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Davies J, Chu K, Tabiri S, Byiringiro JC, Bekele A, Razzak J, D’Ambruoso L, Ignatowicz A, Bojke L, Nkonki L, Laurenzi C, Sitch A, Bagahirwa I, Belli A, Sam NB, Amberbir A, Whitaker J, Ndangurura D, Ghalichi L, MacQuene T, Tshabalala N, Fikadu Berhe D, Nepomuscene NJ, Agbeko AE, Sarfo-Antwi F, Babar Chand Z, Wajidali Z, Sahibjan F, Atiq H, Mali Y, Tshabalala Z, Khalfe F, Nodo O, Umwali G, Twizeyimana E, Mugisha N, Munyura NO, Nakure S, Ishimwe SMC, Nzasabimana P, Dramani A, Acquaye J, Tanweer A. Equitable access to quality injury care; Equi-Injury project protocol for prioritizing interventions in four low- or middle-income countries: a mixed method study. BMC Health Serv Res 2024; 24:429. [PMID: 38576004 PMCID: PMC10996087 DOI: 10.1186/s12913-024-10668-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 01/31/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Equitable access to quality care after injury is an essential step for improved health outcomes in low- and middle-income countries (LMICs). We introduce the Equi-Injury project, in which we will use integrated frameworks to understand how to improve equitable access to quality care after injury in four LMICs: Ghana, Pakistan, Rwanda and South Africa. METHODS This project has 5 work packages (WPs) as well as essential cross-cutting pillars of community engagement, capacity building and cross-country learning. In WP1, we will identify needs, barriers, and facilitators to impactful stakeholder engagement in developing and prioritising policy solutions. In WP2, we will collect data on patient care and outcomes after injuries. In WP3, we will develop an injury pathway model to understand which elements in the pathway of injury response, care and treatment have the biggest impact on health and economic outcomes. In WP4, we will work with stakeholders to gain consensus on solutions to address identified issues; these solutions will be implemented and tested in future research. In WP5, in order to ascertain where learning is transferable across contexts, we will identify which outcomes are shared across countries. The study has received approval from ethical review boards (ERBs) of all partner countries in South Africa, Rwanda, Ghana, Pakistan and the University of Birmingham. DISCUSSION This health system evaluation project aims to provide a deeper understanding of injury care and develop evidence-based interventions within and across partner countries in four diverse LMICs. Strong partnership with multiple stakeholders will facilitate utilisation of the results for the co-development of sustainable interventions.
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Hardy BM, Varghese A, Adams MJ, Enninghorst N, Balogh ZJ. The outcomes of the most severe polytrauma patients: a systematic review of the use of high ISS cutoffs for performance measurement. Eur J Trauma Emerg Surg 2023:10.1007/s00068-023-02409-3. [PMID: 38108840 DOI: 10.1007/s00068-023-02409-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/19/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND This systematic review aimed to describe the outcomes of the most severely injured polytrauma patients and identify the consistent Injury Severity Score based definition of utilised for their definition. This could provide a global standard for trauma system benchmarking. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was applied to this review. We searched Medline, Embase, Cochrane Reviews, CINAHL, CENTRAL from inception until July 2022. Case reports were excluded. Studies in all languages that reported the outcomes of adult and paediatric patients with an ISS 40 and above were included. Abstracts were screened by two authors and ties adjudicated by the senior author. RESULTS 7500 abstracts were screened after excluding 13 duplicates. 56 Full texts were reviewed and 37 were excluded. Reported ISS groups varied widely between the years 1986 and 2022. ISS groups reported ranged from 40-75 up to 51-75. Mortality varied between 27 and 100%. The numbers of patients in the highest ISS group ranged between 15 and 1451. CONCLUSIONS There are very few critically injured patients reported during the last 48 years. The most critically injured polytrauma patients still have at least a 50% risk of death. There is no consistent inclusion and exclusion criteria for this high-risk cohort. The current approach to reporting is not suitable for monitoring the epidemiology and outcomes of the critically injured polytrauma patients. LEVEL OF EVIDENCE Level 4-systematic review of level 4 studies.
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Affiliation(s)
- Benjamin M Hardy
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, 2310, Australia
- University of Newcastle, Newcastle, NSW, Australia
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, Australia
| | - Adrian Varghese
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, 2310, Australia
| | - Megan J Adams
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, 2310, Australia
| | - Natalie Enninghorst
- University of Newcastle, Newcastle, NSW, Australia
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, Australia
| | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, 2310, Australia.
- University of Newcastle, Newcastle, NSW, Australia.
- Injury and Trauma Research Program, Hunter Medical Research Institute, Newcastle, Australia.
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Kim JS, Schellenberg M, Navarette S, Demetriades D. Understanding the Impact of Trauma Admissions to Nonsurgical Services. Am Surg 2023; 89:4142-4146. [PMID: 37259498 DOI: 10.1177/00031348231177940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The American College of Surgeons Committee on Trauma (ACS COT) delineates trauma center standards, one of which limits the number of injured patients admitted to nonsurgical services. Performance improvement review of nonsurgical admissions (NSAs), particularly those with Injury Severity Score (ISS) > 9, is required. OBJECTIVE To examine trauma patients with NSA for appropriateness of admission and any potential clinical effect as a result of NSA. METHODS All trauma patients presenting to our ACS COT-verified level 1 trauma center in Southern California (05/2021-04/2022) were retrospectively screened. Nonsurgical admissions with ISS > 9 were included without exclusions. Appropriateness and clinical impact of NSA were assessed by the Trauma Medical Director (TMD) and Associate TMD. RESULTS Forty patients met study criteria, with a mean age of 54 years (range 5 d-99 y). The mean ISS was 19 (range 10-30). Nonsurgical admissions most commonly sustained traumatic brain injury (TBI) (n = 27, 68%) after ground level falls (GLF) (n = 32, 80%). All NSAs were evaluated by ≥1 surgical service, commonly neurosurgery (n = 33, 83%) and trauma surgery (n = 13, 33%). Sixteen patients (40%) died, 75% (n = 12) of which were secondary to catastrophic TBI. Upon detailed review, all NSAs were deemed appropriate and without potential clinical impact. CONCLUSIONS All NSAs in this study were appropriate admissions without clinical effect from lack of surgical admission. Nonsurgical admissions were typically elderly patients with head injuries after GLF. With the anticipated increase in geriatric trauma due to our aging population, NSA with surgical consultation may be an important way to manage trauma admissions without compromising care of injured patients.
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Affiliation(s)
- Jennie S Kim
- Division of Acute Care Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Morgan Schellenberg
- Division of Acute Care Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Sixta Navarette
- Division of Acute Care Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery, LAC + USC Medical Center, University of Southern California, Los Angeles, CA, USA
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Toida C, Muguruma T, Gakumazawa M, Shinohara M, Abe T, Takeuchi I. Evaluating the definition of severely injured patients: a Japanese nationwide 5-year retrospective study. BMJ Open 2023; 13:e062619. [PMID: 36822812 PMCID: PMC9950884 DOI: 10.1136/bmjopen-2022-062619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVES The definition of severely injured patients lacks universal consensus based on quantitative measures. The most widely used definition of severe injury is based on the Injury Severity Score (ISS), which is calculated using the Abbreviated Injury Scale in Japan. This study aimed to compare the prevalence, in-hospital mortality and OR for mortality in patients with ISS ≥16, ISS ≥18 and ISS ≥26 by age groups. DESIGN Retrospective cohort study. SETTING Japan Trauma Data Bank, which is a nationwide trauma registry with data from 280 hospitals. PARTICIPANTS We used data of 117 199 injured patients from a national database. We included injured patients who were transferred from the scene of injury by ambulance and/or physician. PRIMARY AND SECONDARY OUTCOME MEASURES Prevalence, in-hospital mortality and OR for mortality with respect to age and injury level (ISS group). RESULTS In all age categories, the in-hospital mortality of patient groups with an ISS ≥16, ISS ≥18 and ISS ≥26 was 13.3%, 17.4% and 23.5%, respectively. The in-hospital mortality for patients aged >75 years was the highest (20% greater than that of the other age groups). Moreover, in-hospital mortality for age group 5-14 years was the lowest (4.0-10.9%). In all the age groups, the OR for mortality for patients with ISS ≥16, ISS ≥18 and ISS ≥26 was 12.8, 11.0 and 8.4, respectively. CONCLUSIONS Our results revealed the lack of an acceptable definition, with a high in-hospital mortality and high OR for mortality for all age groups.
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Affiliation(s)
- Chiaki Toida
- Department of Emergency Medicine, Teikyo University School of Medicine Graduate School of Medicine, Itabashi-ku, Tokyo, Japan
- Department of Emergency Medicine, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Takashi Muguruma
- Department of Emergency Medicine, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Masayasu Gakumazawa
- Department of Emergency Medicine, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Mafumi Shinohara
- Department of Emergency Medicine, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Takeru Abe
- Department of Emergency Medicine, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University School of Medicine Graduate School of Medicine, Yokohama, Kanagawa, Japan
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Toida C, Muguruma T, Gakumazawa M, Shinohara M, Abe T, Takeuchi I. Ten-year in-hospital mortality trends among Japanese injured patients by age, injury severity, injury mechanism, and injury region: A nationwide observational study. PLoS One 2022; 17:e0272573. [PMID: 35994453 PMCID: PMC9394834 DOI: 10.1371/journal.pone.0272573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/21/2022] [Indexed: 11/18/2022] Open
Abstract
The Injury Severity Score (ISS) is widely used in trauma research worldwide. An ISS cutoff value of ≥16 is frequently used as the definition of severe injury in Japan. The mortality of patients with ISS ≥16 has decreased in recent years, owing to the developing the trauma care system. This study aimed to analyze the prevalence, in-hospital mortality, and odds ratio (OR) for mortality in Japanese injured patients by age, injury mechanism, injury region, and injury severity over 10 years. This study used the Japan Trauma Data Bank (JTDB) dataset, which included 315,614 patients registered between 2009 and 2018. 209,290 injured patients were utilized. This study evaluated 10-year trends of the prevalence and in-hospital mortality and risk factors associated with in-hospital mortality. The overall in-hospital mortality was 10.5%. During the 10-year study period in Japan, the mortality trend among all injured patient groups with ISS 0–15, 16–25, and ≥26 showed significant decreases (p <0.001). Moreover, the mortality risk of patients with ISS ≥26 was significantly higher than that of patients with ISS 0–15 and 16–25 (p <0.001, OR = 0.05 and p<0.001, OR = 0.22). If we define injured patients who are expected to have a mortality rate of 20% or more as severely injured, it may be necessary to change the injury severity definition according to reduction of trauma mortality as ISS cutoff values to ≥26 instead of ≥16. From 2009 to 2018, the in-hospital mortality trend among all injured patient groups with ISS 0–15, 16–25, and ≥26 showed significant decreases in Japan. Differences were noted in mortality trends and risks according to anatomical injury severity.
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Affiliation(s)
- Chiaki Toida
- Department of Disaster Medical Management, The University of Tokyo, Tokyo, Japan
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
- * E-mail:
| | - Takashi Muguruma
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masayasu Gakumazawa
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Mafumi Shinohara
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Takeru Abe
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Pape HC, Moore EE, McKinley T, Sauaia A. Pathophysiology in patients with polytrauma. Injury 2022; 53:2400-2412. [PMID: 35577600 DOI: 10.1016/j.injury.2022.04.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/13/2022] [Indexed: 02/02/2023]
Abstract
The pathophysiology after polytrauma represents a complex network of interactions. While it was thought for a long time that the direct and indirect effects of hypoperfusion are most relevant due to the endothelial permeability changes, it was discovered that the innate immune response to trauma is equally important in modifying the organ response. Recent multi center studies provided a "genetic storm" theory, according to which certain neutrophil changes are activated at the time of injury. However, a second hit phenomenon can be induced by activation of certain molecules by direct organ injury, or pathogens (damage associated molecular patterns, DAMPS - pathogen associated molecular patterns, PAMPS). The interactions between the four pathogenetic cycles (of shock, coagulopathy, temperature loss and soft tissue injuries) and cross-talk between coagulation and inflammation have also been identified as important modifiers of the clinical status. In a similar fashion, overzealous surgeries and their associated soft tissue injury and blood loss can induce secondary worsening of the patient condition. Therefore, staged surgeries in certain indications represent an important alternative, to allow for performing a "safe definitive surgery" strategy for major fractures. The current review summarizes all these situations in a detailed fashion.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland.
| | - E E Moore
- Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Aurora, CO, USA.
| | - T McKinley
- Department of Orthopaedics, Indiana University, 200 Hawkins Dr, Iowa City, IA 52242, USA.
| | - A Sauaia
- Schools of Public Health and Medicine, University of Colorado, Aurora, Colorado, USA.
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Alharbi RJ, Shrestha S, Lewis V, Miller C. The effectiveness of trauma care systems at different stages of development in reducing mortality: a systematic review and meta-analysis. World J Emerg Surg 2021; 16:38. [PMID: 34256793 PMCID: PMC8278750 DOI: 10.1186/s13017-021-00381-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/23/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Traumatic injury remains the leading cause of death, with more than five million deaths every year. Little is known about the comparative effectiveness in reducing mortality of trauma care systems at different stages of development. The objective of this study was to review the literature and examine differences in mortality associated with different stages of trauma system development. METHOD A systematic review of peer-reviewed population-based studies retrieved from MEDLINE, EMBASE, and CINAHL. Additional studies were identified from references of articles, through database searching, and author lists. Articles written in English and published between 2000 and 2020 were included. Selection of studies, data extraction, and quality assessment of the included studies were performed by two independent reviewers. The results were reported as odds ratio (OR) with 95 % confidence intervals (CI). RESULTS A total of 52 studies with a combined 1,106,431 traumatic injury patients were included for quantitative analysis. The overall mortality rate was 6.77% (n = 74,930). When patients were treated in a non-trauma centre compared to a trauma centre, the pooled statistical odds of mortality were reduced (OR 0.74 [95% CI 0.69-0.79]; p < 0.001). When patients were treated in a non-trauma system compared to a trauma system the odds of mortality rates increased (OR 1.17 [95% CI 1.10-1.24]; p < 0.001). When patients were treated in a post-implementation/initial system compared to a mature system, odds of mortality were significantly higher (OR 1.46 [95% CI 1.37-1.55]; p < 0.001). CONCLUSION The present study highlights that the survival of traumatic injured patients varies according to the stage of trauma system development in which the patient was treated. The analysis indicates a significant reduction in mortality following the introduction of the trauma system which is further enhanced as the system matures. These results provide evidence to support efforts to, firstly, implement trauma systems in countries currently without and, secondly, to enhance existing systems by investing in system development. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42019142842 .
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Affiliation(s)
- Rayan Jafnan Alharbi
- School of Nursing & Midwifery, La Trobe University, 1st floor, HSB 1, La Trobe University, Bundoora, VIC, 3086, Australia. .,Department of Emergency Medical Service, Jazan University, Jazan, Saudi Arabia.
| | - Sumina Shrestha
- Australian Institute for Primary Care and Ageing, School of Nursing & Midwifery, La Trobe University, Bundoora, VIC, Australia.,Community Development and Environment Conservation Forum, Chautara, Nepal
| | - Virginia Lewis
- Australian Institute for Primary Care and Ageing, School of Nursing & Midwifery, La Trobe University, Bundoora, VIC, Australia
| | - Charne Miller
- School of Nursing & Midwifery, La Trobe University, 1st floor, HSB 1, La Trobe University, Bundoora, VIC, 3086, Australia
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Driessen MLS, Sturms LM, van Zwet EW, Bloemers FW, Ten Duis HJ, Edwards MJR, den Hartog D, de Jongh MAC, Leenhouts PA, Poeze M, Schipper IB, Spanjersberg R, Wendt KW, de Wit RJ, van Zutphen SWAM, Leenen LPH. Evaluation of the Berlin polytrauma definition: A Dutch nationwide observational study. J Trauma Acute Care Surg 2021; 90:694-699. [PMID: 33443988 DOI: 10.1097/ta.0000000000003071] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Berlin polytrauma definition (BPD) was established to identify multiple injury patients with a high risk of mortality. The definition includes injuries with an Abbreviated Injury Scale score of ≥3 in ≥2 body regions (2AIS ≥3) combined with the presence of ≥1 physiological risk factors (PRFs). The PRFs are based on age, Glasgow Coma Scale, hypotension, acidosis, and coagulopathy at specific cutoff values. This study evaluates and compares the BPD with two other multiple injury definitions used to identify patients with high resource utilization and mortality risk, using data from the Dutch National Trauma Register (DNTR). METHODS The evaluation was performed based on 2015 to 2018 DNTR data. First, patient characteristics for 2AIS ≥3, Injury Severity Score (ISS) of ≥16, and BPD patients were compared. Second, the PRFs prevalence and odds ratios of mortality for 2AIS ≥3 patients were compared with those from the Deutsche Gesellschaft für Unfallchirurgie Trauma Register. Subsequently, the association between PRF and mortality was assessed for 2AIS ≥3-DNTR patients and compared with those with an ISS of ≥16. RESULTS The DNTR recorded 300,649 acute trauma admissions. A total of 15,711 patients sustained an ISS of ≥16, and 6,263 patients had suffered a 2AIS ≥3 injury. All individual PRFs were associated with a mortality of >30% in 2AIS ≥3-DNTR patients. The increase in PRFs was associated with a significant increase in mortality for both 2AIS ≥3 and ISS ≥16 patients. A total of 4,264 patients met the BPDs criteria. Overall mortality (27.2%), intensive care unit admission (71.2%), and length of stay were the highest for the BPD group. CONCLUSION This study confirms that the BPD identifies high-risk patients in a population-based registry. The addition of PRFs to the anatomical injury scores improves the identification of severely injured patients with a high risk of mortality. Compared with the ISS ≥16 and 2AIS ≥3 multiple injury definitions, the BPD showed to improve the accuracy of capturing patients with a high medical resource need and mortality rate. LEVEL OF EVIDENCE Epidemiological study, level III.
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Affiliation(s)
- Mitchell L S Driessen
- From the Dutch Network for Emergency Care (M.L.S.D., L.M.S.), Utrecht; Department of Medical Statistics (E.W.v.Z.), Leiden University Medical Center, Leiden; Department of Surgery (F.W.B.), Amsterdam University Medical Center, VU, Amsterdam; Department of Trauma Surgery (M.J.R.E.), Radboud University Medical Center, Nijmegen; Trauma Research Unit, Department of Surgery (D.d.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam; Brabant Trauma Registry (M.A.C.d.J.), Network Emergency Care Brabant, Tilburg; Department of Surgery (P.A.L.), Amsterdam University Medical Center, AMC, Amsterdam; Department of Surgery (M.P.), Maastricht University Medical Center, Maastricht; Department of Trauma Surgery (I.B.S.), Leiden University Medical Center, Leiden; Department of Trauma Surgery (R.S.), Isala Hospitals, Zwolle; Department of Trauma Surgery (K.W.W.), University Medical Center Groningen, Groningen; Department of Trauma Surgery (R.J.d.W.), Medical Spectrum Twente, Enschede; Department of Surgery Elisabeth Two Cities Hospital (S.W.A.M.v.Z.), Tilburg; and Department of Surgery (L.P.H.L.), University Medical Center Utrecht, Utrecht, the Netherlands
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9
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Severe traffic injuries in the Helsinki Trauma Registry between 2009-2018. Injury 2020; 51:2946-2952. [PMID: 33004203 DOI: 10.1016/j.injury.2020.09.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/21/2020] [Accepted: 09/15/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The European Union (EU) has adopted the Vision Zero and Safe System approach to eliminate deaths and serious traffic injuries on European roads by 2050. Detailed information on serious injuries, injury mechanisms and consequences are needed. The aim of this study was to describe and compare by injury mechanism the demographics, injuries, injury severity, and treatment of seriously injured road traffic trauma patients. MATERIAL AND METHODS We analysed data on severe traffic injury trauma patients aged ≥16 years of the Helsinki Trauma Registry (HTR) covering the years 2009-2018. The variables analysed were basic patient demographics, injury mechanism, Abbreviated Injury Scale (AIS) codes, injured body regions, patient Injury Severity Score (ISS) and New Injury Severity Score (NISS) values, NISS groups (NISS 16-24 and NISS ≥25), AIS 3+ injuries, trauma bay and 30-day mortality, length of stay (LOS) at ICU and in hospital, surgeries performed, pre-injury classification, and intention of injury. RESULTS A total of 1 063 traffic injury patients were analysed; 38.6% were motor vehicle occupants, 28.5% motorcyclists or moped drivers, 17.2% bicyclists, and 15.7% pedestrians. The mean age of patients was 44.3 years (SD 20.2). Median ISS score was 22 and median NISS score was 27. Both scores were highest in pedestrians. Among all patients, total hospital LOS was 12 517 days (median 9) and total ICU LOS was 6 311 days (median 5). The most common AIS 3+ injuries according to ISS body regions were chest injuries (60%) and head or neck injuries (43.7%). Chest injuries occurred more frequently in motorcyclists and motor vehicle occupants, whereas head or neck injuries were most common among bicyclists and pedestrians. CONCLUSIONS Severely injured pedestrians and bicyclists were older and they had higher mortality than motorcyclists and motor vehicle occupants. According to NISS, the overall severity was highest among pedestrians followed by bicyclists. However, the both median ICU LOS and hospital LOS were highest for pedestrians but lowest for bicyclists. The most common AIS 3+ injuries were chest and head or neck injuries. To specify effective injury prevention measures, hospital data should be complemented with information on the circumstances of the accident.
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Balogh ZJ, Way TL, Bendinelli C, Warren KJ. Current concepts on haemorrhage control in severe trauma. ANZ J Surg 2020; 90:406-408. [DOI: 10.1111/ans.15873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Zsolt J. Balogh
- Department of TraumatologyJohn Hunter Hospital and the University of Newcastle Newcastle New South Wales Australia
| | - Teagan L. Way
- Department of TraumatologyJohn Hunter Hospital and the University of Newcastle Newcastle New South Wales Australia
| | - Cino Bendinelli
- Department of TraumatologyJohn Hunter Hospital and the University of Newcastle Newcastle New South Wales Australia
| | - Kirrily‐Rae J. Warren
- Department of TraumatologyJohn Hunter Hospital and the University of Newcastle Newcastle New South Wales Australia
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Abstract
The American College of Surgeons Committee on Trauma requires that trauma centers with greater than 10 per cent injured patients admitted to non-trauma services (NTSs) have processes to review these for appropriateness of care. We previously described an algorithm to determine the appropriateness of NTS admissions. Our objective was to determine if the outcome and process of care was similar between TS- and NTS-admitted patients. We conducted a retrospective analysis of our trauma registry. NTS-appropriate patients by algorithm were included. Differences between patients admitted to a TS and an NTS were compared. Nine hundred forty-one patients met the algorithm criteria as appropriate for the NTS; 694 were admitted to TS and 247 to NTS. Contact with TS was the most common association with admission to TS. NTS patients were older and had similar Injury Severity Scores, and a similar proportion had three or greater pre-existing comorbidities. NTS-admitted patients had similar risk for mortality and complications, but longer length of stay, and were less likely to have a desirable discharge disposition. Minimally injured elderly patients constitute most of NTS and a large proportion of TS admissions. NTS admission seems appropriate with respect to mortality and complications. Differences in the care process may have accounted for longer length of stay and differences in disposition destination.
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Affiliation(s)
- Brandon J. Fumanti
- Division of Acute Care Surgery, Department of Surgery, Northwell Health Southside Hospital, Bay Shore, New York
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York; and
| | - Lisa Szydziak
- Division of Acute Care Surgery, Department of Surgery, Northwell Health Southside Hospital, Bay Shore, New York
| | - Michael D. Grossman
- Division of Trauma and Acute Care Surgery, Department of Surgery, St. Luke's Hospital, New Bedford, Massachusetts
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Voskens FJ, van Rein EAJ, van der Sluijs R, Houwert RM, Lichtveld RA, Verleisdonk EJ, Segers M, van Olden G, Dijkgraaf M, Leenen LPH, van Heijl M. Accuracy of Prehospital Triage in Selecting Severely Injured Trauma Patients. JAMA Surg 2019; 153:322-327. [PMID: 29094144 DOI: 10.1001/jamasurg.2017.4472] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Importance A major component of trauma care is adequate prehospital triage. To optimize the prehospital triage system, it is essential to gain insight in the quality of prehospital triage of the entire trauma system. Objective To prospectively evaluate the quality of the field triage system to identify severely injured adult trauma patients. Design, Setting, and Participants Prehospital and hospital data of all adult trauma patients during 2012 to 2014 transported with the highest priority by emergency medical services professionals to 10 hospitals in Central Netherlands were prospectively collected. Prehospital data collected by the emergency medical services professionals were matched to hospital data collected in the trauma registry. An Injury Severity Score of 16 or more was used to determine severe injury. Main Outcomes and Measures The quality and diagnostic accuracy of the field triage protocol and compliance of emergency medical services professionals to the protocol. Results A total of 4950 trauma patients were evaluated of which 436 (8.8%) patients were severely injured. The undertriage rate based on actual destination facility was 21.6% (95% CI, 18.0-25.7) with an overtriage rate of 30.6% (95% CI, 29.3-32.0). Analysis of the protocol itself, regardless of destination facility, resulted in an undertriage of 63.8% (95% CI, 59.2-68.1) and overtriage of 7.4% (95% CI, 6.7-8.2). The compliance to the field triage trauma protocol was 73% for patients with a level 1 indication. Conclusions and Relevance More than 20% of the patients with severe injuries were not transported to a level I trauma center. These patients are at risk for preventable morbidity and mortality. This finding indicates the need for improvement of the prehospital triage protocol.
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Affiliation(s)
- Frank J Voskens
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Eveline A J van Rein
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Roderick M Houwert
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.,Utrecht Trauma Center, Utrecht, the Netherlands
| | - Robert Anton Lichtveld
- Regional Ambulance Facility Utrecht, Regionale Ambulance Voorziening Utrecht, Utrecht, the Netherlands
| | - Egbert J Verleisdonk
- Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, the Netherlands
| | - Michiel Segers
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Ger van Olden
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | - Marcel Dijkgraaf
- Clinical Research Unit, Academic Medical Center, Amsterdam, the Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
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Warren KRJ, Morrey C, Oppy A, Pirpiris M, Balogh ZJ. The overview of the Australian trauma system. OTA Int 2019; 2:e018. [PMID: 37675256 PMCID: PMC10479347 DOI: 10.1097/oi9.0000000000000018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/11/2018] [Indexed: 09/08/2023]
Abstract
Trauma management in Australia is predominantly that of blunt mechanism trauma spread across a geographically large and sparsely populated country. A complex network of patient care has evolved to manage major trauma. Over recent decades, focus has been given to improving and co-ordinating transfer of patients into major trauma centers and improved data collection with the corresponding improved patient outcomes. This article provides an overview of the nature and structure of the Australian trauma system and its regulation.
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Affiliation(s)
| | - Chris Morrey
- Orthopaedic and Trauma Unit, Cairns Hospital and James Cook University, Carins, QLD
| | | | | | - Zsolt J Balogh
- Department of Traumatology, John Hunter Hospital and University of Newcastle, Newcastle, NSW, Australia
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14
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Liang Y, Lo-Cao E, Punch G, Lam V, Richardson A. International publication trends in hepato-pancreato-biliary surgery: emergency compared to oncology. ANZ J Surg 2018; 89:383-387. [PMID: 30513546 DOI: 10.1111/ans.14962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND There is growing interest in publishing trends given the increasing amount of research publication across various specialities. Studies relating to hepato-pancreato-biliary (HPB) surgery show an oncological focus compared to benign, emergency and trauma. METHODS Analysis of ISI JCR impact factors in the Web of Knowledge and the Scimago Journal Rank through Scopus was performed to select four readily available, relevant and frequently read journals from the surgery category. A total of 5265 articles between 2012 and 2016 were categorized relating to emergency or oncology topics. A secondary analysis of PubMed MeSH term was performed to scrutinize trends of publishing over the period 1960-2016. RESULTS Of the 5265 articles screened, 2062 related to HPB surgery. Of these, 49% (1007 of 2062) were oncology related. This trend towards oncology-related topics is continued in HPB subspecialty journals where 51% (679 of 1320) of articles are oncology related. Emergency- and trauma-related topics accounted 10% (198 of 2062) overall, whereas in subspecialty journals, they account for 8% (111 of 1320). Secondary analysis of MeSH term trends demonstrated a now stable trend over the last 20 years of liver and pancreatic trauma to oncology ratio of 1:10 publications, and biliary trauma to oncology publishing ratio of 1:5. CONCLUSIONS Quantitatively oncology topics are published favourably, whereas emergency- and trauma-related HPB articles appear static. This is in keeping with baseline trends over the last five decades. Further analysis could delineate whether publishing in trauma subspecialty journals compensate for this trend.
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Affiliation(s)
- Yi Liang
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of General Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Edward Lo-Cao
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Gratian Punch
- Department of General Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Vincent Lam
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of General Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Arthur Richardson
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of General Surgery, Westmead Hospital, Sydney, New South Wales, Australia
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15
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Tan AL, Chiong Y, Nadkarni N, Cheng JYX, Chiu MT, Wong TH. Predictors of Change in Functional Outcome at six months and twelve months after Severe Injury: A Retrospective Cohort Study. World J Emerg Surg 2018; 13:57. [PMID: 30524498 PMCID: PMC6276158 DOI: 10.1186/s13017-018-0217-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 11/14/2018] [Indexed: 02/03/2023] Open
Abstract
Background There is increasing focus on long-term survival, function and quality-of-life for trauma patients. There are few studies tracking longitudinal changes in functional outcome over time. The goal of our study was to compare the Glasgow Outcome Scale-Extended (GOSE) at 6 months and 12 months in blunt trauma survivors with an Injury Severity Score (ISS) of more than 15. Methods Using the Singapore National Trauma Registry 2011–2013, patients with 6-month GOSE and 12-month GOSE scores were analysed. Patients were grouped into three categories—those with the same score at 6 months and 12 months, an improvement in score, and a worse score at 12 months. Ordinal regression was used to identify risk factors for improved score. Patients with missing scores at either 6 months or 12 months were excluded. Results We identified 478 patients: 174 had an improvement in score, 233 stayed the same, and 71 had worse scores at 12 months compared to 6 months. On univariate ordinal regression, the following variables were associated with same or better function at 12-months compared to 6-months: male gender, being employed pre-injury, thoracic Abbreviated Injury Scale (AIS) of 3 or more, anatomical polytrauma (AIS of 3 or more in 2 or more body regions), and road traffic injury mechanism. Older age, low fall, increasing Charlson comorbidity scores, new injury severity score, and head and neck AIS of 3 or more were associated with worse function at 12 months compared to 6 months. ISS and revised trauma score were not significant predictors on univariate or multivariable analysis. On multivariable ordinal regression, motor vehicle mechanism (OR 2.78, 1.51–5.12, p = 0.001) was associated with improved function, while male gender (OR 1.36, 95% CI 1.02–1.82, p = 0.039) predicted improved function at 12 months. Conclusions Females experience worse functional outcomes at 12 months, potentially due to majority of female injuries being low falls in the elderly. In contrast, motor vehicle injury patients had better functional outcomes at 12 months. Additional interventional strategies for high-risk groups should be explored.
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Affiliation(s)
- Aidan Lyanzhiang Tan
- 1Preventive Medicine, National University Hospital, Singapore, Singapore.,2Health Services Research Unit, Singapore General Hospital, Singapore, Singapore
| | - Yi Chiong
- 3Department of Rehabilitation Medicine, Singapore General Hospital, Singapore, Singapore
| | - Nivedita Nadkarni
- 4Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore, Singapore
| | | | - Ming Terk Chiu
- 5National Trauma Unit, Tan Tock Seng Hospital, Singapore, Singapore.,6Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Ting Hway Wong
- 7General and Trauma Surgery, Singapore General Hospital, Singapore, Singapore.,8Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore
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17
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The Evolution of Trauma in Los Angeles County Over More Than a Decade. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 25:E17-E20. [PMID: 29494413 DOI: 10.1097/phh.0000000000000745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Explore trends in trauma incidence and mortality rates in Los Angeles County. DESIGN Data for patients treated at Los Angeles County trauma centers from 2000 to 2011 were analyzed for this study. Age-adjusted incidence and mortality rates were calculated by gender, race, injury type, injury severity, and mechanism of injury. Trends were assessed using linear regression to determine the annual percentage change (APC). RESULTS There were 223 773 patients included. The trauma incidence rate increased by 14.6% driven by an increase in blunt injury of 5.4% annually (P < .05). Penetrating injury decreased at -6.9% APC (P < .01). Mortality rate decreased at -11.5% APC (P < .01), with reduction in both blunt (-6.8% APC [P < .01]) and penetrating injuries (-16.7% APC [P < .01]). The trends in mortality persisted with stratification by age, gender, race, and injury severity score. CONCLUSION In this mature trauma system, the trauma incidence increased slightly from 2000 to 2011, while the mortality steadily declined. Public health officials in other areas could perform a similar self-evaluation to describe and monitor injury events and trends in their jurisdictions, a reassessment of priority and trauma system resource allocation, which will directly benefit the regional population.
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18
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Frost PJ, Wise MP. 24/7 Consultant working in the NHS: 12 years experience in intensive care. QJM 2018; 111:149-150. [PMID: 29024983 DOI: 10.1093/qjmed/hcx141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- P J Frost
- University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
- Institute of Medical Education, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4XN, UK
| | - M P Wise
- University Hospital of Wales, Heath Park, Cardiff, CF14?4XW, UK
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19
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Injury severity, sex, and transfusion volume, but not transfusion ratio, predict inflammatory complications after traumatic injury. Heart Lung 2017; 46:114-119. [DOI: 10.1016/j.hrtlng.2016.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 10/25/2016] [Accepted: 12/11/2016] [Indexed: 01/28/2023]
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20
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Barrie J, Jamdar S, Iniguez MF, Bouamra O, Jenks T, Lecky F, O'Reilly DA. Improved outcomes for hepatic trauma in England and Wales over a decade of trauma and hepatobiliary surgery centralisation. Eur J Trauma Emerg Surg 2017; 44:63-70. [PMID: 28204851 PMCID: PMC5808051 DOI: 10.1007/s00068-017-0765-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 01/20/2017] [Indexed: 11/30/2022]
Abstract
Background Over the last decade trauma services have undergone a reconfiguration in England and Wales. The objective is to describe the epidemiology, management and outcomes for liver trauma over this period and examine factors predicting survival. Methods Patients sustaining hepatic trauma were identified using the Trauma Audit and Research Network database. Demographics, management and outcomes were assessed between January 2005 and December 2014 and analysed over five, 2-year study periods. Independent predictor variables for the outcome of liver trauma were analysed using multiple logistic regression. Results 4368 Patients sustained hepatic trauma (with known outcome) between January 2005 and December 2014. Median age was 34 years (interquartile range 23–49). 81% were due to blunt and 19% to penetrating trauma. Road traffic collisions were the main mechanism of injury (58.2%). 241 patients (5.5%) underwent liver-specific surgery. The overall 30-day mortality rate was 16.4%. Improvements were seen in early consultant input, frequency and timing of computed tomography (CT) scanning, use of tranexamic acid and 30-day mortality over the five time periods. Being treated in a unit with an on-site HPB service increased the odds of survival (odds ratio 3.5, 95% confidence intervals 2.7–4.5). Conclusions Our study has shown that being treated in a unit with an on-site HPB service increased the odds of survival. Further evaluation of the benefits of trauma and HPB surgery centralisation is warranted.
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Affiliation(s)
- J Barrie
- Department of Hepato-pancreatobiliary Surgery, Manchester Royal Infirmary, Central Manchester Foundation Trust, Oxford Rd, Manchester, M13 9WL, UK
| | - S Jamdar
- Department of Hepato-pancreatobiliary Surgery, Manchester Royal Infirmary, Central Manchester Foundation Trust, Oxford Rd, Manchester, M13 9WL, UK
| | - M F Iniguez
- Trauma Audit and Research Network (TARN), Manchester Academic Health Science Centre, The University of Manchester, Manchester, M6 8HD, UK
| | - O Bouamra
- Trauma Audit and Research Network (TARN), Manchester Academic Health Science Centre, The University of Manchester, Manchester, M6 8HD, UK
| | - T Jenks
- Trauma Audit and Research Network (TARN), Manchester Academic Health Science Centre, The University of Manchester, Manchester, M6 8HD, UK
| | - F Lecky
- Trauma Audit and Research Network (TARN), Manchester Academic Health Science Centre, The University of Manchester, Manchester, M6 8HD, UK.,EMRiS Group, HSR Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - D A O'Reilly
- Department of Hepato-pancreatobiliary Surgery, Manchester Royal Infirmary, Central Manchester Foundation Trust, Oxford Rd, Manchester, M13 9WL, UK. .,School of Medical Sciences, The University of Manchester, Manchester, UK.
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The Effect of Availability of Manpower on Trauma Resuscitation Times in a Tertiary Academic Hospital. PLoS One 2016; 11:e0154595. [PMID: 27136299 PMCID: PMC4852985 DOI: 10.1371/journal.pone.0154595] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/16/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND For trauma patients, delays to assessment, resuscitation, and definitive care affect outcomes. We studied the effects of resuscitation area occupancy and trauma team size on trauma team resuscitation speed in an observational study at a tertiary academic institution in Singapore. METHODS From January 2014 to January 2015, resuscitation videos of trauma team activated patients with an Injury Severity Score of 9 or more were extracted for review within 14 days by independent reviewers. Exclusion criteria were patients dead on arrival, inter-hospital transfers, and up-triaged patients. Data captured included manpower availability (trauma team size and resuscitation area occupancy), assessment (airway, breathing, circulation, logroll), interventions (vascular access, imaging), and process-of-care time intervals (time to assessment/intervention/adjuncts, time to imaging, and total time in the emergency department). Clinical data were obtained by chart review and from the trauma registry. RESULTS Videos of 70 patients were reviewed over a 13-month period. The median time spent in the emergency department was 154.9 minutes (IQR 130.7-207.5) and the median resuscitation team size was 7, with larger team sizes correlating with faster process-of-care time intervals: time to airway assessment (p = 0.08) and time to disposition (p = 0.04). The mean resuscitation area occupancy rate (RAOR) was 1.89±2.49, and the RAOR was positively correlated with time spent in the emergency department (p = 0.009). CONCLUSION Our results suggest that adequate staffing for trauma teams and resuscitation room occupancy are correlated with faster trauma resuscitation and reduced time spent in the emergency department.
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22
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Wong TH, Krishnaswamy G, Nadkarni NV, Nguyen HV, Lim GH, Bautista DCT, Chiu MT, Chow KY, Ong MEH. Combining the new injury severity score with an anatomical polytrauma injury variable predicts mortality better than the new injury severity score and the injury severity score: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2016; 24:25. [PMID: 26955863 PMCID: PMC4784376 DOI: 10.1186/s13049-016-0215-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 02/27/2016] [Indexed: 11/21/2022] Open
Abstract
Background Anatomy-based injury severity scores are commonly used with physiological scores for reporting severity of injury in a standardized manner. However, there is lack of consensus on choice of scoring system, with the commonly used injury severity score (ISS) performing poorly for certain sub-groups, eg head-injured patients. We hypothesized that adding a dichotomous variable for polytrauma (yes/no for Abbreviated Injury Scale (AIS) scores of 3 or more in at least two body regions) to the New Injury Severity Score (NISS) would improve the prediction of in-hospital mortality in injured patients, including head-injured patients—a subgroup that has a disproportionately high mortality. Our secondary hypothesis was that the ISS over-estimates the risk of death in polytrauma patients, while the NISS under-estimates it. Methods Univariate and multivariable analysis was performed on retrospective cohort data of blunt injured patients aged 18 and over with an ISS over 9 from the Singapore National Trauma Registry from 2011–2013. Model diagnostics were tested using discrimination (c-statistic) and calibration (Hosmer-Lemeshow goodness-of-fit statistic). All models included age, gender, and comorbidities. Results Our results showed that the polytrauma and NISS model outperformed the other models (polytrauma and ISS, NISS alone or ISS alone) in predicting 30-day and in-hospital mortality. The NISS underestimated the risk of death for patients with polytrauma, while the ISS overestimated the risk of death for these patients. When used together with the NISS and polytrauma, categorical variables for deranged physiology (systolic blood pressure of 90 mmHg or less, GCS of 8 or less) outperformed the traditional ‘ISS and RTS (Revised Trauma Score)’ model, with a c-statistic of greater than 0.90. This could be useful in cases when the RTS cannot be scored due to missing respiratory rate. Discussion The NISS and polytrauma model is superior to current scores for prediction of 30-day and in-hospital mortality. We propose that this score replace the ISS or NISS in institutions using AIS-based scores. Conclusions Adding polytrauma to the NISS or ISS improves prediction of 30-day mortality. The superiority of the NISS or ISS depends on the proportion of polytrauma and head-injured patients in the study population.
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Affiliation(s)
- Ting Hway Wong
- Department of General Surgery, Singapore General Hospital, Outram Road, Singapore, 169608, Republic of Singapore. .,Duke-National University of Singapore, Singapore, Singapore.
| | | | | | - Hai V Nguyen
- Duke-National University of Singapore, Singapore, Singapore.
| | | | | | | | | | - Marcus Eng Hock Ong
- Duke-National University of Singapore, Singapore, Singapore. .,Department of Emergency medicine, Singapore General Hospital, Singapore, Singapore.
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23
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Defining major trauma using the 2008 Abbreviated Injury Scale. Injury 2016; 47:109-15. [PMID: 26283084 DOI: 10.1016/j.injury.2015.07.003] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/26/2015] [Accepted: 07/01/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Injury Severity Score (ISS) is the most ubiquitous summary score derived from Abbreviated Injury Scale (AIS) data. It is frequently used to classify patients as 'major trauma' using a threshold of ISS >15. However, it is not known whether this is still appropriate, given the changes which have been made to the AIS codeset since this threshold was first used. This study aimed to identify appropriate ISS and New Injury Severity Score (NISS) thresholds for use with the 2008 AIS (AIS08) which predict mortality and in-hospital resource use comparably to ISS >15 using AIS98. METHODS Data from 37,760 patients in a state trauma registry were retrieved and reviewed. AIS data coded using the 1998 AIS (AIS98) were mapped to AIS08. ISS and NISS were calculated, and their effects on patient classification compared. The ability of selected ISS and NISS thresholds to predict mortality or high-level in-hospital resource use (the need for ICU or urgent surgery) was assessed. RESULTS An ISS >12 using AIS08 was similar to an ISS >15 using AIS98 in terms of both the number of patients classified major trauma, and overall major trauma mortality. A 10% mortality level was only seen for ISS 25 or greater. A NISS >15 performed similarly to both of these ISS thresholds. However, the AIS08-based ISS >12 threshold correctly classified significantly more patients than a NISS >15 threshold for all three severity measures assessed. CONCLUSIONS When coding injuries using AIS08, an ISS >12 appears to function similarly to an ISS >15 in AIS98 for the purposes of identifying a population with an elevated risk of death after injury. Where mortality is a primary outcome of trauma monitoring, an ISS >12 threshold could be adopted to identify major trauma patients. LEVEL OF EVIDENCE Level II evidence--diagnostic tests and criteria.
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Dinh MM, Bein KJ, Hendrie D, Gabbe B, Byrne CM, Ivers R. Incremental cost-effectiveness of trauma service improvements for road trauma casualties: experience of an Australian major trauma centre. AUST HEALTH REV 2015; 40:385-390. [PMID: 26363826 DOI: 10.1071/ah14205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 07/31/2015] [Indexed: 11/23/2022]
Abstract
Objective The aim of the present study was to estimate the cost-effectiveness of trauma service funding enhancements at an inner city major trauma centre. Methods The present study was a cost-effectiveness analysis using retrospective trauma registry data of all major trauma patients (injury severity score >15) presenting after road trauma between 2001 and 2012. The primary outcome was cost per life year gained associated with the intervention period (2007-12) compared with the pre-intervention period (2001-06). Incremental costs were represented by all trauma-related funding enhancements undertaken between 2007 and 2010. Risk adjustment for years of life lost was conducted using zero-inflated negative binomial regression modelling. All costs were expressed in 2012 Australian dollar values. Results In all, 876 patients were identified during the study period. The incremental cost of trauma enhancements between 2007 and 2012 totalled $7.91million, of which $2.86million (36%) was attributable to road trauma patients. After adjustment for important covariates, the odds of in-hospital mortality reduced by around half (adjusted odds ratio (OR) 0.48; 95% confidence interval (CI) 0.27, 0.82; P=0.01). The incremental cost-effectiveness ratio was A$7600 per life year gained (95% CI A$5524, $19333). Conclusion Trauma service funding enhancements that enabled a quality improvement program at a single major trauma centre were found to be cost-effective based on current international and Australian standards. What is known about this topic? Trauma quality improvement programs have been implemented across most designated trauma hospitals in an effort to improve hospital care processes and outcomes for injured patients. These involve a combination of education and training, the use of audit and key performance indicators. What does this paper add? A trauma quality improvement program initiated at an Australian Major Trauma Centre was found to be cost-effective over 12 years with respect to years of life saved in road trauma patients. What are the implications for practitioners? The results suggest that adequate resourcing of trauma centres to enable quality improvement programs may be a cost-effective measure to reduce in-hospital mortality following road trauma.
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Affiliation(s)
- Michael M Dinh
- Department of Trauma Services, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia.
| | - Kendall J Bein
- Department of Trauma Services, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia.
| | - Delia Hendrie
- Centre for Population Health Research, Curtin University, Bentley, WA 6102, Australia. Email
| | - Belinda Gabbe
- Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Vic. 3004, Australia. Email
| | - Christopher M Byrne
- Department of Trauma Services, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia.
| | - Rebecca Ivers
- Injury Division, The George Institute for Global Health, The University of Sydney, Sydney Medical School, 321 Kent Street, Sydney, NSW 2000, Australia. Email
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Increased mortality in adult patients with trauma transfused with blood components compared with whole blood. J Trauma Nurs 2015; 21:22-9. [PMID: 24399315 DOI: 10.1097/jtn.0000000000000025] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Hemorrhage is a preventable cause of death among patients with trauma, and management often includes transfusion, either whole blood or a combination of blood components (packed red blood cells, platelets, fresh frozen plasma). We used the 2009 National Trauma Data Bank data set to evaluate the relationship between transfusion type and mortality in adult patients with major trauma (n = 1745). Logistic regression analysis identified 3 independent predictors of mortality: Injury Severity Score, emergency medical system transfer time, and type of blood transfusion, whole blood or components. Transfusion of whole blood was associated with reduced mortality; thus, it may provide superior survival outcomes in this population.
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The definition of polytrauma revisited: An international consensus process and proposal of the new 'Berlin definition'. J Trauma Acute Care Surg 2014; 77:780-786. [PMID: 25494433 DOI: 10.1097/ta.0000000000000453] [Citation(s) in RCA: 188] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The nomenclature for patients with multiple injuries with high mortality rates is highly variable, and there is a lack of a uniform definition of the term polytrauma. A consensus process was therefore initiated by a panel of international experts with the goal of assessing an improved, database-supported definition for the polytraumatized patient. METHODS The consensus process involved the following: RESULTS: A total of 28,211 patients in the trauma registry met the inclusion criteria. The mean (SD) age of the study cohort was 42.9 (20.2) years (72% males, 28% females). The mean (SD) ISS was 30.5 (12.2), with an overall mortality rate of 18.7% (n = 5,277) and an incidence of 3% of penetrating injuries (n = 886). Five independent physiologic variables were identified, and their individual cutoff values were calculated based on a set mortality rate of 30%: hypotension (systolic blood pressure ≤ 90 mm Hg), level of consciousness (Glasgow Coma Scale [GCS] score ≤ 8), acidosis (base excess ≤ -6.0), coagulopathy (international normalized ratio ≥ 1.4/partial thromboplastin time ≥ 40 seconds), and age (≥70 years). CONCLUSION Based on several consensus meetings and a database analysis, the expert panel proposes the following parameters for a definition of "polytrauma": significant injuries of three or more points in two or more different anatomic AIS regions in conjunction with one or more additional variables from the five physiologic parameters. Further validation of this proposal should occur, favorably by mutivariate analyses of these parameters in a separate data set.
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Lank PM, Crandall ML. Outcomes for older trauma patients in the emergency department screening positive for alcohol, cocaine, or marijuana use. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2014; 40:118-24. [PMID: 24588418 DOI: 10.3109/00952990.2014.880450] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Substance use among older adults is an increasing concern, with the prevalence of substance use in older populations expected to double in the next decade. Drug and alcohol use is associated with trauma risk and outcomes, but little is known about the specific risk for older trauma patients. OBJECTIVES To evaluate the association between drug and alcohol use and trauma outcomes among adults aged 55 years and older. METHODS This retrospective observational study included older adults from the Illinois Trauma Registry between 1999 and 2009. Exclusion criteria were age younger than 55 years or absent date of birth, ethanol level, or urine drug screen (UDS). Alcohol intoxication was defined as ethanol level greater than 80 mg/dL. UDS was used to screen cocaine and marijuana use. Analyses, for both the alcohol and the marijuana/cocaine groups, compared outcomes for patients with negative vs. positive screens. RESULTS 21 320 patients were included in the alcohol analysis and 17 077 in the drug analysis. Compared to non-intoxicated patients, alcohol-intoxicated patients had significantly (p < 0.001) lower in-hospital mortality, decreased ICU admission, decreased intubation rate, and shorter hospital length of stay. Patients screening positive for cocaine or marijuana had significantly longer lengths of stay with increased ICU admission compared with those who screened negative. CONCLUSION Among older trauma patients, this study shows significant associations with multiple trauma outcomes, including one between elevated ethanol concentrations and improved outcomes. Future research into the causes of these findings could inform the care of older trauma patients and aid in prevention of injuries.
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Lumsdaine W, Easton RM, Lott NJ, White A, Malmanche TLD, Lemmert K, Weber DG, Balogh ZJ. Neutrophil oxidative burst capacity for peri-operative immune monitoring in trauma patients. Injury 2014; 45:1144-8. [PMID: 24815374 DOI: 10.1016/j.injury.2014.04.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/18/2014] [Accepted: 04/05/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Post injury immune dysfunction can result in serious complications. Measurement of biomarkers may guide the optimal timing of surgery in clinically borderline patients and therefore prevent complications. AIM peri-operative measurement of neutrophil oxidative burst capacity as an indicator of the immune response to major orthopaedic surgical procedures. METHODS Prospective cohort study of trauma patients aged ≥16 yrs with pelvic, acetabular, femoral shaft or tibial shaft fractures requiring surgical intervention. Blood samples were taken immediately pre-op and at 30 min, 7, 24 and 72-9 6 h post-operatively. Neutrophil oxidative burst capacity was measured both with and without stimulation by formyl-methionyl-leucyl-phenylalanine (fMLP, a chemotactic factor). Clinical outcomes measured were mortality, length of stay, MOF, pneumonia, acute respiratory distress syndrome (ARDS) and sepsis. RESULTS 100 consecutive orthopaedic trauma patients were enrolled over a 16 month period. 78% were male, with a mean age of 42 ± 18 years and an average ISS of 19 ± 13. Neutrophil oxidative burst capacity was significantly elevated at 7 h (p = 0.006) and 24 h (p = 0.022) post operatively. Patients who developed infective complications (pneumonia and sepsis) had higher levels of oxidative burst capacity pre-operatively (pneumonia: 1.52 ± 0.93 v 0.99 ± 0.66 p = 0.032, sepsis: 1.39 ± 0.86 v 0.97 ± 0.56 p = 0.024) and at 24 h post op (pneumonia: 2.72 ± 2.38 v 1.12 ± 0.63 p = < 0.001, sepsis: 2.16 ± 2.09 v 1.10 ± 0.54 p = < 0.001). When analysed by operation type, no statistical difference was seen between major and minor operations. No correlation was found between length of stay, length of ICU stay, ISS or age and neutrophil oxidative burst capacity at any time point. CONCLUSIONS Neutrophil oxidative burst capacity response to orthopaedic trauma surgery is associated with the infective post injury complications. There was no correlation between magnitude of injury or operation and oxidative burst capacity. These results are promising for the development of tools for prediction of post-operative complications and guidance for optimal timing for surgical intervention.
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Affiliation(s)
- William Lumsdaine
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Ruth Miriam Easton
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Natalie Jane Lott
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Amanda White
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Theo L de Malmanche
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Karla Lemmert
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Dieter Georg Weber
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia
| | - Zsolt J Balogh
- Department of Traumatology, Division of Surgery, John Hunter Hospital and University of Newcastle, Locked Bag 1, Newcastle 2310, NSW, Australia.
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Dinh MM, Bein KJ, Gabbe BJ, Byrne CM, Petchell J, Lo S, Ivers R. A trauma quality improvement programme associated with improved patient outcomes: 21 years of experience at an Australian Major Trauma Centre. Injury 2014; 45:830-4. [PMID: 24290523 DOI: 10.1016/j.injury.2013.11.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Revised: 10/08/2013] [Accepted: 11/06/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Quality improvement programmes are an important part of care delivery in trauma centres. The objective was to describe the effect of a comprehensive quality improvement programme on long term patient outcome trends at a low volume major trauma centre in Australia. METHODS All patients aged 15 years and over with major trauma (Injury Severity Score>15) admitted to a single inner city major trauma centre between 1992 and 2012 were studied. The outcomes of interest were in-hospital mortality and transfer to rehabilitation. Time series analysis using integer valued autoregressive Poisson models was used to determine the reduction in adjusted monthly count data associated with the intervention period (2007-2012). Risk adjusted odds ratios for mortality over three yearly intervals was also obtained using multivariable logistic regression. Crude and risk adjusted mortality was compared before and after the implementation period. RESULTS 3856 patients were analysed. Crude in-hospital mortality fell from 16% to 10% after implementation (p<0.001). The intervention period was associated with a 25% decrease in monthly mortality counts. Risk adjusted mortality remained stable from 1992 to 2006 and did not fall until the intervention period. Crude and risk adjusted transfer to in-patient rehabilitation after major trauma also declined during the intervention period. CONCLUSION In this low volume major trauma centre, the implementation of a comprehensive quality improvement programme was associated with a reduction in crude and risk adjusted mortality and risk adjusted discharge to rehabilitation in severely injured patients.
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Affiliation(s)
- Michael M Dinh
- Royal Prince Alfred Hospital, Department of Trauma Services, Australia; Sydney Medical School, University of Sydney, Australia.
| | - Kendall J Bein
- Royal Prince Alfred Hospital, Emergency Department, Australia.
| | - Belinda J Gabbe
- Monash University, Department of Epidemiology and Preventive Medicine, Australia.
| | | | - Jeffrey Petchell
- Royal Prince Alfred Hospital, Department of Trauma Services, Australia.
| | - Serigne Lo
- Sydney Medical School, University of Sydney, Australia; The George Institute for Global Health, Injury Division, Australia.
| | - Rebecca Ivers
- Sydney Medical School, University of Sydney, Australia; The George Institute for Global Health, Injury Division, Australia.
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