1
|
Zhuang Q, Liu J, Liu W, Ye X, Chai X, Sun S, Feng C, Li L. Development and validation of risk prediction model for adverse outcomes in trauma patients. Ann Med 2024; 56:2391018. [PMID: 39155796 PMCID: PMC11334749 DOI: 10.1080/07853890.2024.2391018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 08/20/2024] Open
Abstract
BACKGROUND The prognosis of trauma patients is highly dependent on early medical diagnosis. By constructing a nomogram model, the risk of adverse outcomes can be displayed intuitively and individually, which has important clinical implications for medical diagnosis. OBJECTIVE To develop and evaluate models for predicting patients with adverse outcomes of trauma that can be used in different data availability settings in China. METHODS This was a retrospective prognostic study using data from 8 public tertiary hospitals in China from 2018. The data were randomly divided into a development set and a validation set. Simple, improved and extended models predicting adverse outcomes were developed, with adverse outcomes defined as in-hospital death or ICU transfer, and patient clinical characteristics, vital signs, diagnoses, and laboratory test values as predictors. The results of the models were presented in the form of nomograms, and performance was evaluated using area under the receiver operating characteristic curve (ROC-AUC), precision-recall (PR) curves (PR-AUC), Hosmer-Lemeshow goodness-of-fit test, calibration curve, and decision curve analysis (DCA). RESULTS Our final dataset consisted of 18,629 patients (40.2% female, mean age of 52.3), 1,089 (5.85%) of whom resulted in adverse outcomes. In the external validation set, three models achieved ROC-AUC of 0.872, 0.881, and 0.903, and a PR-AUC of 0.339, 0.337, and 0.403, respectively. In terms of the calibration curves and DCA, the models also performed well. CONCLUSIONS This prognostic study found that three prediction models and nomograms including the patient clinical characteristics, vital signs, diagnoses, and laboratory test values can support clinicians in more accurately identifying patients who are at risk of adverse outcomes in different settings based on data availability.
Collapse
Affiliation(s)
- Qian Zhuang
- Department of Innovative Medical Research, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Jianchao Liu
- Department of Innovative Medical Research, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Wei Liu
- Department of Innovative Medical Research, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Xiaofei Ye
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Xuan Chai
- Outpatient Department, Capital Medical University Affiliated Beijing Shijitan Hospital, Beijing, China
| | - Songmei Sun
- The Second Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Cong Feng
- Department of Emergency, First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Lin Li
- Department of Innovative Medical Research, Chinese People’s Liberation Army General Hospital, Beijing, China
| |
Collapse
|
2
|
Doshi H, Deshpande K. Burden of fever and hospital mortality in patients admitted to the intensive care unit with isolated traumatic brain injury-A retrospective cohort study using continuous temperature data. Aust Crit Care 2024; 37:694-700. [PMID: 38604918 DOI: 10.1016/j.aucc.2024.03.002] [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] [Received: 08/24/2023] [Revised: 02/18/2024] [Accepted: 03/05/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Fever has been shown to be associated with poor outcomes in patients with traumatic brain injury. Earlier studies have used peak daily temperature to derive the burden of fever. The association between hospital mortality and fever burden calculated as the area under the temperature-time curve for the entire duration of intensive care unit (ICU) stay has not been studied before. OBJECTIVES The objective of this study was to investigate the association between the burden of fever and hospital mortality in patients with isolated traumatic brain injury admitted to the ICU. METHODS We conducted this retrospective cohort study using an electronic database in a tertiary ICU in Sydney. We included all adult patients admitted to the ICU with isolated traumatic brain injury over 3 years from 1 July 2017 to 30 June 2020. We collected data on demographics, clinical characteristics, and interventions for all patients. We defined the burden of fever as an area under the temperature-time curve above 37 °C. The primary outcome was hospital mortality. We used multivariable logistic regression to determine the association between burden of fever and hospital mortality. We assessed the importance of the burden of fever in a predictive model using machine-learning methods (Bagging and Random Forest). RESULTS A total of 88 patients (76% males, mean age: 54 ± 23 years, mean Acute Physiology and Chronic Health Evaluation [APACHE] II score: 15 ± 7) were included in the study, and 18 (20.5%) of the 88 patients died in hospital. Compared to survivors, the nonsurvivors had lower mean Glasgow Coma Scale (GCS) score at the scene, higher mean APACHE II and III scores, and higher rates of intracranial pressure monitoring, surgery, mechanical ventilation, use of vasopressors, and cooling. On multivariable logistic regression, age (odds ratio: 1.05, 95% confidence interval: 1.02-1.09, p = 0.01) was found to be an independent predictor of hospital mortality. A higher GCS score at the scene (odds ratio: 0.81, 95% confidence interval: 0.66-0.98, p = 0.03) was associated with survival. The burden of fever was not associated with hospital mortality. The top three important variables in the predictive model were APACHE III, GCS score at scene, and age. CONCLUSION The burden of fever was not an independent predictor of hospital mortality. The results of this study need to be confirmed in a large multicenter study.
Collapse
Affiliation(s)
- Hemang Doshi
- St George Hospital, Gray Street, Kogarah, NSW 2217, Australia.
| | - Kush Deshpande
- St George Hospital, Gray Street, Kogarah, NSW 2217, Australia.
| |
Collapse
|
3
|
Akinci D'Antonoli T, Mercaldo ND. Reply to Letter to the Editor: "Obsolescence of nomograms in radiomics research". Eur Radiol 2024; 34:5054-5055. [PMID: 38240806 DOI: 10.1007/s00330-023-10570-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 12/06/2023] [Accepted: 12/11/2023] [Indexed: 07/18/2024]
Affiliation(s)
- Tugba Akinci D'Antonoli
- Institute of Radiology and Nuclear Medicine, Cantonal Hospital Baselland, Liestal, Switzerland.
| | | |
Collapse
|
4
|
Halligan S, Mallett S. Letter to the Editor: "Obsolescence of nomograms in radiomics research". Eur Radiol 2024; 34:5052-5053. [PMID: 38206407 DOI: 10.1007/s00330-023-10569-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 09/30/2023] [Accepted: 12/11/2023] [Indexed: 01/12/2024]
Affiliation(s)
- Steve Halligan
- Centre for Medical Imaging, Division of Medicine, University College London UCL, London, UK.
| | - Sue Mallett
- Centre for Medical Imaging, Division of Medicine, University College London UCL, London, UK
| |
Collapse
|
5
|
Andaur Navarro CL, Damen JAA, Ghannad M, Dhiman P, van Smeden M, Reitsma JB, Collins GS, Riley RD, Moons KGM, Hooft L. SPIN-PM: a consensus framework to evaluate the presence of spin in studies on prediction models. J Clin Epidemiol 2024; 170:111364. [PMID: 38631529 DOI: 10.1016/j.jclinepi.2024.111364] [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] [Received: 10/24/2023] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES To develop a framework to identify and evaluate spin practices and its facilitators in studies on clinical prediction model regardless of the modeling technique. STUDY DESIGN AND SETTING We followed a three-phase consensus process: (1) premeeting literature review to generate items to be included; (2) a series of structured meetings to provide comments discussed and exchanged viewpoints on items to be included with a panel of experienced researchers; and (3) postmeeting review on final list of items and examples to be included. Through this iterative consensus process, a framework was derived after all panel's researchers agreed. RESULTS This consensus process involved a panel of eight researchers and resulted in SPIN-Prediction Models which consists of two categories of spin (misleading interpretation and misleading transportability), and within these categories, two forms of spin (spin practices and facilitators of spin). We provide criteria and examples. CONCLUSION We proposed this guidance aiming to facilitate not only the accurate reporting but also an accurate interpretation and extrapolation of clinical prediction models which will likely improve the reporting quality of subsequent research, as well as reduce research waste.
Collapse
Affiliation(s)
- Constanza L Andaur Navarro
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Johanna A A Damen
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mona Ghannad
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Paula Dhiman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maarten van Smeden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK; NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Richard D Riley
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lotty Hooft
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
6
|
Gulickx M, Lokerman RD, Waalwijk JF, Dercksen B, van Wessem KJP, Tuinema RM, Leenen LPH, van Heijl M. Pre-hospital tranexamic acid administration in patients with a severe hemorrhage: an evaluation after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol. Eur J Trauma Emerg Surg 2024; 50:139-147. [PMID: 37067552 PMCID: PMC10923991 DOI: 10.1007/s00068-023-02262-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 03/16/2023] [Indexed: 04/18/2023]
Abstract
PURPOSE To evaluate the pre-hospital administration of tranexamic acid in ambulance-treated trauma patients with a severe hemorrhage after the implementation of tranexamic acid administration in the Dutch pre-hospital protocol. METHODS All patients with a severe hemorrhage who were treated and conveyed by EMS professionals between January 2015, and December 2017, to any trauma-receiving emergency department in the eight participating trauma regions in the Netherlands, were included. A severe hemorrhage was defined as extracranial injury with > 20% body volume blood loss, an extremity amputation above the wrist or ankle, or a grade ≥ 4 visceral organ injury. The main outcome was to determine the proportion of patients with a severe hemorrhage who received pre-hospital treatment with tranexamic acid. A Generalized Linear Model (GLM) was performed to investigate the relationship between pre-hospital tranexamic acid treatment and 24 h mortality. RESULTS A total of 477 patients had a severe hemorrhage, of whom 124 patients (26.0%) received tranexamic acid before arriving at the hospital. More than half (58.4%) of the untreated patients were suspected of a severe hemorrhage by EMS professionals. Patients treated with tranexamic acid had a significantly lower risk on 24 h mortality than untreated patients (OR 0.43 [95% CI 0.19-0.97]). CONCLUSION Approximately a quarter of the patients with a severe hemorrhage received tranexamic acid before arriving at the hospital, while a severe hemorrhage was suspected in more than half of the non-treated patients. Severely hemorrhaging patients treated with tranexamic acid before arrival at the hospital had a lower risk to die within 24 h after injury.
Collapse
Affiliation(s)
- Max Gulickx
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Robin D Lokerman
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Job F Waalwijk
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bert Dercksen
- Department of Anesthesiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Karlijn J P van Wessem
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Rinske M Tuinema
- Regional Ambulance Facilities Utrecht, Bilthoven, The Netherlands
- Department of Emergency Medicine, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, The Netherlands
| | - Luke P H Leenen
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Trauma Center Utrecht, Utrecht, The Netherlands
| | - Mark van Heijl
- Department of Surgery, University Medical Center Utrecht, C04.332, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Trauma Center Utrecht, Utrecht, The Netherlands
- Department of Surgery, DiakonessenhuisUtrecht/Zeist/Doorn, Utrecht, The Netherlands
| |
Collapse
|
7
|
Petroudi D, Papagelopoulos PJ, Kontogeorgakos V. Road Accidents, Polytrauma Patients, and Their Economic Burden. J Long Term Eff Med Implants 2024; 34:21-23. [PMID: 37938201 DOI: 10.1615/jlongtermeffmedimplants.2023045680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Trauma is a problem of global public health with economic, social and political extensions. It is constantly growing due to road accidents. The cost of hospitalization and the loss of working hours for those who managed to reach the hospital are huge for the national economy of each country. The purpose of the present study is to record the polytrauma patients of road accidents and to search for their economic cost. A total of 68 injured people were the study sample during the period 2014-2017. The study was conducted in a University hospital in Athens (Greece). The mean age of the patients was 36.67 years. The mortality was 13.2% and the mean cost of every polytrauma patient was 14.272 Euros. Nearly half of them had an infection, which increased the cost. Accident prevention, proper and timely treatment of injuries, monitoring, recording and controlling infections and reducing the length of hospitalization are some of the ways to reduce the financial cost of a traumatized person.
Collapse
Affiliation(s)
- Dimitra Petroudi
- Department of Orthopaedic Surgery, Attikon Hospital, Athens, Greece
| | | | - Vasileios Kontogeorgakos
- National & Kapodistrian University of Athens, Department of Orthopaedic Surgery, Attikon Hospital, Athens, Greece
| |
Collapse
|
8
|
Wyssusek KH, Wagner MK, Lee J, Okano S, Wullschleger M, van Zundert AA. Blood management practices during rapid transfer of urgent trauma patients pre- and post-implementation of ROTEM ®-guided transfusion. TRAUMA-ENGLAND 2023. [DOI: 10.1177/14604086231159687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Objective The ‘Red Blanket’ protocol fast tracks trauma patients with severe blood loss to the designated trauma operating theatre directly from the hospital helipad or Emergency Department. This study aimed to assess the impact of patient blood management (PBM) strategies on severely injured trauma patients treated under the ‘Red Blanket’ protocol at a quaternary referral hospital. Methods This retrospective review was conducted on all urgent trauma cases that were treated under the ‘Red Blanket’ protocol in a ten-year period between January 2007 and December 2017. The use of blood products and patient outcomes was compared between the 3.5-year periods pre- and post-ROTEM® implementation on 30th June 2014 (Jan 2011-June 2014 versus July 2014-Dec 2017). Results During the study period, 120 trauma patients were treated under the ‘Red Blanket’ protocol at our institution. Intention to treat analysis showed a reduction in fresh frozen plasma usage following the introduction of ROTEM®-guided transfusion. Furthermore, subgroup analysis suggested reduced blood product usage in patients who survived. Conclusions Patient blood management is a coordinated package of systems and tools, including education, patient logistics, anaemia management, intraoperative cell salvage, rotational thromboelastometry and massive transfusion protocols that together conserve blood products and improve outcomes. The implementation of ROTEM®-guided transfusion demonstrated a reduction in fresh frozen plasma usage.
Collapse
Affiliation(s)
- Kerstin H. Wyssusek
- Department of Anesthesia & Perioperative Medicine, Royal Brisbane & Women's Hospital, St Herston, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Herston, QLD, Australia
| | - Matthew K. Wagner
- Department of Anesthesia & Perioperative Medicine, Royal Brisbane & Women's Hospital, St Herston, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Herston, QLD, Australia
| | - Julie Lee
- Department of Anesthesia & Perioperative Medicine, Royal Brisbane & Women's Hospital, St Herston, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Herston, QLD, Australia
| | - Satomi Okano
- Statistics Unit, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia
| | - Martin Wullschleger
- School of Clinical Medicine, The University of Queensland, Herston, QLD, Australia
- Department of Trauma Service, Royal Brisbane and Women’s Hospital, Herston, QLD, Australia
| | - André A. van Zundert
- Department of Anesthesia & Perioperative Medicine, Royal Brisbane & Women's Hospital, St Herston, QLD, Australia
- School of Clinical Medicine, The University of Queensland, Herston, QLD, Australia
| |
Collapse
|
9
|
Jávor P, Hanák L, Hegyi P, Csonka E, Butt E, Horváth T, Góg I, Lukacs A, Soós A, Rumbus Z, Pákai E, Toldi J, Hartmann P. Predictive value of tachycardia for mortality in trauma-related haemorrhagic shock: a systematic review and meta-regression. BMJ Open 2022; 12:e059271. [PMID: 36261235 PMCID: PMC9582324 DOI: 10.1136/bmjopen-2021-059271] [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: 11/12/2022] Open
Abstract
OBJECTIVES Heart rate (HR) is one of the physiological variables in the early assessment of trauma-related haemorrhagic shock, according to Advanced Trauma Life Support (ATLS). However, its efficiency as predictor of mortality is contradicted by several studies. Furthermore, the linear association between HR and the severity of shock and blood loss presented by ATLS is doubtful. This systematic review aims to update current knowledge on the role of HR in the initial haemodynamic assessment of patients who had a trauma. DESIGN This study is a systematic review and meta-regression that follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. DATA SOURCES EMBASE, MEDLINE, CENTRAL and Web of Science databases were systematically searched through on 1 September 2020. ELIGIBILITY CRITERIA Papers providing early HR and mortality data on bleeding patients who had a trauma were included. Patient cohorts were considered haemorrhagic if the inclusion criteria of the studies contained transfusion and/or positive focused assessment with sonography for trauma and/or postinjury haemodynamical instability and/or abdominal gunshot injury. Studies on burns, traumatic spinal or brain injuries were excluded. Papers published before January 2010 were not considered. DATA EXTRACTION AND SYNTHESIS Data extraction and risk of bias were assessed by two independent investigators. The association between HR and mortality of patients who had a trauma was assessed using meta-regression analysis. As subgroup analysis, meta-regression was performed on patients who received blood products. RESULTS From a total of 2017 papers, 19 studies met our eligibility criteria. Our primary meta-regression did not find a significant relation (p=0.847) between HR and mortality in patients who had a trauma with haemorrhage. Our subgroup analysis included 10 studies, and it could not reveal a linear association between HR and mortality rate. CONCLUSIONS In accordance with the literature demonstrating the multiphasic response of HR to bleeding, our study presents the lack of linear association between postinjury HR and mortality. Modifying the pattern of HR derangements in the ATLS shock classification may result in a more precise teaching tool for young clinicians.
Collapse
Affiliation(s)
- Péter Jávor
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Lilla Hanák
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Centre for Translational Medicine and Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Translational Pancreatology Research Group, Interdisciplinary Centre of Excellence for Research Development and Innovation, University of Szeged, Szeged, Hungary
| | - Endre Csonka
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Edina Butt
- Department of Traumatology, University of Szeged, Szeged, Hungary
| | - Tamara Horváth
- Institute of Surgical Research, University of Szeged, Szeged, Hungary
| | - István Góg
- Department of Vascular Surgery, Hungarian Defense Forces Medical Center - Military Hospital, Budapest, Hungary
| | - Anita Lukacs
- Department of Physiology, Anatomy and Neuroscience, Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
| | - Alexandra Soós
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Zoltán Rumbus
- Department of Thermophysiology, Medical School, University of Pécs, Pécs, Hungary
| | - Eszter Pákai
- Department of Thermophysiology, Medical School, University of Pécs, Pécs, Hungary
| | - János Toldi
- Department of Anesthesiology and Intensive Care, Medical School, University of Pécs, Pécs, Hungary
| | - Petra Hartmann
- Department of Traumatology, University of Szeged, Szeged, Hungary
| |
Collapse
|
10
|
Ooi SZY, Spencer RJ, Hodgson M, Mehta S, Phillips NL, Preest G, Manivannan S, Wise MP, Galea J, Zaben M. Interleukin-6 as a prognostic biomarker of clinical outcomes after traumatic brain injury: a systematic review. Neurosurg Rev 2022; 45:3035-3054. [PMID: 35790656 PMCID: PMC9256073 DOI: 10.1007/s10143-022-01827-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/12/2022] [Accepted: 06/12/2022] [Indexed: 11/25/2022]
Abstract
Traumatic brain injury (TBI) is a major cause of mortality and morbidity worldwide. There are currently no early biomarkers for prognosis in routine clinical use. Interleukin-6 (IL-6) is a potential biomarker in the context of the established role of neuroinflammation in TBI recovery. Therefore, a systematic review of the literature was performed to assess and summarise the evidence for IL-6 secretion representing a useful biomarker for clinical outcomes. A multi-database literature search between January 1946 and July 2021 was performed. Studies were included if they reported adult TBI patients with IL-6 concentration in serum, cerebrospinal fluid (CSF) and/or brain parenchyma analysed with respect to functional outcome and/or mortality. A synthesis without meta-analysis is reported. Fifteen studies were included, reporting 699 patients. Most patients were male (71.7%), and the pooled mean age was 40.8 years; 78.1% sustained severe TBI. Eleven studies reported IL-6 levels in serum, six in CSF and one in the parenchyma. Five studies on serum demonstrated higher IL-6 concentrations were associated with poorer outcomes, and five showed no signification association. In CSF studies, one found higher IL-6 levels were associated with poorer outcomes, one found them to predict better outcomes and three found no association. Greater parenchymal IL-6 was associated with better outcomes. Despite some inconsistency in findings, it appears that exaggerated IL-6 secretion predicts poor outcomes after TBI. Future efforts require standardisation of IL-6 measurement practices as well as assessment of the importance of IL-6 concentration dynamics with respect to clinical outcomes, ideally within large prospective studies. Prospero registration number: CRD42021271200
Collapse
Affiliation(s)
| | - Robert James Spencer
- Brain Research and Intracranial Neurotherapeutics (BRAIN) Unit, Neuroscience and Mental Health Innovation Institute, Cardiff University, Cardiff, UK.,Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Megan Hodgson
- Cardiff University School of Medicine, Heath Park, Cardiff, UK
| | - Samay Mehta
- University of Birmingham Medical School, Birmingham, UK
| | | | | | - Susruta Manivannan
- Department of Neurosurgery, Southampton General Hospital, Southampton, UK
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - James Galea
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
| | - Malik Zaben
- Brain Research and Intracranial Neurotherapeutics (BRAIN) Unit, Neuroscience and Mental Health Innovation Institute, Cardiff University, Cardiff, UK. .,Department of Neurosurgery, University Hospital of Wales, Cardiff, UK.
| |
Collapse
|
11
|
Alhenaki AM, Ali AS, Kadir B, Ahmed Z. Pre-hospital administration of tranexamic acid in trauma patients: A systematic review and meta-analysis. TRAUMA-ENGLAND 2022. [DOI: 10.1177/14604086211001163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage-2 (CRASH-2) trial proved that tranexamic acid (TXA) is a time-dependent drug, having a better outcome if given within 1-hour of injury. In order to test this theory, studies have been conducted to examine the effect of TXA in the pre-hospital setting. We conducted a systematic search and meta-analysis to evaluate the role of TXA administration in the civilian pre-hospital setting on patient outcomes. Methods Embase, Medline, CINAHL and Cochrane were searched for randomized control trials (RCTs), retrospective, and prospective studies that examined the effect of TXA on patients in the pre-hospital setting versus a control group. Outcome measures were overall mortality rate and thromboembolic events. Two authors extracted the data independently. To appraise the included studies, we used the NIH quality assessment tool for cohort and cross-sectional studies. Results are presented as Risk Ratio (RR), a random-effect model was implemented, and the I2 test was used to assess heterogeneity. Results The search identified 1886 papers, but only five retrospective studies met the inclusion/exclusion criteria and were selected for further analysis. A meta-analysis confirmed that TXA reduced the overall mortality rate (pooled risk ratio of 0.74 (95% CI 0.45, 1.25)) and thromboembolic events (risk ratio of 0.71 (95% CI 0.35, 1.44)). Conclusion The pooled effects for both outcome measures favour the administration of TXA in the pre-hospital setting, although none of the findings reported a significant effect. Our study highlights the need for additional high-quality evidence to validate the significance of these findings. Level of evidence Level III, therapeutic study.
Collapse
Affiliation(s)
- Abdulrahman M Alhenaki
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Ayesha S Ali
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Bryar Kadir
- Cancer Research UK Clinical Trials Unit, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Zubair Ahmed
- Neuroscience and Ophthalmology, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Surgical Reconstruction and Microbiology Research Centre, National Institute for Health Research, Queen Elizabeth Hospital, Birmingham, UK
| |
Collapse
|
12
|
El-Menyar A, Ahmed K, Hakim S, Kanbar A, Mathradikkal S, Siddiqui T, Jogol H, Younis B, Taha I, Mahmood I, Ajaj A, Atique S, Alaieb A, Bahey AAA, Asim M, Alinier G, Castle NR, Mekkodathil A, Rizoli S, Al-Thani H. Efficacy and safety of the second in-hospital dose of tranexamic acid after receiving the prehospital dose: double-blind randomized controlled clinical trial in a level 1 trauma center. Eur J Trauma Emerg Surg 2021; 48:3089-3099. [PMID: 34910219 PMCID: PMC9360064 DOI: 10.1007/s00068-021-01848-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/23/2021] [Indexed: 11/29/2022]
Abstract
Background Prehospital administration of tranexamic acid (TXA) to injured patients is increasing worldwide. However, optimal TXA dose and need of a second infusion on hospital arrival remain undetermined. We investigated the efficacy and safety of the second in-hospital dose of TXA in injured patients receiving 1 g of TXA in the prehospital setting. We hypothesized that a second in-hospital dose of TXA improves survival of trauma patients. Methods A prospective, double-blind, placebo-controlled randomized, clinical trial included adult trauma patients receiving 1 g of TXA in the prehospital settings. Patients were then blindly randomized to Group I (second 1-g TXA) and Group II (placebo) on hospital arrival. The primary outcome was 24-h (early) and 28-day (late) mortality. Secondary outcomes were thromboembolic events, blood transfusions, hospital length of stay (HLOS) and organs failure (MOF). Results A total of 220 patients were enrolled, 110 in each group. The TXA and placebo groups had a similar early [OR 1.000 (0.062–16.192); p = 0.47] and late mortality [OR 0.476 (95% CI 0.157–1.442), p = 0.18].The cause of death (n = 15) was traumatic brain injury (TBI) in 12 patients and MOF in 3 patients. The need for blood transfusions in the first 24 h, number of transfused blood units, HLOS, thromboembolic events and multiorgan failure were comparable in the TXA and placebo groups. In seriously injured patients (injury severity score > 24), the MTP activation was higher in the placebo group (31.3% vs 11.10%, p = 0.13), whereas pulmonary embolism (6.9% vs 2.9%, p = 0.44) and late mortality (27.6% vs 14.3%, p = 0.17) were higher in the TXA group but did not reach statistical significance. Conclusion The second TXA dose did not change the mortality rate, need for blood transfusion, thromboembolic complications, organ failure and HLOS compared to a single prehospital dose and thus its routine administration should be revisited in larger and multicenter studies. Trial registration ClinicalTrials.gov Identifier: NCT03846973.
Collapse
Affiliation(s)
- Ayman El-Menyar
- Trauma & Vascular Surgery, Clinical Research, Hamad General Hospital, Hamad Medical Corporation (HMC), P.O Box 3050, Doha, Qatar. .,Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Khalid Ahmed
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Suhail Hakim
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Ahad Kanbar
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Saji Mathradikkal
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Tariq Siddiqui
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Hisham Jogol
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Ibrahim Taha
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Ismail Mahmood
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Ahmed Ajaj
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Sajid Atique
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Abubaker Alaieb
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | | | - Mohammad Asim
- Trauma & Vascular Surgery, Clinical Research, Hamad General Hospital, Hamad Medical Corporation (HMC), P.O Box 3050, Doha, Qatar
| | - Guillaume Alinier
- Hamad Medical Corporation Ambulance Service, Medical City, HMC, Doha, Qatar.,Weill Cornell Medicine-Qatar, Doha, Qatar.,School of Health and Social Work, Paramedic Division, University of Hertfordshire, Hatfield, UK.,Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Nicholas R Castle
- Hamad Medical Corporation Ambulance Service, Medical City, HMC, Doha, Qatar
| | - Ahammed Mekkodathil
- Trauma & Vascular Surgery, Clinical Research, Hamad General Hospital, Hamad Medical Corporation (HMC), P.O Box 3050, Doha, Qatar
| | - Sandro Rizoli
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery, Hamad General Hospital, HMC, Doha, Qatar
| |
Collapse
|
13
|
The Impact of Age on Predictive Performance of National Early Warning Score at Arrival to Emergency Departments: Development and External Validation. Ann Emerg Med 2021; 79:354-363. [PMID: 34742589 DOI: 10.1016/j.annemergmed.2021.09.434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/17/2021] [Accepted: 09/24/2021] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE To investigate how age affects the predictive performance of the National Early Warning Score (NEWS) at arrival to the emergency department (ED) regarding inhospital mortality and intensive care admission. METHODS International multicenter retrospective cohorts from 2 Danish and 3 Dutch ED. Development cohort: 14,809 Danish patients aged ≥18 years with at least systolic blood pressure or pulse measured from the Danish Multicenter Cohort. External validation cohort: 50,448 Dutch patients aged ≥18 years with all vital signs measured from the Netherlands Emergency Department Evaluation Database (NEED). Multivariable logistic regression was used for model building. Performance was evaluated overall and within age categories: 18 to 64 years, 65 to 80 years, and more than 80 years. RESULTS In the Danish Multicenter Cohort, a total of 2.5% died inhospital, and 2.8% were admitted to the ICU, compared with 2.8% and 1.6%, respectively, in the NEED. Age did not add information for the prediction of intensive care admission but was the strongest predictor for inhospital mortality. For NEWS alone, severe underestimation of risk was observed for persons above 80 while overall Area Under Receiver Operating Characteristic (AUROC) was 0.82 (confidence interval [CI] 0.80 to 0.84) in the Danish Multicenter Cohort versus 0.75 (CI 0.75 to 0.77) in the NEED. When combining NEWS with age, underestimation of risks was eliminated for persons above 80, and overall AUROC increased significantly to 0.86 (CI 0.85 to 0.88) in the Danish Multicenter Cohort versus 0.82 (CI 0.81 to 0.83) in the NEED. CONCLUSION Combining NEWS with age improved the prediction performance regarding inhospital mortality, mostly for persons aged above 80, and can potentially improve decision policies at arrival to EDs.
Collapse
|
14
|
Halligan S, Menu Y, Mallett S. Why did European Radiology reject my radiomic biomarker paper? How to correctly evaluate imaging biomarkers in a clinical setting. Eur Radiol 2021; 31:9361-9368. [PMID: 34003349 PMCID: PMC8589811 DOI: 10.1007/s00330-021-07971-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/06/2021] [Accepted: 03/31/2021] [Indexed: 12/23/2022]
Abstract
This review explains in simple terms, accessible to the non-statistician, general principles regarding the correct research methods to develop and then evaluate imaging biomarkers in a clinical setting, including radiomic biomarkers. The distinction between diagnostic and prognostic biomarkers is made and emphasis placed on the need to assess clinical utility within the context of a multivariable model. Such models should not be restricted to imaging biomarkers and must include relevant disease and patient characteristics likely to be clinically useful. Biomarker utility is based on whether its addition to the basic clinical model improves diagnosis or prediction. Approaches to both model development and evaluation are explained and the need for adequate amounts of representative data stressed so as to avoid underpowering and overfitting. Advice is provided regarding how to report the research correctly. KEY POINTS: • Imaging biomarker research is common but methodological errors are encountered frequently that may mean the research is not clinically useful. • The clinical utility of imaging biomarkers is best assessed by their additive effect on multivariable models based on clinical factors known to be important. • The data used to develop such models should be sufficient for the number of variables investigated and the model should be evaluated, preferably using data unrelated to development.
Collapse
Affiliation(s)
- Steve Halligan
- Centre for Medical Imaging, University College London UCL, 43-45 Foley Street, London, W1W 7TS, UK.
| | - Yves Menu
- Department of Diagnostic and Interventional Radiology, Saint Antoine Hospital, APHP-Sorbonne University, Paris, France
| | - Sue Mallett
- Centre for Medical Imaging, University College London UCL, 43-45 Foley Street, London, W1W 7TS, UK
| |
Collapse
|
15
|
Sarang B, Bhandarkar P, Raykar N, O'Reilly GM, Soni KD, Wärnberg MG, Khajanchi M, Dharap S, Cameron P, Howard T, Gadgil A, Jarwani B, Mohan M, Bhoi S, Roy N. Associations of On-arrival Vital Signs with 24-hour In-hospital Mortality in Adult Trauma Patients Admitted to Four Public University Hospitals in Urban India: A Prospective Multi-Centre Cohort Study. Injury 2021; 52:1158-1163. [PMID: 33685640 DOI: 10.1016/j.injury.2021.02.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/20/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In India, more than a million people die annually due to injuries. Identifying the patients at risk of early mortality (within 24 hour of hospital arrival) is essential for triage. A bilateral Government Australia-India Trauma System Collaboration generated a trauma registry in the context of India, which yielded a cohort of trauma patients for systematic observation and interventions. The aim of this study was to determine the independent association of on-arrival vital signs and Glasgow Coma Score (GCS) with 24-hour mortality among adult trauma patients admitted at four university public hospitals in urban India. METHODS We performed an analysis of a prospective multicentre observational study of trauma patients across four urban public university hospitals in India, between April 2016 and February 2018. The primary outcome was 24-hour in-hospital mortality. We used logistic regression to determine mutually independent associations of the vital signs and GCS with 24-hour mortality. RESULTS A total of 7497 adult patients (18 years and above) were included. The 24-hour mortality was 1.9%. In univariable logistic regression, Glasgow Coma Score (GCS) and the vital signs systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and peripheral capillary oxygen saturation (SpO2) had statistically significant associations with 24-hour mortality. These relationships held in multivariable analysis with hypotension (SBP<90mm Hg), tachycardia (HR>100bpm) and bradycardia (HR<60bpm), hypoxia (SpO2<90%), Tachypnoea (RR>20brpm) and severe (3-8) and moderate (9-12) GCS having strong association with 24-hour mortality. Notably, the patients with missing values for SBP, HR and RR also demonstrated higher odds of 24-hour mortality. The Injury Severity Scores (ISS) did not corelate with 24-hour mortality. CONCLUSION The routinely measured GCS and vital signs including SBP, HR, SpO2 and RR are independently associated with 24-hour in-hospital mortality in the context of university hospitals of urban India. These easily measured parameters in the emergency setting may help improve decision-making and guide further management in the trauma victims. A poor short-term prognosis was also observed in patients in whom these physiological variables were not recorded.
Collapse
Affiliation(s)
- Bhakti Sarang
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; Associate Professor, Terna Medical College & Hospital, Nerul, New Mumbai, India
| | - Prashant Bhandarkar
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; School of Health System Studies, Tata Institute of Social Sciences, Mumbai, India
| | - Nakul Raykar
- Trauma Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA; Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Gerard M O'Reilly
- NHMRC Research Fellow & Head of Epidemiology & Biostatistics, National Trauma Research Institute, The Alfred, Melbourne, Australia; Adjunct Clinical Associate Professor, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia; Emergency Physician & Head of Global programs, Emergency & Trauma Centre, The Alfred, Melbourne, Australia
| | - Kapil Dev Soni
- Additional Professor, Critical & Intensive Care, JPN Apex Trauma Centre, AIIMS, New Delhi
| | | | - Monty Khajanchi
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; Associate Professor, Seth.G.S. Medical College & K.E.M. Hospital, Parel, Mumbai, India
| | - Satish Dharap
- Professor & Head of General Surgery, Topiwala National Medical College & B.Y.L. Nair Ch. Hospital, Mumbai, India
| | - Peter Cameron
- Academic Director, Emergency & Trauma Centre, The Alfred Hospital, Melbourne Australia; Professor, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Teresa Howard
- Central Clinical School, Monash University, Melbourne, Australia; Burnet Institute, Melbourne, Australia; National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia
| | - Anita Gadgil
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India
| | - Bhavesh Jarwani
- Associate Professor, Emergency Medicine Department, Vadilal Sarabhai General Hospital, Ahmedabad, Gujarat, India
| | - Monali Mohan
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Nobhojit Roy
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; Affiliate, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Adjunct Professor (Research), School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia.
| |
Collapse
|
16
|
Mitra B, Bernard S, Gantner D, Burns B, Reade MC, Murray L, Trapani T, Pitt V, McArthur C, Forbes A, Maegele M, Gruen RL. Protocol for a multicentre prehospital randomised controlled trial investigating tranexamic acid in severe trauma: the PATCH-Trauma trial. BMJ Open 2021; 11:e046522. [PMID: 33722875 PMCID: PMC7970250 DOI: 10.1136/bmjopen-2020-046522] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Haemorrhage causes most preventable prehospital trauma deaths and about a third of in-hospital trauma deaths. Tranexamic acid (TXA), administered soon after hospital arrival in certain trauma systems, is an effective therapy in preventing or managing acute traumatic coagulopathy. However, delayed administration of TXA appears to be ineffective or harmful. The effectiveness of prehospital TXA, incidence of thrombotic complications, benefit versus risk in advanced trauma systems and the mechanism of benefit remain uncertain. METHODS AND ANALYSIS The Pre-hospital Anti-fibrinolytics for Traumatic Coagulopathy and Haemorrhage (The PATCH-Trauma study) is comparing TXA, initiated prehospital and continued in hospital over 8 hours, with placebo in patients with severe trauma at risk of acute traumatic coagulopathy. We present the trial protocol and an overview of the statistical analysis plan. There will be 1316 patients recruited by prehospital clinicians in Australia, New Zealand and Germany. The primary outcome will be the eight-level Glasgow Outcome Scale Extended (GOSE) at 6 months after injury, dichotomised to favourable (GOSE 5-8) and unfavourable (GOSE 1-4) outcomes, analysed using an intention-to-treat (ITT) approach. Secondary outcomes will include mortality at hospital discharge and at 6 months, blood product usage, quality of life and the incidence of predefined adverse events. ETHICS AND DISSEMINATION The study was approved by The Alfred Hospital Research and Ethics Committee in Victoria and also approved in New South Wales, Queensland, South Australia, Tasmania and the Northern Territory. In New Zealand, Northern A Health and Disability Ethics Committee provided approval. In Germany, Witten/Herdecke University has provided ethics approval. The PATCH-Trauma study aims to provide definitive evidence of the effectiveness of prehospital TXA, when used in conjunction with current advanced trauma care, in improving outcomes after severe injury. TRIAL REGISTRATION NUMBER NCT02187120.
Collapse
Affiliation(s)
- Biswadev Mitra
- Emergency and Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia
- National Trauma Research Institute, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Dashiell Gantner
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Brian Burns
- Greater Sydney Area Helicopter Emergency Medical Service, Sydney, New South Wales, Australia
- Sydney Medical School, Sydney University, Sydney, New South Wales, Australia
| | - Michael C Reade
- Faculty of Medicine, The University of Queensland, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Joint Health Command, Australian Defence Force, Canberra, Australian Capital Territory, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Lynnette Murray
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Tony Trapani
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Veronica Pitt
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Colin McArthur
- Critical Care Medicine, Auckland District Health Board, Auckland, New Zealand
| | - Andrew Forbes
- Department of Epidemiology and Preventive Medicine, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Marc Maegele
- Cologne Merheim Medical Center, Department of Traumatology, Othopedic Surgery and Sportsmedicine, University of Witten/Herdecke, Cologne, Germany
- Institute for Research in Operative Medicine, University Witten-Herdecke, Cologne, Germany
| | - Russell L Gruen
- College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory, Australia
| |
Collapse
|
17
|
Tso S, Saha A, Cusimano MD. The Traumatic Brain Injury Model Systems National Database: A Review of Published Research. Neurotrauma Rep 2021; 2:149-164. [PMID: 34223550 PMCID: PMC8240866 DOI: 10.1089/neur.2020.0047] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The Traumatic Brain Injury Model Systems (TBIMS) is the largest longitudinal TBI data set in the world. Our study reviews the works using TBIMS data for analysis in the last 5 years. A search (2015–2020) was conducted across PubMed, EMBASE, and Google Scholar for studies that used the National Institute on Disability, Independent Living and Rehabilitation Research NIDILRR/VA-TBIMS data. Search terms were as follows: [“TBIMS” national database] within PubMed and Google Scholar, and [“TBIMS” AND national AND database] on EMBASE. Data sources, study foci (in terms of data processing and outcomes), study outcomes, and follow-up information usage were collected to categorize the studies included in this review. Variable usage in terms of TBIMS' form-based variable groups and limitations from each study were also noted. Assessment was made on how TBIMS' objectives were met by the studies. Of the 74 articles reviewed, 23 used TBIMS along with other data sets. Fifty-four studies focused on specific outcome measures only, 6 assessed data aspects as a major focus, and 13 explored both. Sample sizes of the included studies ranged from 11 to 15,835. Forty-two of the 60 longitudinal studies assessed follow-up from 1 to 5 years, and 15 studies used 10 to 25 years of the same. Prominent variable groups as outcome measures were “Employment,” “FIM,” “DRS,” “PART-O,” “Satisfaction with Life,” “PHQ-9,” and “GOS-E.” Limited numbers of studies were published regarding tobacco consumption, the Brief Test of Adult Cognition by Telephone (BTACT), the Supervision Rating Scale (SRS), general health, and comorbidities as variables of interest. Generalizability was the most significant limitation mentioned by the studies. The TBIMS is a rich resource for large-sample longitudinal analyses of various TBI outcomes. Future efforts should focus on under-utilized variables and improving generalizability by validation of results across large-scale TBI data sets to better understand the heterogeneity of TBI.
Collapse
Affiliation(s)
- Samantha Tso
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ashirbani Saha
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Michael D Cusimano
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
18
|
Al-Jeabory M, Szarpak L, Attila K, Simpson M, Smereka A, Gasecka A, Wieczorek W, Pruc M, Koselak M, Gawel W, Checinski I, Jaguszewski MJ, Filipiak KJ. Efficacy and Safety of Tranexamic Acid in Emergency Trauma: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:1030. [PMID: 33802254 PMCID: PMC7958951 DOI: 10.3390/jcm10051030] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 02/25/2021] [Accepted: 02/26/2021] [Indexed: 12/01/2022] Open
Abstract
In trauma patients, bleeding can lead to coagulopathy, hemorrhagic shock, and multiorgan failure, and therefore is of fundamental significance in regard to early morbidity. We conducted a meta-analysis to evaluate the efficacy and safety of tranexamic acid (TXA) in civil and military settings and its impact on in-hospital mortality (survival to hospital discharge or 30-day survival), intensive care unit and hospital length of stay, incidence of adverse events (myocardial infarct and neurological complications), and volume of blood product transfusion. The systematic review and meta-analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic review of the literature using PubMed, Scopus, EMBASE, Web of Science, and the Cochrane Central Register and Controlled Trials (CENTRAL) database was conducted from inception to 10 January 2021. In-hospital mortality was reported in 14 studies and was 15.5% for the TXA group as compared with 16.4% for the non-TXA group (OR = 0.81, 95% CI 0.62-1.06, I2 = 83%, p = 0.12). In a civilian TXA application, in-hospital mortality in the TXA and non-TXA groups amounted to 15.0% and 17.1%, respectively (OR = 0.69, 95% CI 0.51-0.93, p = 0.02, I2 = 78%). A subgroup analysis of the randomized control trial (RCT) studies showed a statistically significant reduction in in-hospital mortality in the TXA group (14.3%) as compared with the non-TXA group (15.7%, OR = 0.89, 95% CI 0.83-0.96, p = 0.003, I2 = 0%). To summarize, TXA used in civilian application reduces in-hospital mortality. Application of TXA is beneficial for severely injured patients who undergoing shock and require massive blood transfusions. Patients who undergo treatment with TXA should be monitored for clinical signs of thromboembolism, since TXA is a standalone risk factor of a thromboembolic event and the D-dimers in traumatic patients are almost always elevated.
Collapse
Affiliation(s)
- Mahdi Al-Jeabory
- Outcomes Research Unit, Polish Society of Disaster Medicine, P.O. Box 78, 05-090 Raszyn, Poland
| | - Lukasz Szarpak
- Maria Sklodowska-Curie Bialystok Oncology Center, 15-027 Bialystok, Poland
| | - Kecskes Attila
- NATO Centre of Excellence for Military Medicine, 1555 Budapest, Hungary
| | | | - Adam Smereka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Aleksandra Gasecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
- Department of Cardiology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Wojciech Wieczorek
- Department of Emergency Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Michal Pruc
- Outcomes Research Unit, Polish Society of Disaster Medicine, P.O. Box 78, 05-090 Raszyn, Poland
| | - Maciej Koselak
- Maria Sklodowska-Curie Medical Academy in Warsaw, 03-411 Warsaw, Poland
| | - Wladyslaw Gawel
- Department of Surgery, The Silesian Hospital in Opava, 746 01 Opava, Czech Republic
| | - Igor Checinski
- Department of Emergency Medical Service, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Milosz J Jaguszewski
- First Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Krzysztof J Filipiak
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland
| |
Collapse
|
19
|
Khodadadi F, Bahaoddini A, Tavassoli A, Ketabchi F. Heart rate variability and pulmonary dysfunction in rats subjected to hemorrhagic shock. BMC Cardiovasc Disord 2020; 20:331. [PMID: 32652932 PMCID: PMC7353764 DOI: 10.1186/s12872-020-01606-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 06/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The activity of autonomic nervous system and its association with organ damage have not been entirely elucidated in hemorrhagic shock. The aim of this study was to investigate heart rate variability (HRV) and pulmonary gas exchange in hemorrhagic shock during unilateral subdiaphragmatic vagotomy. METHODS Male Sprague Dawley rats were randomly assigned into groups of Sham, vagotomized (Vag), hemorrhagic shock (HS) and Vag + HS. HS was induced in conscious animals by blood withdrawal until reaching to mean arterial blood pressure (MAP) of 40 ± 5 mmHg. Then, it was allowed to MAP returning toward the basal values. MAP and heart rate (HR) were recorded throughout the experiments, HRV components of low (LF, sympathetic index), high (LH, parasympathetic index), and very low (VLF, injury index) frequencies and the LF/HF ratio calculated, and the lung histological and blood gas parameters assessed. RESULTS In the initial phases of HS, the increase in HR with no change in MAP were observed in both HS and Vag + HS groups, while LF increased only in the HS group. In the second phase, HR and MAP decreased sharply in the HS group, whereas, only MAP decreased in the Vag + HS group. Meanwhile, LF and HF increased relative to their baselines in the HS and Vag + HS groups, even though the values were much pronounced in the HS group. In the third phase, HR, MAP, LF, HF, and the LF/HF ratio were returned back to their baselines in both HS and Vag + HS groups. In the Vag + HS group, the VLF was lower and HR was higher than those in the other groups. Furthermore, blood gas parameters and lung histology indicated the impairment of gas exchange in the Vag + HS group. CONCLUSIONS The sympathetic activity is predominant in the first phase, whereas the parasympathetic activity is dominant in the second and third phases of hemorrhagic shock. There is an inverse relationship between the level of VLF and lung injury in vagotomized animals subjected to hemorrhagic shock.
Collapse
Affiliation(s)
- Fateme Khodadadi
- Department of Biology, College of Sciences, Shiraz University, Shiraz, Iran
| | | | - Alireza Tavassoli
- Department of Pathology, Fasa University of Medical Sciences, Fasa, Iran
| | - Farzaneh Ketabchi
- Department of Physiology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.
| |
Collapse
|
20
|
Association Between Trauma Center Designation Levels and Survival of Patients With Motor Vehicular Transport Injuries in the United States. J Emerg Med 2020; 58:398-406. [DOI: 10.1016/j.jemermed.2019.12.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 12/09/2019] [Accepted: 12/19/2019] [Indexed: 11/19/2022]
|
21
|
METHODS OF RADIATION DIAGNOSTICS OF COMPLICATIONS IN COMBINED CRANIOCEREBRAL TRAUMA AND ABDOMINAL TRAUMA. WORLD OF MEDICINE AND BIOLOGY 2020. [DOI: 10.26724/2079-8334-2020-3-73-42-46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
22
|
Ageron FX, Gayet-Ageron A, Steyerberg E, Bouzat P, Roberts I. Prognostic model for traumatic death due to bleeding: cross-sectional international study. BMJ Open 2019; 9:e026823. [PMID: 31142526 PMCID: PMC6549712 DOI: 10.1136/bmjopen-2018-026823] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To develop and validate a prognostic model and a simple model to predict death due to bleeding in trauma patients. DESIGN Cross-sectional study with multivariable logistic regression using data from two large trauma cohorts. SETTING 274 hospitals from 40 countries in the Clinical Randomisation of Anti-fibrinolytic in Significant Haemorrhage (CRASH-2) trial and 24 hospitals in the Northern French Alps Trauma registry. PARTICIPANTS 13 485 trauma patients in the CRASH-2 trial and 9945 patients in the Northern French Alps Trauma registry who were admitted to hospital within 3 hours of injury. MAIN OUTCOME MEASURE In-hospital death due to bleeding within 28 days. RESULTS There were 815 (6%) deaths from bleeding in the CRASH-2 trial and 102 (1%) in the Northern French Alps Trauma registry. The full model included age, systolic blood pressure (SBP), Glasgow Coma Scale (GCS), heart rate, respiratory rate and type of injury (penetrating). The simple model included age, SBP and GCS. In a cross-validation procedure by country, discrimination and calibration were adequate (pooled C-statistic 0.85 (95% CI 0.81 to 0.88) for the full model and 0.84 (95% CI 0.80 to 0.88) for the simple model). CONCLUSION This prognostic model can identify trauma patients at risk of death due to bleeding in a wide range of settings and can support prehospital triage and trauma audit, including audit of tranexamic acid use.
Collapse
Affiliation(s)
- Francois-Xavier Ageron
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
- Emergency Department and Northern French Alps Emergency Network, Hospital Annecy Genevois, Annecy, France
| | - Angele Gayet-Ageron
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Research Center and Division of Clinical Epidemiology, Department of Health and Community Medicine, University Hospital Geneva, Geneva, Switzerland
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Pierre Bouzat
- Grenoble Alpes Trauma Center, Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
23
|
Tan JH, Mohamad Y, Imran Alwi R, Henry Tan CL, Chairil Ariffin A, Jarmin R. Development and validation of a new simplified anatomic trauma mortality score. Injury 2019; 50:1125-1132. [PMID: 30686543 DOI: 10.1016/j.injury.2019.01.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/02/2019] [Accepted: 01/14/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Most trauma mortality prediction scores are complex in nature. GAP (Glasgow Coma Scale, Age, Systolic blood pressure) and mGAP (mechanism, Glasgow Coma Scale, Age, Systolic blood pressure) scores are relatively simple scoring tools. However, these scores were not validated in low and middle income countries including Malaysia and its accuracies are influenced by the fluctuating physiologic parameters. This study aims to develop a relevant simplified anatomic trauma scoring system for the local trauma patients in Malaysia. METHOD A total of 3825 trauma patients from 2011 to 2016 were extracted from the Hospital Sultanah Aminah Trauma Surgery Registry. Patients were split into a development sample (n = 2683) and a validation sample (n = 1142). Univariate analysis is applied to identify significant anatomic predictors. These predictors were further analyzed using multivariable logistic regression to develop the new score and compared to existing score systems. The quality of prediction was determined regarding discrimination using sensitivity, specificity and receiver operating characteristic [ROC] curve. RESULTS Existing simplified score systems (GAP & mGAP) revealed areas under the ROC curve of 0.825 and 0.806. The newly developed HeCLLiP (Head, cervical spine, lung, liver, pelvic fracture) score combines only five anatomic components: injury involving head, cervical spine, lung, liver and pelvic bone. The probabilities of mortality can be estimated by charting the total score points onto a graph chart or using the cut-off value of (>2) with a sensitivity of 79.2 and specificity of 70.6% on the validation dataset. The HeCLLiP score achieved comparable values of 0.802 for the area under the ROC curve in validation samples. CONCLUSION HeCLLiP Score is a simplified anatomic score suited to the local Malaysian population with a good predictive ability for trauma mortality.
Collapse
Affiliation(s)
- Jih Huei Tan
- General Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Malaysia; Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Malaysia.
| | - Yuzaidi Mohamad
- General Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Malaysia.
| | - Rizal Imran Alwi
- General Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Malaysia.
| | - Chor Lip Henry Tan
- General Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Malaysia; Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Malaysia.
| | | | - Razman Jarmin
- Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Malaysia.
| |
Collapse
|
24
|
Alghnam S, Alsulaim HA, BinMuneif YA, Al-Zamil A, Alahmari A, Alshafi A, Alsaif A, Albabtain I. Injuries following motorcycle crashes at a level-1 trauma center in Riyadh. Ann Saudi Med 2019; 39:185-191. [PMID: 31215223 PMCID: PMC6832331 DOI: 10.5144/0256-4947.2019.185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/02/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Motor vehicle crashes are the third leading cause of death in Saudi Arabia. Motorcycle riders, in particular, are considered more vulnerable than occupants, yet there are no previous studies that have examined the epidemiology of their injuries and outcomes in the country. Better understanding is needed to inform policymakers and guide future prevention programs. OBJECTIVE Describe patterns of injury among conscious and unconscious patients injured in motorcycle crashes. DESIGN Retrospective chart review. SETTINGS Level 1 trauma center in Riyadh. PATIENTS AND METHODS This retrospective study included all patients involved in motorcycle crashes who were admitted between 2001 and 2017. Medical records were reviewed, and data about injury characteristics, outcomes and healthcare utilization were ascertained. MAIN OUTCOME MEASURES Injury site and mortality rate. SAMPLE SIZE AND CHARACTERISTICS 572 patients included 488 males (85.3%) and 232 <18 years of age (40.5%), mean (SD) age 21.1 (11.6) years. RESULTS About 3% of patients died either before or after admission. Extremity injuries (356, 62.2%) were most common followed by head injuries (229, 40%). Fifty-six (9%) suffered amputation, mostly to a lower limb. CONCLUSION This study underscores the significant burden of motorcycle-related injuries on population health of Saudi Arabia. The number of amputations due to motorcycle injuries is striking. Therefore, we need to increase enforcement of safety measures during recreational use of motorcycles and to raise awareness about the dangers of motorcycle crashes to improve traffic safety and ultimately population health. LIMITATIONS The study was conducted at a single hospital which may affect the generalizability of the data to the Saudi population. CONFLICT OF INTEREST None.
Collapse
Affiliation(s)
- Suliman Alghnam
- From the Department of Population Helath, King Abdullah International Research Center, Riyadh, Saudi Arabia
| | - Hatim A. Alsulaim
- From the Department of Surgery, Unaizah College of Medicine, Qassim University, Qassim, Saudi Arabia
| | | | - Abdulmohsen Al-Zamil
- From the College of Medicine, Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Abdullah Alahmari
- From the College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Abdullah Alshafi
- From the College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Ahmad Alsaif
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ibrahim Albabtain
- From the Department of Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
25
|
El-Menyar A, Sathian B, Wahlen BM, Abdelrahman H, Peralta R, Al-Thani H, Rizoli S. Prehospital administration of tranexamic acid in trauma patients: A 1:1 matched comparative study from a level 1 trauma center. Am J Emerg Med 2019; 38:266-271. [PMID: 31060862 DOI: 10.1016/j.ajem.2019.04.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 04/28/2019] [Accepted: 04/29/2019] [Indexed: 11/19/2022] Open
Abstract
PURPOSE The purpose of this study was to test the efficacy of prehospital administration of tranexamic acid (TXA) to injured patients on mortality, thromboembolic events and need for blood transfusion in a level 1 trauma center. METHODS We conducted a retrospective study comparing adult trauma patients receiving or not receiving prehospital TXA between January 2017 and September 2018. Patients not receiving TXA but transfused within 4 h of admission were 1:1 matched to TXA-treated patients for age, sex, injury severity score, head abbreviated injury score, prehospital heart rate and systolic blood pressure. RESULTS In total 204 patients were included (102 TXA and 102 control), with a mean age of 31 years. On admission, shock index (p = 0.03) and serum lactate (p = 0.001) were greater in the control group, whereas the initial base deficit, hemoglobin levels and EMS time were comparable in both groups. The odd ratio (OR) for shock index ≥0.9 after TXA administration was 0.44 (95% CI 0.23-0.84). The median amount of blood transfusion was greater in the control group [eight units (range 1-40) vs three (range 0-40), p = 0.01] as well as the use of massive blood transfusion [OR 0.35 (95% CI 0.19-0.67)]. In the TXA group, VTE was higher [OR 2.0 (95% CI 0.37-11.40)]; whereas the overall mortality was lower [OR 0.78 (95% CI 0.42-1.45)] without reaching statistical significance. CONCLUSIONS Prehospital TXA administration is associated with less in-hospital blood transfusion and massive transfusion protocol (MTP). There is no significant increase in the thromboembolic events and mortality, however, further evaluation in larger clinical trials is needed.
Collapse
Affiliation(s)
- Ayman El-Menyar
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital (HGH), Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
| | - Brijesh Sathian
- Department of Surgery, Clinical Research, Trauma & Vascular Surgery, Hamad General Hospital (HGH), Doha, Qatar
| | | | | | - Ruben Peralta
- Department of Surgery, Trauma Surgery, HGH, Doha, Qatar; Department of Surgery, Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic
| | | | - Sandro Rizoli
- Department of Surgery, Trauma Surgery, HGH, Doha, Qatar
| |
Collapse
|
26
|
Bonnett LJ, Snell KIE, Collins GS, Riley RD. Guide to presenting clinical prediction models for use in clinical settings. BMJ 2019; 365:l737. [PMID: 30995987 DOI: 10.1136/bmj.l737] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Laura J Bonnett
- Department of Biostatistics, University of Liverpool, Liverpool L69 3GL, UK
| | - Kym I E Snell
- Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Richard D Riley
- Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
| |
Collapse
|
27
|
Sujenthiran A, Elshout PJ, Veskimae E, MacLennan S, Yuan Y, Serafetinidis E, Sharma DM, Kitrey ND, Djakovic N, Lumen N, Kuehhas FE, Summerton DJ. Is Nonoperative Management the Best First-line Option for High-grade Renal trauma? A Systematic Review. Eur Urol Focus 2019; 5:290-300. [DOI: 10.1016/j.euf.2017.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 04/10/2017] [Accepted: 04/29/2017] [Indexed: 10/19/2022]
|
28
|
Cassignol A, Markarian T, Cotte J, Marmin J, Nguyen C, Cardinale M, Pauly V, Kerbaul F, Meaudre E, Bobbia X. Evaluation and Comparison of Different Prehospital Triage Scores of Trauma Patients on In-Hospital Mortality. PREHOSP EMERG CARE 2019; 23:543-550. [DOI: 10.1080/10903127.2018.1549627] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
29
|
Moons KGM, Wolff RF, Riley RD, Whiting PF, Westwood M, Collins GS, Reitsma JB, Kleijnen J, Mallett S. PROBAST: A Tool to Assess Risk of Bias and Applicability of Prediction Model Studies: Explanation and Elaboration. Ann Intern Med 2019; 170:W1-W33. [PMID: 30596876 DOI: 10.7326/m18-1377] [Citation(s) in RCA: 682] [Impact Index Per Article: 136.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Prediction models in health care use predictors to estimate for an individual the probability that a condition or disease is already present (diagnostic model) or will occur in the future (prognostic model). Publications on prediction models have become more common in recent years, and competing prediction models frequently exist for the same outcome or target population. Health care providers, guideline developers, and policymakers are often unsure which model to use or recommend, and in which persons or settings. Hence, systematic reviews of these studies are increasingly demanded, required, and performed. A key part of a systematic review of prediction models is examination of risk of bias and applicability to the intended population and setting. To help reviewers with this process, the authors developed PROBAST (Prediction model Risk Of Bias ASsessment Tool) for studies developing, validating, or updating (for example, extending) prediction models, both diagnostic and prognostic. PROBAST was developed through a consensus process involving a group of experts in the field. It includes 20 signaling questions across 4 domains (participants, predictors, outcome, and analysis). This explanation and elaboration document describes the rationale for including each domain and signaling question and guides researchers, reviewers, readers, and guideline developers in how to use them to assess risk of bias and applicability concerns. All concepts are illustrated with published examples across different topics. The latest version of the PROBAST checklist, accompanying documents, and filled-in examples can be downloaded from www.probast.org.
Collapse
Affiliation(s)
- Karel G M Moons
- Julius Center for Health Sciences and Primary Care and Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M., J.B.R.)
| | - Robert F Wolff
- Kleijnen Systematic Reviews, York, United Kingdom (R.F.W., M.W.)
| | - Richard D Riley
- Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom (R.D.R.)
| | - Penny F Whiting
- Bristol Medical School of the University of Bristol and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol National Health Service Foundation Trust, Bristol, United Kingdom (P.F.W.)
| | - Marie Westwood
- Kleijnen Systematic Reviews, York, United Kingdom (R.F.W., M.W.)
| | - Gary S Collins
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom (G.S.C.)
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care and Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M., J.B.R.)
| | - Jos Kleijnen
- Kleijnen Systematic Reviews, York, United Kingdom, and School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands (J.K.)
| | - Sue Mallett
- Institute of Applied Health Research, National Institute for Health Research Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom (S.M.)
| |
Collapse
|
30
|
Wolff RF, Moons KGM, Riley RD, Whiting PF, Westwood M, Collins GS, Reitsma JB, Kleijnen J, Mallett S. PROBAST: A Tool to Assess the Risk of Bias and Applicability of Prediction Model Studies. Ann Intern Med 2019; 170:51-58. [PMID: 30596875 DOI: 10.7326/m18-1376] [Citation(s) in RCA: 1022] [Impact Index Per Article: 204.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Clinical prediction models combine multiple predictors to estimate risk for the presence of a particular condition (diagnostic models) or the occurrence of a certain event in the future (prognostic models). PROBAST (Prediction model Risk Of Bias ASsessment Tool), a tool for assessing the risk of bias (ROB) and applicability of diagnostic and prognostic prediction model studies, was developed by a steering group that considered existing ROB tools and reporting guidelines. The tool was informed by a Delphi procedure involving 38 experts and was refined through piloting. PROBAST is organized into the following 4 domains: participants, predictors, outcome, and analysis. These domains contain a total of 20 signaling questions to facilitate structured judgment of ROB, which was defined to occur when shortcomings in study design, conduct, or analysis lead to systematically distorted estimates of model predictive performance. PROBAST enables a focused and transparent approach to assessing the ROB and applicability of studies that develop, validate, or update prediction models for individualized predictions. Although PROBAST was designed for systematic reviews, it can be used more generally in critical appraisal of prediction model studies. Potential users include organizations supporting decision making, researchers and clinicians who are interested in evidence-based medicine or involved in guideline development, journal editors, and manuscript reviewers.
Collapse
Affiliation(s)
- Robert F Wolff
- Kleijnen Systematic Reviews, York, United Kingdom (R.F.W., M.W.)
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care and Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M., J.B.R.)
| | - Richard D Riley
- Centre for Prognosis Research, Research Institute for Primary Care and Health Sciences, Keele University, Keele, United Kingdom (R.D.R.)
| | - Penny F Whiting
- Medical School of the University of Bristol and National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care West, University Hospitals Bristol National Health Service Foundation Trust, Bristol, United Kingdom (P.F.W.)
| | - Marie Westwood
- Kleijnen Systematic Reviews, York, United Kingdom (R.F.W., M.W.)
| | - Gary S Collins
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom (G.S.C.)
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary Care and Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (K.G.M., J.B.R.)
| | - Jos Kleijnen
- Kleijnen Systematic Reviews, York, United Kingdom, and School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands (J.K.)
| | - Sue Mallett
- Institute of Applied Health Research, National Institute for Health Research Birmingham Biomedical Research Centre, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom (S.M.)
| |
Collapse
|
31
|
Janati A, Mousazadeh Y, Sadeghi-Bazargani H, Pouraghaei M, Rahmani F. Prediction of mortality risk in patients with traffic injury: A case study in tabriz hospitals, Iran. ARCHIVES OF TRAUMA RESEARCH 2019. [DOI: 10.4103/atr.atr_5_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
32
|
El-Menyar A, Sathian B, Asim M, Latifi R, Al-Thani H. Efficacy of prehospital administration of tranexamic acid in trauma patients: A meta-analysis of the randomized controlled trials. Am J Emerg Med 2018; 36:1079-1087. [PMID: 29573898 DOI: 10.1016/j.ajem.2018.03.033] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/14/2018] [Accepted: 03/14/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Antifibrinolytic agent tranexamic acid (TXA) has a potential clinical benefit for in-hospital patients with severe bleeding but its effectiveness in pre-hospital settings remains unclear. We conducted a systematic review and meta-analysis to evaluate whether pre-hospital administration of TXA compared to placebo improve patients' outcomes? METHODS PubMed, MEDLINE, Cochrane Library, WHO International Clinical Trials Registry Platform, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, clinicaltrials.gov and Google scholar databases were searched for a retrospective, prospective and randomized (RCT) or quasi-RCT studies that assessed the effect of prehospital administration of TXA versus placebo on the outcomes of trauma patients with significant hemorrhage. The main outcomes of interest were 24hour 30-day mortality and in-hospital thromboembolic complications. Two authors independently abstracted the data using a data collection form. Results from different studies were pooled for the analysis, when appropriate. RESULTS Out of 92 references identified through the search, two analytical studies met the inclusion criteria. The effect of TXA on 24-hour mortality had a pooled odds ratio (OR) of 0.49 (95% CI 0.28-0.85), 30-day mortality OR of 0.86 (95% CI, 0.56-1.32), and thromboembolic events OR of 0.74 (95% CI, 0.27-2.07). CONCLUSION Prehospital TXA appears to reduce early mortality in trauma patients. The pooled analysis also shows a trend toward lower 30-day mortality and reduced risk of thromboembolic events. Additional randomized controlled clinical trials are needed to determine the significance of these trends.
Collapse
Affiliation(s)
- Ayman El-Menyar
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar; Clinical Medicine, Weill Cornell Medical School, Doha, Qatar.
| | - Brijesh Sathian
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar.
| | - Mohammed Asim
- Department of Surgery, Trauma Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar.
| | - Rifat Latifi
- Department of Surgery, Westchester Medical Center, Valhalla, NY, USA.
| | - Hassan Al-Thani
- Department of Surgery, Trauma & Vascular Surgery, Hamad General Hospital, Doha, Qatar
| |
Collapse
|
33
|
Gayet-Ageron A, Prieto-Merino D, Ker K, Shakur H, Ageron FX, Roberts I. Effect of treatment delay on the effectiveness and safety of antifibrinolytics in acute severe haemorrhage: a meta-analysis of individual patient-level data from 40 138 bleeding patients. Lancet 2018; 391:125-132. [PMID: 29126600 PMCID: PMC5773762 DOI: 10.1016/s0140-6736(17)32455-8] [Citation(s) in RCA: 209] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/25/2017] [Accepted: 08/31/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Antifibrinolytics reduce death from bleeding in trauma and post-partum haemorrhage. We examined the effect of treatment delay on the effectiveness of antifibrinolytics. METHODS We did an individual patient-level data meta-analysis of randomised trials done with more than 1000 patients that assessed antifibrinolytics in acute severe bleeding. We identified trials done between Jan 1, 1946, and April 7, 2017, from MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, PubMed, Popline, and the WHO International Clinical Trials Registry Platform. The primary measure of treatment benefit was absence of death from bleeding. We examined the effect of treatment delay on treatment effectiveness using logistic regression models. We investigated the effect of measurement error (misclassification) in sensitivity analyses. This study is registered with PROSPERO, number 42016052155. FINDINGS We obtained data for 40 138 patients from two randomised trials of tranexamic acid in acute severe bleeding (traumatic and post-partum haemorrhage). Overall, there were 3558 deaths, of which 1408 (40%) were from bleeding. Most (884 [63%] of 1408) bleeding deaths occurred within 12 h of onset. Deaths from post-partum haemorrhage peaked 2-3 h after childbirth. Tranexamic acid significantly increased overall survival from bleeding (odds ratio [OR] 1·20, 95% CI 1·08-1·33; p=0·001), with no heterogeneity by site of bleeding (interaction p=0·7243). Treatment delay reduced the treatment benefit (p<0·0001). Immediate treatment improved survival by more than 70% (OR 1·72, 95% CI 1·42-2·10; p<0·0001). Thereafter, the survival benefit decreased by 10% for every 15 min of treatment delay until 3 h, after which there was no benefit. There was no increase in vascular occlusive events with tranexamic acid, with no heterogeneity by site of bleeding (p=0·5956). Treatment delay did not modify the effect of tranexamic acid on vascular occlusive events. INTERPRETATION Death from bleeding occurs soon after onset and even a short delay in treatment reduces the benefit of tranexamic acid administration. Patients must be treated immediately. Further research is needed to deepen our understanding of the mechanism of action of tranexamic acid. FUNDING UK NIHR Health Technology Assessment programme, Pfizer, BUPA Foundation, and J P Moulton Charitable Foundation (CRASH-2 trial). London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation (WOMAN trial).
Collapse
Affiliation(s)
- Angèle Gayet-Ageron
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK; Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - David Prieto-Merino
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Katharine Ker
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - Haleema Shakur
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| | - François-Xavier Ageron
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK; Department of Emergency Medicine-Northern French Alps Emergency Network, Annecy Genevois Hospital, Annecy, France
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK.
| |
Collapse
|
34
|
Tan JH, Tan HCL, Noh NAM, Mohamad Y, Alwi RI. Validation of the trauma mortality prediction scores from a Malaysian population. BURNS & TRAUMA 2017; 5:37. [PMID: 29299483 PMCID: PMC5740795 DOI: 10.1186/s41038-017-0102-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 12/06/2017] [Indexed: 11/17/2022]
Abstract
Background Well-known trauma mortality prediction scores such as New Injury Severity Score (NISS), Revised Trauma Score (RTS), and Trauma and Injury Severity Score (TRISS) have been externally validated from high-income countries with established trauma databases. However, these scores were never used in Malaysian population. In this current study, we attempted to validate these scoring systems using our regional trauma surgery database. Methods A retrospective analysis of the regional Malaysian Trauma Surgery Database was performed over a period of 3 years from May 2011 to April 2014. NISS, RTS, Major Trauma Outcome Study (MTOS)-TRISS, and National Trauma Database (NTrD)-TRISS scores were recorded and calculated. Individual scoring system’s performance in predicting trauma mortality was compared by calculating the area under the receiver operating characteristic (AUC) curve. Youden index and associated optimal cutoff values for each scoring system was calculated to predict mortality. The corresponding positive predictive value, negative predictive value, and accuracy of the cutoff values were calculated. Results A total of 2208 trauma patients (2004 blunt and 204 penetrating injuries) with mean age of 36 (SD = 16) years were included. There were 239 deaths with a corresponding mortality rate of 10.8%. The AUC calculated for the NISS, RTS, MTOS-TRISS, and NTrD-TRISS were 0.878, 0.802, 0.812, and 0.848, respectively. The NISS score with a cutoff value of 24, sensitivity of 86.6% and specificity of 74.3%, outperformed the rest (p < 0.001). Mortality was predicted by NISS with an overall accuracy of 75.6%; its positive predictive value was at 29.02% and negative predictive value at 97.86%. Conclusion Amongst the four scores, the NISS score is the best trauma mortality prediction model suited for a local Malaysian trauma population. Further validation with multicentre data in the country may require to ascertain the finding.
Collapse
Affiliation(s)
- Jih Huei Tan
- General Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Malaysia.,Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Malaysia.,Clinical Research Centre, Hospital Sultan Ismail, Johor Bahru, Malaysia
| | - Henry Chor Lip Tan
- General Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Malaysia.,Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Malaysia.,Clinical Research Centre, Hospital Sultan Ismail, Johor Bahru, Malaysia
| | - Nur Azlin Md Noh
- General Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - Yuzaidi Mohamad
- General Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| | - Rizal Imran Alwi
- General Surgery Department, Hospital Sultanah Aminah, Johor Bahru, Malaysia
| |
Collapse
|
35
|
Gaston E, Fraser JF, Xu ZP, Ta HT. Nano- and micro-materials in the treatment of internal bleeding and uncontrolled hemorrhage. NANOMEDICINE-NANOTECHNOLOGY BIOLOGY AND MEDICINE 2017; 14:507-519. [PMID: 29162534 DOI: 10.1016/j.nano.2017.11.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 11/01/2017] [Accepted: 11/05/2017] [Indexed: 12/14/2022]
Abstract
Internal bleeding is defined as the loss of blood that occurs inside of a body cavity. After a traumatic injury, hemorrhage accounts for over 35% of pre-hospital deaths and 40% of deaths within the first 24 hours. Coagulopathy, a disorder in which the blood is not able to properly form clots, typically develops after traumatic injury and results in a higher rate of mortality. The current methods to treat internal bleeding and coagulopathy are inadequate due to the requirement of extensive medical equipment that is typically not available at the site of injury. To discover a potential route for future research, several current and novel treatment methods have been reviewed and analyzed. The aim of investigating different potential treatment options is to expand available knowledge, while also call attention to the importance of research in the field of treatment for internal bleeding and hemorrhage due to trauma.
Collapse
Affiliation(s)
- Elizabeth Gaston
- Australian Institute for Bioengineering and Nanotechnology, the University of Queensland, Brisbane, QLD, Australia; Department of Bioengineering, Clemson University, Clemson, SC, USA
| | - John F Fraser
- Faculty of Medicine, Critical Care Research Group, Prince Charles Hospital and the University of Queensland, Brisbane, Brisbane, QLD, Australia
| | - Zhi Ping Xu
- Australian Institute for Bioengineering and Nanotechnology, the University of Queensland, Brisbane, QLD, Australia
| | - Hang T Ta
- Australian Institute for Bioengineering and Nanotechnology, the University of Queensland, Brisbane, QLD, Australia.
| |
Collapse
|
36
|
Abstract
Old age is a risk factor for poor outcome in trauma patients, as a result of undertriage and the presence of occult life-threatening injuries. The mechanisms of injury for geriatric trauma differ from those in younger patients, with a much higher incidence of low-impact trauma, especially falls from a low height. Frailty is a risk factor for severe injury after minor trauma, and caring for these patients require a multidisciplinary team with both trauma and geriatric expertise. With early recognition and aggressive management, severe injuries can still be associated with good outcomes, even in very elderly patients.
Collapse
Affiliation(s)
- Katrin Hruska
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden.
| | - Toralph Ruge
- Department of Emergency Medicine, Karolinska University Hospital, Huddinge, Sweden; Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
37
|
Ocular Myasthenia Gravis: Toward a Risk of Generalization Score and Sample Size Calculation for a Randomized Controlled Trial of Disease Modification. J Neuroophthalmol 2017; 36:252-8. [PMID: 27031125 DOI: 10.1097/wno.0000000000000350] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is currently no prognostic test to determine the risk of developing generalized myasthenia gravis (GMG) risk in patients who first present with ocular disease. Most studies that report risk factors are flawed by the inclusion of patients on immunosuppression, which is likely to reduce the risk. OBJECTIVE To create a prognostic score to predict the risk of GMG. METHODS Multicenter retrospective cohort of patients with ocular myasthenia gravis for minimum 3 months, untreated with immunosuppression for minimum 2 years or until GMG onset. RESULTS One hundred one (57 female) patients were included, with median follow-up of 8.4 years (2-42) from disease onset. Thirty-one developed GMG at median of 1.31 years (3.5 months-20.2 years); 19 occurred within 2 years. Univariable logistic regression analysis produced 3 significant predictors (P < 0.10), adjusted odds ratios in a multivariable logistic model (χ P = 0.01) with multiple imputations for missing data: seropositivity, 5.64 (95% CI, 1.45-21.97); presence of 1 or more comorbidities including autoimmune disorders, 6.49 (95% CI, 0.78-53.90); thymic hyperplasia, 5.41 (95% CI, 0.39-75.43). Prognostic score was derived from the coefficients of the logistic model: sum of the points (1 point for the presence of each of the above predictive factors), classified "low risk" if ≤1 and "high risk" if ≥2. Predicted probabilities were 0.07 (SD, 0.03) for low risk and 0.39 (SD, 0.09) for high risk. Negative predictive value was 91% (95% CI, 79-98), positive predictive value was 38% (95% CI, 23-54), sensitivity was 79% (95% CI, 54-94), specificity was 63% (95% CI, 50-74), area under receiver operating characteristic curve was 0.74 (95% CI, 0.64-0.85). CONCLUSIONS In this preliminary study, we have shown by proof of principle that it is possible to stratify risk of GMG: an approach that may allow us to better counsel patients at diagnosis, complement decision-making, and move us toward addressing the question of modifying GMG risk in high-risk patients. Furthermore, the effect of comorbidities is novel and demands further elucidation.
Collapse
|
38
|
da Costa LGV, Carmona MJC, Malbouisson LM, Rizoli S, Rocha-Filho JA, Cardoso RG, Auler-Junior JOC. Independent early predictors of mortality in polytrauma patients: a prospective, observational, longitudinal study. Clinics (Sao Paulo) 2017; 72:461-468. [PMID: 28954004 PMCID: PMC5577616 DOI: 10.6061/clinics/2017(08)02] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/14/2017] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES: Trauma is an important public health issue and associated with substantial socioeconomic impacts and major adverse clinical outcomes. No single study has previously investigated the predictors of mortality across all stages of care (pre-hospital, emergency room, surgical center and intensive care unit) in a general trauma population. This study was designed to identify early predictors of mortality in severely injured polytrauma patients across all stages of care to provide a better understanding of the physiologic changes and mechanisms by which to improve care in this population. METHODS: A longitudinal, prospective, observational study was conducted between 2010 and 2013 in São Paulo, Brazil. Patients submitted to high-energy trauma were included. Exclusion criteria were as follows: injury severity score <16, <18 years old or insufficient data. Clinical and laboratory data were collected at four time points: pre-hospital, emergency room, and 3 and 24 hours after hospital admission. The primary outcome assessed was mortality within 30 days. Data were analyzed using tests of association as appropriate, nonparametric analysis of variance and generalized estimating equation analysis (p<0.05). ClinicalTrials.gov: NCT01669577. RESULTS: Two hundred patients were included. Independent early predictors of mortality were as follows: arterial hemoglobin oxygen saturation (p<0.001), diastolic blood pressure (p<0.001), lactate level (p<0.001), Glasgow Coma Scale score (p<0.001), infused crystalloid volume (p<0.015) and presence of traumatic brain injury (p<0.001). CONCLUSION: Our results suggest that arterial hemoglobin oxygen saturation, diastolic blood pressure, lactate level, Glasgow Coma Scale, infused crystalloid volume and presence of traumatic brain injury are independent early mortality predictors.
Collapse
Affiliation(s)
- Luiz Guilherme V. da Costa
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Grupo de Resgate e Atendimento as Urgencias (GRAU), Secretaria de Estado da Saude, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Maria José C. Carmona
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz M. Malbouisson
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Sandro Rizoli
- University of Toronto Trauma and Acute Care Service, St Michael’s Hospital, Toronto, Canada
| | - Joel Avancini Rocha-Filho
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Ricardo Galesso Cardoso
- Grupo de Resgate e Atendimento as Urgencias (GRAU), Secretaria de Estado da Saude, Sao Paulo, SP, BR
| | - José Otávio C. Auler-Junior
- Divisao de Anestesiologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| |
Collapse
|
39
|
Nguyen TL, Collins GS, Spence J, Fontaine C, Daurès JP, Devereaux PJ, Landais P, Le Manach Y. Magnitude and direction of missing confounders had different consequences on treatment effect estimation in propensity score analysis. J Clin Epidemiol 2017; 87:87-97. [PMID: 28412467 DOI: 10.1016/j.jclinepi.2017.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 01/19/2017] [Accepted: 04/04/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Propensity score (PS) analysis allows an unbiased estimate of treatment effects but assumes that all confounders are measured. We assessed the impact of omitting confounders from a PS analysis on clinical decision making. STUDY DESIGN AND SETTING We conducted Monte Carlo simulations on hypothetical observational studies based on virtual populations and on the population from a large randomized trial (CRASH-2). In both series of simulations, PS analysis was conducted with all confounders and with omitted confounders, which were defined to have different strengths of association with the outcome and treatment exposure. After inverse probability of treatment weighting, we calculated the absolute risk differences and numbers needed to treat (NNT). RESULTS In both series of simulations, omitting a confounder that was moderately associated with the outcome and exposure led to negligible bias on the NNT scale. The bias induced by omitting strongly positive confounding variables remained less than 15 patients to treat. Major bias and reversed effects were found only when omitting highly prevalent, strongly negative confounders that were similarly associated with the outcome and exposure with odds ratios greater than 4.00 (or <0.25). This omission was accompanied by a substantial decrease in analysis power. CONCLUSION The omission of strongly negative confounding variables from a PS analysis can lead to incorrect clinical decision making. However, omitting these variables also decreases the analysis power, which may prevent the reporting of significant but misleading effects.
Collapse
Affiliation(s)
- Tri-Long Nguyen
- Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES EA 2415, Montpellier University, Montpellier, France; Department of Anesthesia, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada; Department of Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada; Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, Hamilton, Canada
| | - Gary S Collins
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Windmill Road, Oxford, UK
| | - Jessica Spence
- Department of Anesthesia, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada; Department of Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada; Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, Hamilton, Canada
| | - Charles Fontaine
- Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES EA 2415, Montpellier University, Montpellier, France
| | - Jean-Pierre Daurès
- Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES EA 2415, Montpellier University, Montpellier, France
| | - Philip J Devereaux
- Department of Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada; Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, Hamilton, Canada; Department of Medicine, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Paul Landais
- Laboratory of Biostatistics, Epidemiology, Clinical Research and Health Economics, UPRES EA 2415, Montpellier University, Montpellier, France; Department of Biostatistics, Clinical Research and Medical Informatics, Nîmes University Hospital, Nîmes, France
| | - Yannick Le Manach
- Department of Anesthesia, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada; Department of Clinical Epidemiology and Biostatistics, Michael DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Canada; Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, Hamilton, Canada.
| |
Collapse
|
40
|
Subramani K, Lu S, Warren M, Chu X, Toque HA, Caldwell RW, Diamond MP, Raju R. Mitochondrial targeting by dichloroacetate improves outcome following hemorrhagic shock. Sci Rep 2017; 7:2671. [PMID: 28572638 PMCID: PMC5453974 DOI: 10.1038/s41598-017-02495-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 04/12/2017] [Indexed: 12/16/2022] Open
Abstract
Hemorrhagic shock is a leading cause of death in people under the age of 45 and accounts for almost half of trauma-related deaths. In order to develop a treatment strategy based on potentiating mitochondrial function, we investigated the effect of the orphan drug dichloroacetate (DCA) on survival in an animal model of hemorrhagic shock in the absence of fluid resuscitation. Hemorrhagic shock was induced in rats by withdrawing 60% of the blood volume and maintaining a hypotensive state. The studies demonstrated prolonged survival of rats subjected to hemorrhagic injury (HI) when treated with DCA. In separate experiments, using a fluid resuscitation model we studied mitochondrial functional alterations and changes in metabolic networks connected to mitochondria following HI and treatment with DCA. DCA treatment restored cardiac mitochondrial membrane potential and tissue ATP in the rats following HI. Treatment with DCA resulted in normalization of several metabolic and molecular parameters including plasma lactate and p-AMPK/AMPK, as well as Ach-mediated vascular relaxation. In conclusion we demonstrate that DCA can be successfully used in the treatment of hemorrhagic shock in the absence of fluid resuscitation; therefore DCA may be a good candidate in prolonged field care following severe blood loss.
Collapse
Affiliation(s)
- Kumar Subramani
- Department of Laboratory Sciences, Augusta University, Augusta, GA, 30912, United States of America
| | - Sumin Lu
- Department of Laboratory Sciences, Augusta University, Augusta, GA, 30912, United States of America
| | - Marie Warren
- Department of Laboratory Sciences, Augusta University, Augusta, GA, 30912, United States of America
| | - Xiaogang Chu
- Department of Laboratory Sciences, Augusta University, Augusta, GA, 30912, United States of America
| | - Haroldo A Toque
- Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, 30912, United States of America
| | - R William Caldwell
- Department of Pharmacology and Toxicology, Augusta University, Augusta, GA, 30912, United States of America
| | - Michael P Diamond
- Department of Obstetrics and Gynaecology, Augusta University, Augusta, GA, 30912, United States of America
| | - Raghavan Raju
- Department of Laboratory Sciences, Augusta University, Augusta, GA, 30912, United States of America. .,Department of Surgery, Augusta University, Augusta, GA, 30912, United States of America. .,Department of Biochemistry and Molecular Biology, Augusta University, Augusta, GA, 30912, United States of America.
| |
Collapse
|
41
|
Huei TJ, Mohamad Y, Lip HTC, Md Noh N, Imran Alwi R. Prognostic predictors of early mortality from exsanguination in adult trauma: a Malaysian trauma center experience. Trauma Surg Acute Care Open 2017; 2:e000070. [PMID: 29766083 PMCID: PMC5877896 DOI: 10.1136/tsaco-2016-000070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 11/04/2022] Open
Abstract
Background Trauma mortality due to exsanguination is the second most common cause of death. The objective of this study is to investigate the predictors for early death from exsanguination. Methods A prognostic study was done to identify predictors of early mortality due to exsanguination. Data were extracted from our Trauma Surgery Registry database of Sultanah Aminah Hospital, Johor Bahru, Malaysia. All patients who were treated from May 1, 2011 to April 31, 2014 by the trauma team were included. Adult trauma patients included from the Trauma Surgery Registry were divided into two groups for analysis: early death from exsanguination and death from non-exsanguination/survivors. Univariate and multivariate analysis was performed to look for significant predictors of death from exsanguination. Variables analyzed were demography, mechanism of injury, organ injury scale, physiological parameters (systolic blood pressure (SBP), respiratory rate, heart rate, temperature), Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS) and cause of death. Results A total of 2208 patients with an average age of 36 (±16) years were included. Blunt trauma was the majority with 90.5%, followed by penetrating injuries (9.2%). The overall mortality is 239 out of 2208 (10.8%). Seventy-eight patients (32.6%) died due to central nervous system injury, 69 due to sepsis (28.9%) and 58 due to exsanguination (24.3%). After multivariate analysis, age (OR 1.026 (1.009 to 1.044), p=0.002), SBP (OR 0.985 (0.975 to 0.995), p=0.003) and temperature (OR 0.203 (0.076 to 0.543), p=0.001) were found to be the significant physiological parameters. Intra-abdominal injury and NISS were significant anatomic mortality predictors from exsanguination (p<0.001). Patients with intra-abdominal injury had four times higher risk of mortality from exsanguination (OR 3.948 (2.331 to 6.686), p<0.001). Discussion In a Malaysian trauma center, age, SBP, core body temperature, intra-abdominal injury and NISS were significant predictors of early death from exsanguination. Level of evidence II.
Collapse
Affiliation(s)
- Tan Jih Huei
- Department of General Surgery, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia.,Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Malaysia.,Clinical Research Centre, Hospital Sultan Ismail, Johor Bahru, Malaysia
| | - Yuzaidi Mohamad
- Department of General Surgery, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia
| | - Henry Tan Chor Lip
- Department of General Surgery, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia.,Pusat Perubatan Universiti Kebangsaan Malaysia, Cheras, Malaysia.,Clinical Research Centre, Hospital Sultan Ismail, Johor Bahru, Malaysia
| | - Norazlin Md Noh
- Department of General Surgery, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia
| | - Rizal Imran Alwi
- Department of General Surgery, Hospital Sultanah Aminah, Johor Bahru, Johor, Malaysia
| |
Collapse
|
42
|
Hawley C, Sakr M, Scapinello S, Salvo J, Wrenn P. Traumatic brain injuries in older adults-6 years of data for one UK trauma centre: retrospective analysis of prospectively collected data. Emerg Med J 2017; 34:509-516. [PMID: 28052919 DOI: 10.1136/emermed-2016-206506] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 12/03/2016] [Accepted: 12/06/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Our aim was to determine the incidence of traumatic brain injury (TBI) in older adults and investigate the relationship between injury characteristics and outcomes. METHODS Retrospective analysis of prospectively collected data submitted to Trauma Audit and Research Network (TARN) database for a major trauma centre in the West Midlands, UK, from 2008 to 2014. The Mayo Scale was used to categorise TBI. All patients were aged ≥65 years and were admitted with head or brain injuries meeting TARN inclusion criteria: injury resulting in immediate admission to hospital for 3 days, admitted to a high dependency area or death following trauma. We determined age, gender, mechanism of injury, Injury Severity Score, presenting Glasgow Coma Scale (GCS) and Mayo Score, and the association of outcome (Glasgow Outcome Scale (GOS)) with age and clinical presentation. RESULTS 4413 patients were admitted with trauma meeting TARN criteria: 1389 were ≥65 years and 45% (624) had TBI. For patients ≥65 years with TBI, mean age was 79 (range 65-99); 56% were men. Falls accounted for 85% of all TBIs. Most TBIs were moderate/severe (80%) by the Mayo criteria. Of the 279 patients with subdural haematoma, 28% had neurosurgery. Most patients survived TBI (78%); 57% had a good outcome on GOS at discharge (not requiring care package). Mortality was associated with increased age (17% in ages 65-74 years, 19% in 75-84 years, 30% in ≥85 years, p=0.03). Outcome was significantly associated with injury severity (p=0.0001). CONCLUSIONS Patients with TBI represented 45% of all trauma cases meeting TARN inclusion criteria. Falls at home accounted for most TBIs. Most had moderate/severe TBI, yet over half made a good recovery on GOS. Our data indicate that injury prevention initiatives should focus on home safety. Further research is needed to examine rehabilitation and follow-up after hospital discharge.
Collapse
Affiliation(s)
- Carol Hawley
- Division of Mental Health and Wellbeing, Warwick Medical School, Coventry, UK
| | - Magdy Sakr
- Department of Emergency Medicine, University Hospital Coventry and Warwickshire, Coventry, UK
| | | | - Jesse Salvo
- Department of Emergency Care, University Hospital Coventry and Warwickshire, Coventry, UK
| | - Paul Wrenn
- Department of Emergency Care, University Hospital Coventry and Warwickshire, Coventry, UK
| |
Collapse
|
43
|
Alghnam S, Alkelya M, Alfraidy M, Al-Bedah K, Albabtain IT, Alshenqeety O. Outcomes of road traffic injuries before and after the implementation of a camera ticketing system: a retrospective study from a large trauma center in Saudi Arabia. Ann Saudi Med 2017; 37:1-9. [PMID: 28151450 PMCID: PMC6148978 DOI: 10.5144/0256-4947.2017.1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Road traffic injuries (RTIs) are the third leading cause of death in Saudi Arabia. Because speed is a major risk factor for severe crash-related injuries, a camera ticketing system was implemented countrywide in mid-2010 by the traffic police in an effort to improve traffic safety. There are no published studies on the effects of the system in Saudi Arabia. OBJECTIVE To examine injury severity and associated mortality at a large trauma center before and after the implementation of the ticketing system. DESIGN Retrospective, analytical. SETTING Trauma center of a tertiary care center in Riyadh. PATIENTS AND METHODS The study included all trauma registry patients seen in the emergency department for a crash-related injury (automobile occupants, pedestrians, or motorcyclists) between January 2005 and December 2014. Associations with outcome measures were assessed by univariate and multivariate methods. MAIN OUTCOME MEASURE(S) Injury severity score (ISS), Glasgow coma scale (GCS) and mortality. RESULTS The study included all trauma registry patients seen in the emergency department for a crash-related injury. All health outcomes improved in the period following implementation of the ticketing system. Following implementation, ISS scores decreased (-3.1, 95% CI -4.6, -1.6) and GCS increased (0.47, 95% CI 0.08, 0.87) after adjusting for other covariates. The odds of death were 46% lower following implementation than before implementation. When the data were log-transformed to account for skewed data distributions, the results remained statistically significant. CONCLUSIONS This study suggests positive health implications following the implementation of the camera ticketing system. Further investment in public health interventions is warranted to reduce preventable RTIs. LIMITATIONS The study findings represent a trauma center at a single hospital in Riyadh, which may not generalize to the Saudi population.
Collapse
Affiliation(s)
- Suliman Alghnam
- Dr. Suliman Abdulah Alghnam, King Abdulah International Research Center (KAIMRC), Population Health, PO Box 22490,, Riyadh, 11426, Saudi Arabia,, T: 0539468887, , ORCID: http://orcid.org/0000-0001-5817-0481
| | | | | | | | | | | |
Collapse
|
44
|
Evaluation of MGAP and GAP Trauma Scores to Predict Prognosis of Multiple-trauma Patients. Trauma Mon 2016. [DOI: 10.5812/traumamon.33249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
45
|
Gerdin M, Roy N, Khajanchi M, Kumar V, Felländer-Tsai L, Petzold M, Tomson G, von Schreeb J. Validation of a novel prediction model for early mortality in adult trauma patients in three public university hospitals in urban India. BMC Emerg Med 2016; 16:15. [PMID: 26905408 PMCID: PMC4763419 DOI: 10.1186/s12873-016-0079-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/16/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Trauma is one of the top threats to population health globally. Several prediction models have been developed to supplement clinical judgment in trauma care. Whereas most models have been developed in high-income countries the majority of trauma deaths occur in low- and middle-income countries. Almost 20 % of all global trauma deaths occur in India alone. The aim of this study was to validate a basic clinical prediction model for use in urban Indian university hospitals, and to compare it with existing models for use in early trauma care. METHODS We conducted a prospective cohort study in three hospitals across urban India. The model we aimed to validate included systolic blood pressure and Glasgow coma scale. We compared this model with three additional models, which all have been designed for use in bedside trauma care, and two single variable models based on systolic blood pressure and Glasgow coma scale respectively. The outcome was early mortality, defined as death within 24 h from the time when vital signs were first measured. We compared the models in terms of discrimination, calibration, and potential clinical consequences using decision curve analysis. Multiple imputation was used to handle missing data. Performance measures are reported using their median and inter-quartile range (IQR) across imputed datasets. RESULTS We analysed 4440 patients, out of which 1629 were used as an updating sample and 2811 as a validation sample. We found no evidence that the basic model that included only systolic blood pressure and Glasgow coma scale had worse discrimination or potential clinical consequences compared to the other models. A model that also included heart had better calibration. For the model with systolic blood pressure and Glasgow coma scale the discrimination in terms of area under the receiver operating characteristics curve was 0.846 (IQR 0.841-0.849). Calibration measured by estimating a calibration slope was 1.183 (IQR 1.168-1.202). Decision curve analysis revealed that using this model could potentially result in 45 fewer unnecessary surveys per 100 patients. CONCLUSIONS A basic clinical prediction model with only two parameters may prove to be a feasible alternative to more complex models in contexts such as the Indian public university hospitals studied here. We present a colour-coded chart to further simplify the decision making in early trauma care.
Collapse
Affiliation(s)
- Martin Gerdin
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Solna, 171 65, Stockholm, Sweden.
| | - Nobhojit Roy
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Solna, 171 65, Stockholm, Sweden.
- Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India.
- Tata Institute of Social Sciences, School of Habitat, Mumbai, India.
| | - Monty Khajanchi
- General Surgery, Seth GS Medical College & King Edward Memorial Hospital, Mumbai, India.
| | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India.
| | - Li Felländer-Tsai
- Department of Clinical Science Intervention and Technology, Division of Orthopedics and Biotechnology, Karolinska Institutet, Stockholm, Sweden.
| | - Max Petzold
- Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa.
| | - Göran Tomson
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Solna, 171 65, Stockholm, Sweden.
- Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden.
| | - Johan von Schreeb
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, Solna, 171 65, Stockholm, Sweden.
| |
Collapse
|
46
|
Gerdin M, Roy N, Felländer-Tsai L, Tomson G, von Schreeb J, Petzold M, Gupta A, Jhakal A, Basak D, Mohamed Ismail D, Yabo D, Jegadeesan K, Kamble J, Saha ML, Nitnaware M, Khajanchi M, Jothi R, Ghosh SN, Bhoi S, Mahindrakar S, Dharap S, Rao S, Kamal V, Kumar V, Tirlotkar S. Traumatic transfers: calibration is adversely affected when prediction models are transferred between trauma care contexts in India and the United States. J Clin Epidemiol 2016; 74:177-86. [PMID: 26775627 DOI: 10.1016/j.jclinepi.2016.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/13/2015] [Accepted: 01/04/2016] [Indexed: 12/23/2022]
Abstract
OBJECTIVE We evaluated the transferability of prediction models between trauma care contexts in India and the United States and explored updating methods to adjust such models for new contexts. STUDY DESIGN AND SETTINGS Using a combination of prospective cohort and registry data from 3,728 patients of Towards Improved Trauma Care Outcomes in India (TITCO) and from 18,756 patients of the US National Trauma Data Bank (NTDB), we derived models in one context and validated them in the other, assessing them for discrimination and calibration using systolic blood pressure, heart rate, and Glasgow coma scale as candidate predictors. RESULTS Early mortality was 8% in the TITCO and 1-2% in the NTDB samples. Both models discriminated well, but the TITCO model overestimated the risk of mortality in NTDB patients, and the NTDB model underestimated the risk in TITCO patients. CONCLUSION Transferability was good in terms of discrimination but poor in terms of calibration. It was possible to improve this miscalibration by updating the models' intercept. This updating method could be used in samples with as few as 25 events.
Collapse
Affiliation(s)
- Martin Gerdin
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77 Stockholm, Sweden.
| | - Nobhojit Roy
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, Maharashtra 400085, India; School of Habitat, Tata Institute of Social Sciences, Chembur, Mumbai, Maharashtra 400088, India
| | - Li Felländer-Tsai
- Division of Orthopedics and Biotechnology, Department of Clinical Science Intervention and Technology, Karolinska Institutet, Alfred Nobels allé 8, SE-141 52 Huddinge, Sweden
| | - Göran Tomson
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77 Stockholm, Sweden; Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Johan von Schreeb
- Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Max Petzold
- Centre for Applied Biostatistics, Occupational and Environmental Medicine, Sahlgrenska Academy, University of Gothenburg, PO Box 414, SE-405 30 Gothenburg, Sweden; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 7 York Rd, Johannesburg 2193, South Africa
| | | | - Amit Gupta
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India
| | - Ashish Jhakal
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India
| | - Debojit Basak
- Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Harish Mukherjee Rd, Bhowanipore, Kolkata, India
| | - Deen Mohamed Ismail
- Department of Orthopedics, Madras Medical College, Chennai, Tamil Nadu 600003, India
| | - Dusu Yabo
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India
| | - K Jegadeesan
- Madras Medical College, Chennai, Tamil Nadu 600003, India
| | - Jyoti Kamble
- King Edward Memorial Hospital, Mumbai, Maharashtra 400012, India
| | - Makhan Lal Saha
- Department of Surgery, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Harish Mukherjee Rd, Bhowanipore, Kolkata, India
| | - Mangesh Nitnaware
- Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra 400022, India
| | - Monty Khajanchi
- General Surgery, Seth GS Medical College & King Edward Memorial Hospital, Mumbai, Maharashtra 400012, India
| | - Ranganathan Jothi
- Department of Neurosurgery, Madras Medical College, Chennai, Tamil Nadu 600003, India
| | - Samarendra Nath Ghosh
- Department of Neurosurgery, Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Harish Mukherjee Rd, Bhowanipore, Kolkata, India
| | - Sanjeev Bhoi
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India
| | - Santosh Mahindrakar
- Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, Delhi 110029, India
| | - Satish Dharap
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra 400022, India
| | - Shilpa Rao
- Department of Surgery, King Edward Memorial Hospital, Mumbai, Maharashtra 400012, India
| | - Veera Kamal
- Madras Medical College, Chennai, Tamil Nadu 600003, India
| | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra 400022, India
| | - Santosh Tirlotkar
- School of Habitat, Tata Institute of Social Sciences, Chembur, Mumbai, Maharashtra 400088, India
| |
Collapse
|
47
|
Panteli M, Pountos I, Giannoudis PV. Pharmacological adjuncts to stop bleeding: options and effectiveness. Eur J Trauma Emerg Surg 2015; 42:303-10. [PMID: 26660675 PMCID: PMC4886148 DOI: 10.1007/s00068-015-0613-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 11/29/2022]
Abstract
Severe trauma and massive haemorrhage represent the leading cause of death and disability in patients under the age of 45 years in the developed world. Even though much advancement has been made in our understanding of the pathophysiology and management of trauma, outcomes from massive haemorrhage remain poor. This can be partially explained by the development of coagulopathy, acidosis and hypothermia, a pathological process collectively known as the “lethal triad” of trauma. A number of pharmacological adjuncts have been utilised to stop bleeding, with a wide variation in the safety and efficacy profiles. Antifibrinolytic agents in particular, act by inhibiting the conversion of plasminogen to plasmin, therefore decreasing the degree of fibrinolysis. Tranexamic acid, the most commonly used antifibrinolytic agent, has been successfully incorporated into most trauma management protocols effectively reducing mortality and morbidity following trauma. In this review, we discuss the current literature with regard to the management of haemorrhage following trauma, with a special reference to the use of pharmacological adjuncts. Novel insights, concepts and treatment modalities are also discussed.
Collapse
Affiliation(s)
- M Panteli
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.
| | - I Pountos
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK
| | - P V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level A, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
| |
Collapse
|
48
|
Coagulopathy and transfusion strategies in trauma. Overwhelmed by literature, supported by weak evidence. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 14:3-7. [PMID: 26674832 DOI: 10.2450/2015.0244-15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
49
|
Abstract
Tranexamic acid (TXA) reduces blood loss by inhibiting the enzymatic breakdown of fibrin. It is often used in surgery to decrease bleeding and the need for blood transfusion. In 2011, results from a multi-center, randomized, and placebo-controlled trial (CRASH-2 trial) showed that TXA (1 g loading dose over 10 min followed by an infusion of 1 g over 8 h) safely reduces mortality in bleeding trauma patients. Initiation of TXA treatment within 3 h of injury reduces the risk of hemorrhage death by about one-third, regardless of baseline risk. Because it does not have any serious adverse effects, TXA can be administered to a wide spectrum of bleeding trauma patients. Limiting its use to the most severely injured or those with a diagnosis of 'hyperfibrinolysis' would result in thousands of avoidable deaths. A clinical trial (CRASH-3 trial) of TXA in patients with traumatic brain injury is now in progress.
Collapse
Affiliation(s)
- I Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
| |
Collapse
|
50
|
Moons KGM, Altman DG, Reitsma JB, Ioannidis JPA, Macaskill P, Steyerberg EW, Vickers AJ, Ransohoff DF, Collins GS. Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration. Ann Intern Med 2015; 162:W1-73. [PMID: 25560730 DOI: 10.7326/m14-0698] [Citation(s) in RCA: 2928] [Impact Index Per Article: 325.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) Statement includes a 22-item checklist, which aims to improve the reporting of studies developing, validating, or updating a prediction model, whether for diagnostic or prognostic purposes. The TRIPOD Statement aims to improve the transparency of the reporting of a prediction model study regardless of the study methods used. This explanation and elaboration document describes the rationale; clarifies the meaning of each item; and discusses why transparent reporting is important, with a view to assessing risk of bias and clinical usefulness of the prediction model. Each checklist item of the TRIPOD Statement is explained in detail and accompanied by published examples of good reporting. The document also provides a valuable reference of issues to consider when designing, conducting, and analyzing prediction model studies. To aid the editorial process and help peer reviewers and, ultimately, readers and systematic reviewers of prediction model studies, it is recommended that authors include a completed checklist in their submission. The TRIPOD checklist can also be downloaded from www.tripod-statement.org.
Collapse
|