Excellent agreement of Norwegian trauma registry data compared to corresponding data in electronic patient records.

BACKGROUND: The Norwegian Trauma Registry (NTR) is designed to monitor and improve the quality and outcome of trauma care delivered by Norwegian trauma hospitals. Patient care is evaluated through specific quality indicators, which are constructed of variables reported to the registry by certified registrars. Having high-quality data recorded in the registry is essential for the validity, trust and use of data. This study aims to perform a data quality check of a subset of core data elements in the registry by assessing agreement between data in the NTR and corresponding data in electronic patient records (EPRs). METHODS: We validated 49 of the 118 variables registered in the NTR by comparing those with the corresponding ones in electronic patient records for 180 patients with a trauma diagnosis admitted in 2019 at eight public hospitals. Agreement was quantified by calculating observed agreement, Cohen's Kappa and Gwet's first agreement coefficient (AC1) with 95% confidence intervals (CIs) for 27 nominal variables, quadratic weighted Cohen's Kappa and Gwet's second agreement coefficient (AC2) for five ordinal variables. For nine continuous, one date and seven time variables, we calculated intraclass correlation coefficient (ICC). RESULTS: Almost perfect agreement (AC1 /AC2/ ICC > 0.80) was observed for all examined variables. Nominal and ordinal variables showed Gwet's agreement coefficients ranging from 0.85 (95% CI: 0.79-0.91) to 1.00 (95% CI: 1.00-1.00). For continuous and time variables there were detected high values of intraclass correlation coefficients (ICC) between 0.88 (95% CI: 0.83-0.91) and 1.00 (CI 95%: 1.00-1.00). While missing values in both the NTR and EPRs were in general negligeable, we found a substantial amount of missing registrations for a continuous "Base excess" in the NTR. For some of the time variables missing values both in the NTR and EPRs were high. CONCLUSION: All tested variables in the Norwegian Trauma Registry displayed excellent agreement with the corresponding variables in electronic patient records. Variables in the registry that showed missing data need further examination.

Validation of the Norwegian survival prediction model in trauma (NORMIT) in Swedish trauma populations.

BACKGROUND: Trauma survival prediction models can be used for quality assessment in trauma populations. The Norwegian survival prediction model in trauma (NORMIT) has been updated recently and validated internally (NORMIT 2). The aim of this observational study was to compare the accuracy of NORMIT 1 and 2 in two Swedish trauma populations. METHODS: Adult patients registered in the national trauma registry during 2014-2016 were eligible for inclusion. The study populations comprised the total national trauma (NT) population, and a subpopulation of patients admitted to a single level I trauma centre (TC). The primary outcome was 30-day mortality. Model validation included receiver operating characteristic (ROC) curve analysis and GiViTI calibration belts. The calibration was also assessed in subgroups of severely injured patients (New Injury Severity Score (NISS) over 15). RESULTS: A total of 26 504 patients were included. Some 18·7 per cent of patients in the NT population and 2·6 per cent in the TC subpopulation were excluded owing to missing data, leaving 21 554 and 3972 respectively for analysis. NORMIT 1 and 2 showed excellent ability to distinguish between survivors and non-survivors in both populations, but poor agreement between predicted and observed outcome in the NT population with overestimation of survival, including in the subgroup with NISS over 15. In the TC subpopulation, NORMIT 1 underestimated survival irrespective of injury severity, but NORMIT 2 showed good calibration both in the total subpopulation and the subgroup with NISS over 15. CONCLUSION: NORMIT 2 is well suited to predict survival in a Swedish trauma centre population, irrespective of injury severity. Both NORMIT 1 and 2 performed poorly in a more heterogeneous national population of injured patients.

ANTECEDENTES: Los modelos de predicción de supervivencia en los traumatismos pueden ser utilizados para la evaluación de la calidad en las poblaciones con traumatismos. Recientemente, el modelo noruego de predicción de supervivencia en traumatismos (NORMIT) se ha actualizado y validado internamente (NORMIT 2). El objetivo de este estudio observacional fue comparar la precisión de los modelos NORMIT 1 y 2 en dos poblaciones suecas con traumatismos. MÉTODOS: Pacientes adultos registrados en el registro nacional de traumatismos durante 2014-2016 fueron elegibles para el estudio. Las poblaciones de estudio eran: (1) la población total nacional de traumatismos (national trauma, NT) y (2) una subpoblación de pacientes ingresados en un único centro de trauma de nivel I (trauma centre, TC). El resultado primario fue la mortalidad a los 30 días. La validación del modelo incluyó curvas de características operativas del receptor y cinturones GiViTI de calibración. La calibración también se evaluó en subgrupos de pacientes con lesiones graves (New Injury Severity Score, NISS >15). RESULTADOS: Se incluyeron un total de 26.504 pacientes. La exclusión por falta de datos fue del 18,7% en la población NT (n = 21.554) y del 2,6% en la población TC (n = 3.972). Los modelos NORMIT 1 y 2 mostraron una habilidad excelente para distinguir entre supervivientes y no supervivientes en ambas poblaciones, pero con un grado de acuerdo pobre entre el resultado predicho y el observado en la población NT, con sobreestimación de la supervivencia incluido el subgrupo de NISS >15. En la subpoblación TC, NORMIT 1 subestimó la supervivencia independientemente de la gravedad de la lesión, pero NORMIT 2 mostró una buena calibración tanto en la subpoblación total, como en el subgrupo NISS >15. CONCLUSIÓN: El modelo NORMIT 2 es muy apropiado para predecir la supervivencia en la población de un centro de traumatismos sueco independientemente de la gravedad de la lesión. Los modelos tanto NORMIT 1 como NORMIT 2 funcionan mal en una población de traumatismos nacional más heterogenea.

Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury.

BACKGROUND: Hypothermia, acidosis and coagulopathy have long been considered critical combinations after severe injury. The aim of this review was to give a clinical update on this triad in severely injured patients. METHODS: A non-systematic literature search on hypothermia, acidosis and coagulopathy after major injury was undertaken, with a focus on clinical data from the past 5 years. RESULTS: Hypothermia (less than 35 °C) is reported in 1·6-13·3 per cent of injured patients. The occurrence of acidosis is difficult to estimate, but usually follows other physiological disturbances. Trauma-induced coagulopathy (TIC) has both endogenous and exogenous components. Endogenous acute traumatic coagulopathy is associated with shock and hypoperfusion. Exogenous effects of dilution from fluid resuscitation and consumption through bleeding and loss of coagulation factors further add to TIC. TIC is present in 10-34 per cent of injured patients, depending on injury severity, acidosis, hypothermia and hypoperfusion. More expedient detection of coagulopathy is needed. Thromboelastography may be a useful point-of-care measurement. Management of TIC is controversial, with conflicting reports on blood component therapy in terms of both outcome and ratios of blood products to other fluids, particularly in the context of civilian trauma. CONCLUSION: The triad of hypothermia, acidosis and coagulopathy after severe trauma appears to be fairly rare but does carry a poor prognosis. Future research should define modes of early detection and targeted therapy.

Using the Mini-Mental State Examination to screen for delirium in elderly patients with hip fracture.

BACKGROUND: The main aim of this paper was to examine the usefulness of the Mini-Mental State Examination (MMSE) for screening delirium in elderly patients with hip fracture. METHODS: The sample included 364 elderly patients with hip fracture admitted to two hospitals in Oslo. Delirium was assessed by the Confusion Assessment Method (CAM) as an approximation of the gold standard, DSM-IV. To evaluate the psychometric properties of the MMSE scale, we used the Mokken nonparametric latent trait model for unidimensional scaling. RESULTS: In total, 76 (21%) patients were diagnosed with delirium based on the CAM, and 141 (43%) had preexisting cognitive impairment. As a screening tool, the recommended MMSE cut-point of 24 showed an acceptable sensitivity of 88% with a specificity of 54%. The prediction of delirium, based on logistic regression on the MMSE total score and on the 5 items selected by the stepwise logistic regression procedure, gave clearly less acceptable results. CONCLUSIONS: Our study indicates that the MMSE may be useful in screening for delirium, but the high percentage of false positives shows that it does not have diagnostic potential in patients with hip fracture.

Feasibility of comparing core data from existing trauma registries in scandinavia. Reaching for a Scandinavian major trauma outcome study (MTOS).

BACKGROUND: The organisation of trauma care in Scandinavia has several similarities, including trauma registries, but so far there are limited amount of research on efficiency and outcome. Data and results from trauma outcome studies like the US MTOS are not fully applicable to the Scandinavian trauma population. AIMS: To reveal the feasibility of using data from existing trauma registries of major hospitals in Scandinavia, for a minimal common dataset, in a joint, prospective Scandinavian MTOS. MATERIAL AND METHODS: We collected data points, data point definitions, and inclusion/exclusion criteria, from the major trauma registries of the Swedish trauma registry standard, three university hospitals in Denmark, one university hospital in Finland, and the Norwegian National Trauma Registry. The collected material was compared to reveal common data points, inclusion criteria, and the compatibility of data point definitions. RESULTS: The median number of data points was 147 (range 71-257; interquartile range = 90-205). Most registries lacked precise data definition catalogues. Only 16 data points could be considered as common, of which just a few were core trauma data. Four data points had the same data category options but were not considered having the same data point definitions. The inclusion criteria were not uniform. CONCLUSIONS: Trauma registries in Scandinavia have few common core data and data point definitions. There were data points for calculating the Trauma and Injury Severity Score (TRISS) but the inclusion criteria varied too much to ensure a valid comparison. A consensus process for a joint trauma core data set will be initiated by the Scandinavian Networking Group for Trauma and Emergency Management (SCANTEM) to increase research on trauma efficiency and outcome.

Factors affecting grief reactions in close family members to individuals who have died of cancer.

This longitudinal study examined factors related to grief reactions in a systematic and standardized way in 183 close family members to individuals who died of cancer. Grief reactions were measured using the Texas Revised Inventory of Grief (TRIG). A repeated measures MANOVA was used to test and compare the grief reactions of the bereaved for one year after the loss. The female respondents showed stronger grief reactions than the male respondents. The grief reactions increased with age, and those who had lost a younger family member experienced stronger grief reactions than those who had lost an older family member. The relationship to the deceased, the duration of the disease, place of death, aspects of social support such as children living at home, and employment were not related to the grief reactions in the bereaved respondents when controlling for the former factors.

The first year of grief and bereavement in close family members to individuals who have died of cancer.

Using a systematic and standardized method this longitudinal study examines changes in grief reactions in a sample of close family members (n = 183) to individuals who had died of cancer. The respondents were followed for 1 year after the loss. The study sample originated from a cluster randomized trial evaluating comprehensive palliative care (intervention) against conventional care (control). Hence, we also compared grief reactions among close family members to the patients in the intervention and control groups. Overall, the family members' grief reactions, as measured by the second part of the Texas Revised Inventory of Grief (TRIG), showed a significant decline over the period studied. However, we found no significant differences in grief reactions between the family members to the intervention and control patients at any point in time, and the pattern of change did not differ significantly for the two groups.

A follow-up study of the quality of life in cancer patients with different prognoses.

The present study examines differences in quality of life between two points in time in a heterogeneous sample of cancer patients with different prognoses. The original sample comprised 253 patients, while the follow-up data obtained 3-4 years later included 75 patients, that is, 92% of the survivors. All the patients completed a questionnaire including the EORTC QLQ-C30. The research questions focus on overall changes in quality of life, and whether patients with a good prognosis would show less negative changes in quality of life than patients with a poor prognosis. The overall observed changes in quality of life were surprisingly small over a 3-4 year period. This study shows that prognoses do predict changes in social functioning and in some physical aspects of quality of life over a 3-4 year period after the assessment of prognoses by physicians. Prognoses did not, however, predict changes in psychological aspects of quality of life.

Assessing the consistency of psychometric properties of the HRQoL scales within the EORTC QLQ-C30 across populations by means of the Mokken Scaling Model.

This paper demonstrates how the Mokken Scaling Model and other statistical tools may be useful in assessing the consistency of psychometric properties of health-related quality of life (HRQoL) scales across various populations. The main focus is the psychometric performance of the scales proposed for the EORTC QLQ-C30 in seven patient groups totalling more than 2,000 cancer patients. All scales performed satisfactorily in the total sample with the exception of the role functioning and cognitive functioning scales, which failed in terms of reliability and item discriminant validity. The descriptive statistics for the scales show that several of them, particularly those that build upon only two items, have discrimination problems at the extremes, visible in the high percentages at the maximum or the minimum observed values. The scalability analysis in the subsamples showed that the essential assumption in the Mokken Scaling Model of equal item step order does not hold for the cognitive functioning, emotional functioning and physical functioning scales. We conclude that the Mokken Scaling Model is well suited to the purpose of examining the generalizability of HRQoL scales across subpopulations although a global statistical test of the fit of the measurement model is not available.

Prognostic factors and survival in a heterogeneous sample of cancer patients.

This study examines the prognostic value of clinical assessments, including a 3-fold classification of cancer patients by treatment intention. It is based upon a sample of 253 patients with different cancer diagnoses who filled out a 108-item questionnaire. Cox regression analysis (the proportional hazards model) was used to analyse the relationship of the three groups of covariates (clinical, demographic and psychosocial) with survival. The univariate analysis showed that several clinical, demographic and psychosocial covariates are significantly related to survival. The study located two main prognostic factors: the 3-fold classification by treatment intention being the most important one, followed by physical functioning which may be seen as a proxy for performance status. Several additional covariates including psychosocial ones were related to survival when considered separately. However, their effects disappeared when controlling for treatment intention and physical functioning. Thus, the additional psychosocial covariates did no add to the prognostic value of the model.

Quality of life of cancer patients with different prognoses.

This study examines differences and similarities in the quality of life of 253 cancer patients with good, medium and poor prognoses. Our main hypothesis was that patients with a good prognosis will experience a higher quality of life than patients with a medium or poor prognosis. A multivariate analysis of covariance of eight quality of life scales was performed with prognosis as a factor and with age, sex, and the duration of the illness as covariates. Significant main effects of prognosis were found for the general QOL-scale and for physical aspects of quality of life. There were, however, only marginal and non-significant effects of prognosis groups on social and psychological functioning. A final multivariate analysis confirms earlier findings that performance status shows a weak but significant relationship with the psychological functioning. Thus, the physical condition of the patient at the time of measurement seems to have some influence on the psychological functioning, whereas the severity of the disease as indicated by the classification into prognosis groups does not. These results question the general attitude that seriously ill cancer patients have reduced social and psychological well-being. An alternative interpretation is that the scales used to measure psychological aspects of quality of life are inadequately sensitive.

Testing the EORTC Quality of Life Questionnaire on cancer patients with heterogeneous diagnoses.

This study aimed to contribute to the validation of the 30-item Quality of Life Questionnaire developed by the European Organization for Research and Treatment of Cancer Study Group (EORTC QLQ-C30). The sample consisted of 177 cancer patients with heterogeneous diagnoses. A series of scales representing various dimensions of quality of life were tested, including those proposed by the EORTC Study Group. Mokken's non-parametric latent trait model for unidimensional scaling was used as the basic scaling procedure. This model gives coefficients of scalability in addition to reliability coefficients. In terms of scalability measured by Loevinger's H, all EORTC Study Group scales, except the cognitive functioning scale were found to be quite satisfactory. The cognitive functioning scale and the role functioning scale were below the satisfactory level in terms of reliability (internal consistency). In total, our study strengthens the external validity of the EORTC QLQ-C30 and confirms that it may be used on cancer patients with various diagnoses.