurred by malnourished patients through the conscientious coding of malnutrition. We assume that the indirect positive effects of nutritional interventions will have to be taken into account more in the costing calculations and possibly lead to indirect cost compensation.

Assessment of the Influence of Diabetes mellitus and Malnutrition on the Postoperative Complication Rate and Quality of Life of Patients in a Clinic Focused on Trauma Surgery. / Einschätzung der Auswirkungen eines Diabetes mellitus und einer Mangelernährung auf die postoperative Komplikationsrate und Lebensqualität von Patienten in einer unfallchirurgischen Schwerpunktklinik.

BACKGROUND: The prevalence of diabetes mellitus (DM) or malnutrition in hospitalised patients depends on the clinical domain, but is much higher than in the normal population. In trauma surgery, this increase is frequently associated with more postoperative complications and constantly rising costs. In addition, the quality of life of this target group is decreased, but there are only limited data from departments of traumatology and/or orthopaedics. Therefore, we aim to analyse the factors influencing the postoperative complication rate as well as the quality of life of orthopaedic and trauma patients. METHODS: Within this prospective trial in the period of 06/2014 to 02/2017, we analysed data of 1643 patients from traumatology - geriatric and septic traumatology - as well as endoprosthetics with regard to the clinical outcome, the complication rate and the quality of life (Short Form Health Survey 36, SF-36) associated with diabetes mellitus (DM) and the nutritional status (Nutritional Risk Screening 2002, NRS). RESULTS: Within our hospitalised group of trauma patients, the prevalence of diabetes mellitus was 12.4% and the risk for malnutrition (NRS ≥ 3) was 18.3%, which is much higher than in the normal population (DM 7.2%). Patients suffering from diabetes mellitus had significantly more complications than patients without diabetes mellitus. Similar results were found when comparing patients with a risk of malnutrition to the patients without. Furthermore, patients with DM evaluate their subjective quality of life lower than do patients without DM in the most domains of the SF-36, especially in the subjective-physical domains, while patients with NRS ≥ 3 assess their quality of life as being lower than do patients without a risk of malnutrition in all domains of the SF-36 (physical and mental). Additionally, we showed that reduced nutritional status has a greater influence on the decline in quality of life than did diabetes mellitus. CONCLUSION: Both diabetes mellitus and malnutrition seems to influence the subjective quality of life and the complication rate of hospitalised trauma patients. A nationwide data collection and targeted interventions within the frame of interdisciplinary cooperation are necessary. In this way, the postoperative complication rate as well as associated higher treatment costs could be reduced.

TNF-related apoptosis-inducing ligand deficiency enhances survival in murine colon ascendens stent peritonitis.

BACKGROUND: Apart from inducing apoptosis in tumor cells, tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) influences inflammatory reactions. Murine colon ascendens stent peritonitis (CASP) represents a model of diffuse peritonitis. Recently, it has been demonstrated that administration of exogenous TRAIL not only induces apoptosis in neutrophils but also enhances survival in this model. The aim of this study was to examine the impact of genetic TRAIL deficiency on the course of CASP. METHODS: Peritonitis was induced in 6- to 8-week-old female TRAIL (-/-) mice as well as in wild-type mice. The sepsis severity score and survival of mice were monitored. Bacterial loads in blood as well as in the lymphoid organs were examined. Additionally, the number of apoptotic cells within the lymphoid organs was determined. RESULTS: As early as 8 hours postinduction of CASP, TRAIL (-/-) mice were significantly more affected by sepsis than wild-type mice, as measured by the sepsis severity score. However, during the further course of sepsis, TRAIL deficiency led to significantly decreased sepsis severity scores, resulting in an enhanced overall survival in TRAIL (-/-) mice. The better survival of TRAIL (-/-) mice was accompanied by a decreased bacterial load within the blood. In marked contrast, the number of apoptotic cells within the lymphoid organs was highly increased in TRAIL (-/-) mice 20 hours after induction of CASP. CONCLUSION: Hence, exogenous and endogenous TRAIL is protective during the early phase of sepsis, while endogenous TRAIL appears to be detrimental in the later course of this disease.