Trauma survival prediction in Asian population: a modification of TRISS to improve accuracy.

UNLABELLED: The probability of survival (PS) in blunt trauma as calculated by Trauma and Injury Severity Score (TRISS) has been an indispensable tool in trauma audit. The aim of this study is to explore the predictive performance of the latest updated TRISS model by investigating the Age variable recategorisations and application of local Injury Severity Score (ISS) and Revised Trauma Score (RTS) coefficients in a logistic model using a level I trauma centre database involving Asian population. METHODS: Prospectively and consecutively collected 5684 trauma patients' data over a 10-year period at a regional level I trauma centre were reviewed. Four modified TRISS (mTRISS) models using Age coefficient from reclassifications of the Age variable according to their correlation with survival by logistic regression on the local dataset were acquired. RTS and ISS coefficients were derived from the local dataset and then applied to the mTRISS models. mTRISS models were compared with the existing Major Trauma Outcome Study (MTOS)-derived TRISS (eTRISS) model. Model 1=Age effect taken as linear; Model 2=Age classified into two groups (0-54, 55+); Model 3=Age classified into four groups (0-15, 16-54, 55-79, 80+) and Model 4=Age classified into two groups (0-69, 70+). Performance measures including sensitivity, specificity, accuracy and area under the Receiver Operating Characteristic (ROC) curve were used to assess the various models. The cross-validation procedure consisted of comparing the P(S) obtained from mTRISS Models 1 and 2 with the P(S) obtained from the MTOS derived from eTRISS. RESULTS: A 5147 blunt trauma patients' dataset was reviewed. Model 1, where Age was taken as a scale variable, demonstrated a substantial improvement in the survival prediction with 91.6% accuracy in blunt injuries as compared with 89.2% in the MTOS-derived TRISS. The 95% CI for ROC derived from mTRISS Model 1 was (0.923, 0.940), when compared with the hypothesised ROC value 0.886 obtained from eTRISS, it clearly indicated a significant improvement in predicting survival at 5% level. Furthermore, ROCs have shown clearly the superiority of Model 1 over Model 2, and of Model 2 over MTOS-derived TRISS. The recategorisation of the Age variable (Models 3 and 4) also demonstrated improved performance, but their strength was not as intense as in Model 1. Overall, the results point to the adoption of Model 1 as the best model for PS. Cross-validation analysis has further assured the validity of these findings. CONCLUSIONS: The present study has demonstrated that (1) having the Age variable being dichotomised (cut-off at 55 years) as in the eTRISS, but with the application of a local dataset-derived coefficients give better TRISS survival prediction in Asian blunt trauma patients; (2) improved performance are found with certain recategorisation of the Age variable and (3) the accuracy can further be enhanced if the Age effect is taken to be linear, with the application of local dataset-derived coefficients.

Flavored anesthetic lozenge versus Xylocaine spray used as topical pharyngeal anesthesia for unsedated esophagogastroduodenoscopy: a randomized placebo-controlled trial.

BACKGROUND: The use of Xylocaine spray has been the common practice in many endoscopy centers, but scientific evidence is not conclusive on its superiority over other forms of topical anesthesia. This study aimed to compare the effectiveness of Xylocaine spray as a topical pharyngeal anesthesia for upper endoscopy and that of anesthetic lozenges with a characteristic flavor. METHODS: A randomized placebo-controlled trial was performed in a single endoscopy center. For this study, 191 consecutive patients ages 18 to 70 undergoing outpatient esophagogastroduodenoscopy were randomized before the procedure into either a spray group (10% Xylocaine pump spray plus plain Strepsils) or a lozenge group (Strepsils Dual Action anesthetic lozenge plus distilled water spray). The primary outcome was the patient tolerance score, calculated according to the taste of the anesthetic agent, the intensity of numbness, the amount of cough or gag, and the degree of discomfort at esophageal intubation. The secondary outcomes included difficulty of esophageal intubation and the patients' and endoscopists' satisfaction score for the procedure. RESULTS: Randomization assigned 97 patients to the lozenge group and 94 patients to the spray group. The demographic data were similar in the two groups. The spray group had a significantly higher patient tolerance score, a greater intensity of numbness, less gag reflex, and less discomfort than the lozenge group. The lozenge group had a better taste than the spray group. The difficulty of esophageal intubation and the patients' and endoscopists' satisfaction were comparable between the two groups. CONCLUSIONS: Topical Xylocaine spray is superior to the flavored anesthetic lozenge as a topical pharyngeal anesthesia in unsedated esophagogastroduodenoscopy.