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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 688] [Impact Index Per Article: 137.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. RESULTS Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group's belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.
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Affiliation(s)
- Donat R. Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic
- Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005 Hradec Kralove, Czech Republic
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003 Hradec Kralove, Czech Republic
- Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS B3H 2Y9 Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Beverley J. Hunt
- King’s College and Departments of Haematology and Pathology, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000 Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924 Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181 Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
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Kim TH, Yoon YC, Chung JY, Song HK. Strategies for the management of hemodynamically unstable pelvic fractures: From preperitoneal pelvic packing to definitive internal fixation. Asian J Surg 2019; 42:941-946. [PMID: 30685148 DOI: 10.1016/j.asjsur.2019.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/04/2019] [Accepted: 01/07/2019] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND/OBJECTIVE Preperitoneal pelvic packing is useful, and favorable treatment outcomes have been reported. However, the timing of subsequent internal fixation of the pelvis is still debatable. We report the outcomes of a study on patients that underwent internal fixation after preperitoneal packing. METHODS A retrospective review was performed for patients with hemodynamically unstable pelvic fracture who underwent preperitoneal pelvic packing and internal fixation. Patients who underwent internal fixation with simultaneous packing removal were placed in Group 1. Patients who underwent definitive internal fixation later were placed in Group 2. RESULTS Of the 56 patients (mean age 44.7 years), 36 were male. The mean time from injury to internal fixation was 1.3 (1-2) days and 5.6 (3-10) days in Group 1 and 2, respectively. There was a significant difference in the mean duration of stay in the intensive care unit: 10.9 (3-54) days in Group 1 vs. 14.4 (5-43) days in Group 2 (p = 0.019). Thirty-one cases of complications occurred among 14 patients (25%), including six cases of surgical site infection. Among the six cases of infection, four were superficial and two were deep; five of these cases occurred in Group 2, including both cases of deep infection (p = 0.013). CONCLUSION Performing internal fixation with packing removal should aid the return of the patient to a stable state, as it is possible to utilize the same incision line used for the original packing procedure, while providing stability to the pelvis.
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Affiliation(s)
- Tae Hun Kim
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Yong Cheol Yoon
- Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, Incheon, South Korea
| | - Jun Young Chung
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, South Korea
| | - Hyung Keun Song
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, South Korea.
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Blondeau B, Orlando A, Jarvis S, Banton K, Berg GM, Patel N, Meinig R, Tanner A, Carrick M, Bar-Or D. Variability in pelvic packing practices for hemodynamically unstable pelvic fractures at US level 1 trauma centers. Patient Saf Surg 2019; 13:3. [PMID: 30675184 PMCID: PMC6334446 DOI: 10.1186/s13037-019-0183-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Mortality from hemodynamically unstable pelvic fractures remains high. Guidelines offer varying care approaches including the use of pelvic packing (PP), which was recently adopted for potential control of bleeding for this condition. However, the implementation of PP is uncertain as the debate on the optimal resuscitation strategy, angioembolization or PP continues. The study was designed to assess current practices among level 1 trauma centers in the US in regard to PP treatment for hemodynamically unstable pelvic fractures. METHODS A cross-sectional survey was created to assess when to apply PP, application approach, and the respondent's anecdotal perception on safety and effectiveness. Trauma Medical Directors at 158 US level 1 trauma centers were sent biweekly email invitations for 3 months. Participants were allowed to skip questions for any reason. The study hypothesis was that PP practices vary by US census bureau region, annual trauma admissions, and length of time in years since each trauma center received their respective level 1 trauma center designation. RESULTS Twenty-five percent (40/158) of trauma medical directors participated and 75% (118/158) of the trauma medical directors did not participate. Of those who took the survey, 36/40 (90%) completed the survey and 4/40 (10%) partially completed the survey. Only 36 trauma medical directors responded on their perception of safety and effectiveness; 72% (26/36) of participants perceived PP as safe, whereas only a third (12/36) of participants perceived PP as effective. There were 25 trauma medical directors who provided the sequence of treatment modalities utilized at their level 1 trauma center, 76% (19/25) of participants reported that PP is utilized as the third or fourth priority. None of the participating level 1 trauma centers reported a preference towards utilization of PP as the first priority treatment. Half of the participants reported a preference towards applying PP only as a last resort to control hemorrhage. Northeastern and Western level 1 trauma centers were significantly more likely than Midwestern and Southern level 1 trauma centers to have reported application of PP to all hemodynamically unstable patients (p = 0.05). Midwestern, Southern, and Western level 1 trauma centers were significantly more likely to have perceived PP as safe than Northeastern level 1 trauma centers (p = 0.04). All low-volume and 38% high-volume level 1 trauma centers perceived PP to increase infection risks, (p = 0.03). We observed no association between the length of time each trauma center was designated a level 1 trauma center, and all participant responses. CONCLUSION Controversy and varying anecdotal perception regarding safety and effectiveness of PP prevails among trauma medical directors at level 1 trauma centers in the US.
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Affiliation(s)
- Benoit Blondeau
- Research Medical Center, 2316 East Meyer Blvd., Kansas City, MO 64132 USA
- University of Connecticut, Hartford Hospital, Hartford, CT 06106 USA
| | | | - Stephanie Jarvis
- Trauma Research, LLC., 383 Corona St. #319, Denver, CO 80218 USA
| | - Kaysie Banton
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
| | - Gina M. Berg
- Wesley Medical Center, 550 N. Hillside St, Wichita, KS 67214 USA
| | - Nimesh Patel
- St. Anthony’s Hospital, 11600 West 2nd Place, Lakewood, CO 80228 USA
| | - Rick Meinig
- Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO 80907 USA
| | - Allen Tanner
- Penrose Hospital, 2222 North Nevada Ave, Colorado Springs, CO 80907 USA
| | - Matthew Carrick
- Medical City Plano, 3901 West 15th Street, Plano, TX 75075 USA
| | - David Bar-Or
- Swedish Medical Center, 501 E Hampden Ave, Englewood, CO 80113 USA
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Abstract
OBJECTIVE Pelvic fractures represent 5% of all traumatic fractures and 30% are isolated pelvic fractures. Pelvic fractures are found in 10 to 20% of severe trauma patients and their presence is highly correlated to increasing trauma severity scores. The high mortality of pelvic trauma, about 8 to 15%, is related to actively bleeding pelvic injuries and/or associated injuries to the head, abdomen or chest. Regardless of the severity of pelvic trauma, diagnosis and treatment must proceed according to a strategy that does not delay the management of the most severely injured patients. To date, in France, there are no guidelines issued by healthcare authorities or professional societies that address this subject. DESIGN A consensus committee of 22 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et de Réanimation; SFAR) and the French Society of Emergency Medicine (Société Française de Médecine d'Urgence; SFMU) in collaboration with the French Society of Radiology (Société Française de Radiologie; SFR), French Defence Health Service (Service de Santé des Armées; SSA), French Society of Urology (Association Française d'Urologie; AFU), the French Society of Orthopaedic and Trauma Surgery (Société Française de Chirurgie Orthopédique et Traumatologique; SOCFCOT), and the French Society of Digestive Surgery (Société Française de Chirurgie digestive; SFCD) was convened. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently from any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE® methodology. RESULTS The SFAR Guideline panel provided 22 statements on prehospital and hospital management of the unstable patient with pelvic fracture. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, 11 have a high level of evidence (Grade 1 ± ), 11 have a low level of evidence (Grade 2 ± ). CONCLUSIONS Substantial agreement exists among experts regarding many strong recommendations for management of the unstable patient with pelvic fracture.
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Shim H, Jang JY, Kim JW, Ryu H, Jung PY, Kim S, Kwon HY, Kim KM, Chung H, Bae KS. Effectiveness and postoperative wound infection of preperitoneal pelvic packing in patients with hemodynamic instability caused by pelvic fracture. PLoS One 2018; 13:e0206991. [PMID: 30395596 PMCID: PMC6218082 DOI: 10.1371/journal.pone.0206991] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/23/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction Despite the use of a multidisciplinary treatment approach, the mortality rate of hemodynamic instability due to severe pelvic fracture remains 40–60%. Several recent studies have shown that preperitoneal pelvic packing (PPP) was useful for achieving hemostasis in these patients in the acute phase. However, few studies have examined postoperative complications. The purpose of the present study was to evaluate clinical outcomes and wound infections of PPP in these patients. Materials and methods We retrospectively reviewed the medical charts of 62 patients with hemorrhagic shock due to pelvic fracture between March 2011 and May 2017. Excluding four patients (two with other major hemorrhage sites and two who experienced cardiac arrest in the emergency room), the patients were divided into PPP (n = 30) and non-PPP (n = 28) groups according to PPP application. Clinical outcomes including early-stage mortality, transfusion amount, and surgical site infection (SSI) were compared between the two groups. Results The overall mortality rate was 48.3% and the mean Injury Severity Score (ISS) was 39 ± 9. The 30 patients in the PPP group had a significantly lower hemorrhage-induced mortality rate than the 28 patients in the non-PPP group (16.7% vs 50%, p = 0.019), although both groups had similar patient characteristics (age, ISS, and initial serum lactate level). Independent factors associated with hemorrhage-induced mortality were PPP and the requirement of packed red blood cells for 4 h. In the PPP group, SSI occurred in 5 of 25 (20%) patients. Conclusions PPP may be considered as a hemostatic modality for hemodynamic instability due to pelvic fracture because it reduces the hemorrhage-induced mortality rate. However, wound infections after the procedure should be considered.
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Affiliation(s)
- Hongjin Shim
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji Young Jang
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- * E-mail:
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center University of Ulsan, Seoul, Korea
| | - Hoon Ryu
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Pil Young Jung
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seongyup Kim
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hye Youn Kwon
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kwang Min Kim
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hoejeong Chung
- Department of Orthopedic Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Keum Seok Bae
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
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Petrone P, Rodríguez-Perdomo M, Pérez-Jiménez A, Ali F, Brathwaite CEM, Joseph DK. Pre-peritoneal pelvic packing for the management of life-threatening pelvic fractures. Eur J Trauma Emerg Surg 2018; 45:417-421. [DOI: 10.1007/s00068-018-1018-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/20/2018] [Indexed: 11/28/2022]
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Abstract
PURPOSE OF REVIEW Complex traumatic pelvic ring disruptions are associated with a high mortality rate due to associated retroperitoneal hemorrhage, traumatic-hemorrhagic shock, and postinjury coagulopathy. The present review provides an update on current management strategies to improve survival rates form hemodynamically unstable pelvic ring injuries. RECENT FINDINGS Recently published international consensus guidelines have attempted to standardize the classification of hemodynamically unstable pelvic ring injuries and provided classification-based management algorithms for acute resuscitation and pelvic ring stabilization. SUMMARY Acute management strategies for pelvic ring disruptions with associated hemorrhagic shock include resuscitative endovascular balloon occlusion of the aorta for patients 'in extremis' in conjunction with point-of-care guided resuscitation for postinjury coagulopathy. Recent data indicate that a protocol of early pelvic external fixation in conjunction with direct preperitoneal pelvic packing and subsequent angioembolization in patients with ongoing hemorrhage results in significantly improved survival from retroperitoneal exsanguinating hemorrhage in at-risk patients with historic mortality rates as high as 50-60%.
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Tang J, Shi Z, Hu J, Wu H, Yang C, Le G, Zhao J. Optimal sequence of surgical procedures for hemodynamically unstable patients with pelvic fracture: A network meta-analysis. Am J Emerg Med 2018; 37:571-578. [PMID: 29933894 DOI: 10.1016/j.ajem.2018.06.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 06/12/2018] [Accepted: 06/12/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND The mortality rate of patients with hemodynamic instability due to severe pelvic fracture remains substantial and massive transfusion happens frequently. Angio-embolization, external fixation and preperitoneal pelvic packing of the pelvis are the main managements used to control bleeding in these patients. In this paper, we aimed at characterizing the rationale of these surgical managements, and placed them in optimal management algorithm to compose a new guideline. METHODS We selected controlled trials, assessing safety of management for the intervention of hemorrhagic shock from mortality data, and assessing efficacy from volume of first 24 h blood transfusion following hospitalization. Six single and combined managements were extracted as comparison. A pairwise meta-analysis was conducted using a random effect model, and then the analysis was extended to a network meta-analysis. Pooled effect sizes were ranked and demonstrated the probability of being the best treatments for safety and efficacy. RESULTS 13 clinical trials and 24,396 participants were identified for this analysis. The assessment of rank probability indicated that pelvic packing presented the greatest likelihood of improving safety, while external fixation was indicated most efficient among the interventions for controlling hemorrhage. CONCLUSIONS Clinical protocols for guidelines of hemodynamically unstable pelvic fracture patients have been multidirectionally developed. We strongly support the initial application of an external fixator. Provided that patients remain hemodynamically unstable after application of an external fixation, pelvic packing is the next procedure to consider. Angio-embolization is the complementary but not alternative method of choice subsequently.
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Affiliation(s)
- Jingli Tang
- Division of Traumatic Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China; Department of Orthopedics, 530021 Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi 545005, China
| | - Zhanying Shi
- Department of Orthopedics, 530021 Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi 545005, China
| | - Juzheng Hu
- Department of Orthopedics, 530021 Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi 545005, China
| | - Hao Wu
- Department of Orthopedics, 530021 Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi 545005, China
| | - Chengzhi Yang
- Division of Traumatic Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Guoping Le
- Division of Traumatic Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Jinmin Zhao
- Division of Traumatic Surgery, First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China.
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Kim MH, Shim H, Bae KS, Ryu H, Jang JY. Risk Factors Associated with Mortality of Patients with Pelvic Fractures and Hemodynamic Instability in a Korean Trauma Center. JOURNAL OF ACUTE CARE SURGERY 2018. [DOI: 10.17479/jacs.2018.8.1.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Moo-Hyun Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hongjin Shim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Keum Seok Bae
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
| | - Hoon Ryu
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ji Young Jang
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea
- Trauma Center, Wonju Severance Christian Hospital, Wonju, Korea
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Preperitoneal pelvic packing is effective for hemorrhage control in open pelvic fractures. Am J Surg 2018; 215:675-677. [DOI: 10.1016/j.amjsurg.2017.11.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 11/20/2017] [Indexed: 11/19/2022]
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Muntasar AE, Toner E, Alkhazaaleh OA, Arumugam D, Shah N, Hajibandeh S, Hajibandeh S. Effect of angioembolisation versus surgical packing on mortality in traumatic pelvic haemorrhage: A systematic review and meta-analysis. World J Emerg Med 2018; 9:85-92. [PMID: 29576819 DOI: 10.5847/wjem.j.1920-8642.2018.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The management of complex pattern of bleeding associated with pelvic trauma remains a big challenge for trauma surgeons. We aimed to conduct a comprehensive meta-analysis to compare the outcomes of angioembolisation and pelvic packing in patients with pelvic trauma. METHODS We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the CENTRAL; the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists. The primary outcome was defined as mortality. Combined overall effect sizes were calculated using random-effects models. Results are reported as the odds ratio (OR) and 95% confidence interval (CI). RESULTS We identified 3 observational studies reporting a total of 120 patients undergoing angioembolisation (n=60) or pelvic packing (n=60) for pelvic trauma. Reporting of the Injury Severity Score (ISS) was variable, with higher ISS in the pelvic packing group. The risk of bias was low in two studies, and moderate in one. The pooled analysis demonstrated that angioembolisation did not significantly reduce mortality in patients with pelvic trauma compared to surgery (OR=1.99; 95% CI= 0.83-4.78, P=0.12). There was mild between-study heterogeneity (I2=0%, P=0.65). CONCLUSION Our analysis found no significant difference in mortality between angioembolisation and pelvic packing in patients with traumatic pelvic haemorrhage. The current level of evidence in this context is very limited and insufficient to support the superiority of a treatment modality. Future research is required.
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Affiliation(s)
- Ahmed El Muntasar
- Department of General Surgery, Royal Blackburn Hospital, Blackburn, UK
| | - Ethan Toner
- Department of General Surgery, Royal Blackburn Hospital, Blackburn, UK
| | | | | | - Nikhil Shah
- Department of Trauma and Orthopaedics, Wrightington, Wigan and Leigh NHS Foundation Trust, UK
| | | | - Shahin Hajibandeh
- Department of General Surgery, North Manchester General Hospital, Manchester, UK
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Jang JY, Shim H, Kwon HY, Chung H, Jung PY, Kim S, Ryu H, Bae KS. Improvement of outcomes in patients with pelvic fractures and hemodynamic instability after the establishment of a Korean regional trauma center. Eur J Trauma Emerg Surg 2017; 45:107-113. [PMID: 29282484 DOI: 10.1007/s00068-017-0886-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 12/01/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Despite using a multidisciplinary treatment approach, the mortality rate of patients with hemodynamic instability from severe pelvic fractures is still 40-60%. We evaluated the improvement of outcomes in this patient population after the establishment of a regional trauma center in Korea. METHODS We retrospectively reviewed the medical charts of 50 patients with hemodynamic instability due to pelvic fractures between March 2011 and November 2016. Patients were divided into two groups: the pre-trauma center (PTC) group (n = 23) and trauma center (TC) group (n = 27). RESULTS Sixteen (32.0%) patients died of exsanguination. Patients in the TC group had shorter trauma resuscitation room stay (101 vs 273 min, p < 0.001) and underwent preperitoneal pelvic packing (PPP) more frequently (88.9 vs 8.7%, p < 0.001) than those in the PTC group. During the TC period, emergent procedures such as PPP and pelvic angiography were performed more frequently (92.6 vs 39.1%, p < 0.001). Although there was no statistical difference in the overall mortality rate between groups, patients in the TC group had less mortality due to hemorrhage (18.5 vs 47.8%, p = 0.027). Logistic regression analysis demonstrated that initial systolic blood pressure and establishment of trauma center were independent protective factors of mortality from hemorrhage [odds ratio (OR) 0.957, 95% confidence interval (CI) 0.926-0.988, p = 0.007; OR 0.134, 95% CI 0.028-0.633, p = 0.011]. CONCLUSIONS Since the regional trauma center was established, emergent procedures such as pelvic angiography and PPP were performed more frequently, and mortality due to exsanguination was significantly decreased.
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Affiliation(s)
- Ji Young Jang
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Hongjin Shim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Hye Youn Kwon
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Hoejeong Chung
- Department of Orthopedic Surgery, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Pil Young Jung
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Seongyup Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
| | - Hoon Ryu
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea.
| | - Keum Seok Bae
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Gangwon-do, Republic of Korea
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Lai YC, Wu CH, Chen HW, Wang LJ, Wong YC. Predictors of active arterial hemorrhage on angiography in pelvic fracture patients. Jpn J Radiol 2017; 36:223-230. [PMID: 29282615 DOI: 10.1007/s11604-017-0716-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 12/17/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE To determine predictors of active angiographic hemorrhage in pelvic fracture patients. MATERIALS AND METHODS This retrospective study included 66 trauma patients who had major hemorrhages due to pelvic fractures, and who underwent pelvic angiography between January 2012 and December 2014. The study population comprised 31 males and 35 females (mean age 44.2 ± 20.7 years). The main outcome was active hemorrhage on pelvic angiography. Clinical and imaging variables including demographics, hemodynamic parameters, injury severity, types of pelvic fracture, laboratory data, blood transfusions and CT findings were analyzed. Multivariate logistic regression was used to identify predictors of active angiographic hemorrhage. RESULTS Of the 66 study patients included, 41 patients had active angiographic hemorrhage. These patients had more blood transfusions, higher activated partial thromboplastin times and higher rates of contrast extravasation on CT (p < 0.05). Three independent predictors of active angiographic hemorrhage were identified, including contrast extravasation on CT (OR: 74.6, p < 0.001), more than 8 units of RBC transfusions (OR: 12.5, p = 0.018) and ISS ≥ 16 (OR: 11.1, p = 0.029). CONCLUSION Contrast extravasation on CT, high volume RBC transfusions and ISS ≥ 16 can help us to select pelvic fracture patients for angiography more precisely.
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Affiliation(s)
- Ying-Chieh Lai
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Cheng-Hsien Wu
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Huan-Wu Chen
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Li-Jen Wang
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan
| | - Yon-Cheong Wong
- Division of Emergency and Critical Care Radiology, Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University, 5, Fu-Hsing Street, Gueishan, Taoyuan, 333, Taiwan.
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Abstract
Severe pelvic trauma is a challenging condition. The pelvis can create multifocal hemorrhage that is not easily compressible nor managed by traditional surgical methods such as tying off a blood vessel or removing an organ. Its treatment often requires reapproximation of bony structures, damage control resuscitation, assessment for associated injuries, and triage of investigations, as well as multimodality hemorrhage control (external fixation, preperitoneal packing, angioembolization, REBOA [resuscitative endovascular balloon occlusion of the aorta]) by multidisciplinary trauma specialists (general surgeons, orthopedic surgeons, endovascular surgeons/interventional radiologists). This article explores this complex clinical problem and provides a practical approach to its management.
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Affiliation(s)
- Steven Skitch
- Department of Emergency Medicine, McMaster University, Hamilton General Hospital, 6 North Wing - Room 616, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada; Department of Critical Care, McMaster University, Hamilton General Hospital, 6 North Wing - Room 616, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada
| | - Paul T Engels
- Department of Critical Care, McMaster University, Hamilton General Hospital, 6 North Wing - Room 616, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada; Department of Surgery, McMaster University, Hamilton General Hospital, 6 North Wing - Room 616, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
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Sato Y, Sekine K, Shibusawa T, Tajima K, Sasaki J, Imanishi N, Aiso S, Hori S. Effect of Retroperitoneal Pelvic Packing on Pelvic Cavity Pressure: A Cadaveric Study. Orthopedics 2017; 40:e947-e951. [PMID: 28934537 DOI: 10.3928/01477447-20170918-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 07/31/2017] [Indexed: 02/03/2023]
Abstract
Limited clinical evidence demonstrates the effectiveness of direct retroperitoneal pelvic packing for hemorrhage control in pelvic fractures due to the difficulty in measuring pressure on the pelvic walls within the pelvic cavity after retroperitoneal pelvic packing. Using a cadaver model, the authors aimed to assess whether retroperitoneal pelvic packing generates pressure that exceeds the venous return and arterial pressure in the pelvis. The pressure on the pelvic wall was measured in 5 fresh Japanese cadavers. Sensors were placed at 4 points on the pelvic wall, and the pressure at each point was measured after the insertion of each of 3 sponges, per the procedure originally described for direct retroperitoneal pelvic packing. In each specimen, the average pressure across all 4 points on the pelvic wall increased with the addition of each sponge, reaching 12.3±4.5 mm Hg when all 3 sponges were inserted. Furthermore, the pressure at the pelvic floor and posterior pelvic brim increased significantly, whereas the pressure at the anterior and middle pelvic brim increased nonsignificantly. The results of this study suggest that retroperitoneal pelvic packing provides pressure on the pelvic wall that exceeds the venous pressure and is thus effective for the control of venous hemorrhage in pelvic fractures. Currently, the recommended procedure combines external fixation for venous bleeding, transcatheter arterial embolization, and pelvic packing; however, the authors' results suggest that pelvic packing alone may be effective for controlling venous hemorrhage in pelvic fracture. [Orthopedics. 2017; 40(6);e947-e951.].
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66
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Selective versus nonselective embolization versus no embolization in pelvic trauma. J Trauma Acute Care Surg 2017; 83:361-367. [DOI: 10.1097/ta.0000000000001554] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Preperitoneal pelvic packing reduces mortality in patients with life-threatening hemorrhage due to unstable pelvic fractures. J Trauma Acute Care Surg 2017; 82:233-242. [PMID: 27893645 DOI: 10.1097/ta.0000000000001324] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A 2015 American Association for the Surgery of Trauma trial reported a 32% mortality for pelvic fracture patients in shock. Angioembolization (AE) is the most common intervention; the Maryland group revealed time to AE averaged 5 hours. The goal of this study was to evaluate the time to intervention and outcomes of an alternative approach for pelvic hemorrhage. We hypothesized that preperitoneal pelvic packing (PPP) results in a shorter time to intervention and lower mortality. METHODS In 2004, we initiated a PPP protocol for pelvic fracture hemorrhage. RESULTS During the 11-year study, 2,293 patients were admitted with pelvic fractures; 128 (6%) patients underwent PPP (mean age, 44 ± 2 years; Injury Severity Score (ISS), 48 ± 1.2). The lowest emergency department systolic blood pressure was 74 mm Hg and highest heart rate was 120. Median time to operation was 44 minutes and 3 additional operations were performed in 109 (85%) patients. Median RBC transfusions before SICU admission compared with the 24 postoperative hours were 8 versus 3 units (p < 0.05). After PPP, 16 (13%) patients underwent AE with a documented arterial blush.Mortality in this high-risk group was 21%. Death was due to brain injury (9), multiple organ failure (4), pulmonary or cardiac failure (6), withdrawal of support (4), adverse physiology (3), and Mucor infection (1). Of those patients with physiologic exhaustion, 2 died in the operating room at 89 and 100 minutes after arrival, whereas 1 died 9 hours after arrival. CONCLUSIONS PPP results in a shorter time to intervention and lower mortality compared with modern series using AE. Examining mortality, only 3 (2%) deaths were attributed to the immediate sequelae of bleeding with physiologic failure. With time to death under 100 minutes in 2 patients, AE is unlikely to have been feasible. PPP should be used for pelvic fracture-related bleeding in the patient who remains unstable despite initial transfusion. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Burlew CC. Preperitoneal pelvic packing for exsanguinating pelvic fractures. INTERNATIONAL ORTHOPAEDICS 2017; 41:1825-1829. [DOI: 10.1007/s00264-017-3485-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/05/2017] [Indexed: 11/30/2022]
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Coccolini F, Stahel PF, Montori G, Biffl W, Horer TM, Catena F, Kluger Y, Moore EE, Peitzman AB, Ivatury R, Coimbra R, Fraga GP, Pereira B, Rizoli S, Kirkpatrick A, Leppaniemi A, Manfredi R, Magnone S, Chiara O, Solaini L, Ceresoli M, Allievi N, Arvieux C, Velmahos G, Balogh Z, Naidoo N, Weber D, Abu-Zidan F, Sartelli M, Ansaloni L. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg 2017; 12:5. [PMID: 28115984 PMCID: PMC5241998 DOI: 10.1186/s13017-017-0117-6] [Citation(s) in RCA: 216] [Impact Index Per Article: 30.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 01/12/2017] [Indexed: 01/24/2023] Open
Abstract
Complex pelvic injuries are among the most dangerous and deadly trauma related lesions. Different classification systems exist, some are based on the mechanism of injury, some on anatomic patterns and some are focusing on the resulting instability requiring operative fixation. The optimal treatment strategy, however, should keep into consideration the hemodynamic status, the anatomic impairment of pelvic ring function and the associated injuries. The management of pelvic trauma patients aims definitively to restore the homeostasis and the normal physiopathology associated to the mechanical stability of the pelvic ring. Thus the management of pelvic trauma must be multidisciplinary and should be ultimately based on the physiology of the patient and the anatomy of the injury. This paper presents the World Society of Emergency Surgery (WSES) classification of pelvic trauma and the management Guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Philip F Stahel
- Department of Orthopedic Surgery and Department of Neurosurgery, Denver Health Medical Center and University of Colorado School of Medicine, Denver, CO USA
| | - Giulia Montori
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Walter Biffl
- Acute Care Surgery, The Queen's Medical Center, Honolulu, HI USA
| | - Tal M Horer
- Dept. of Cardiothoracic and Vascular Surgery & Dept. Of Surgery Örebro University Hospital and Örebro University, Örebro, Sweden
| | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
| | - Yoram Kluger
- Division of General Surgery Rambam Health Care Campus Haifa, Haifa, Israel
| | | | - Andrew B Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, Pensylvania USA
| | - Rao Ivatury
- Virginia Commonwealth University, Richmond, VA USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, USA
| | | | - Bruno Pereira
- Faculdade de Ciências Médicas (FCM) - Unicamp, Campinas, SP Brazil
| | - Sandro Rizoli
- Trauma & Acute Care Service, St Michael's Hospital, Toronto, ON Canada
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery Foothills Medical Centre, Calgary, AB Canada
| | - Ari Leppaniemi
- Abdominal Center, University Hospital Meilahti, Helsinki, Finland
| | - Roberto Manfredi
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Stefano Magnone
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Osvaldo Chiara
- Emergency and Trauma Surgery, Niguarda Hospital, Milan, Italy
| | - Leonardo Solaini
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Marco Ceresoli
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Niccolò Allievi
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
| | - Catherine Arvieux
- Digestive and Emergency Surgery, UGA-Université Grenoble Alpes, Grenoble, France
| | - George Velmahos
- Harvard Medical School, Division of Trauma, Emergency Surgery and Surgical Critical Care Massachusetts General Hospital, Boston, MA USA
| | - Zsolt Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW Australia
| | - Noel Naidoo
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery, Papa Giovanni XXIII Hospital, P.zza OMS 1, 24128 Bergamo, Italy
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