A retrospective cohort study of 27,049 polytraumatized patients age 60 and above: identifying changes over 16 years

Aim

In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017.

Findings

Trauma mechanism, as well as injury pattern, changed over time. We found length of stay and mortality decreased despite an increase in patient age.

Message

We ascribe this observation mainly to increased use of diagnostic tools and improved treatment algorithms and underline the importance of the implementation of specialized geriatric trauma centers allowing interdisciplinary care.

Purpose

The number of severely injured patients exceeding the age of 60 has shown a steep increase within the last decades. These patients present with numerous co-morbidities, polypharmacy, and increased frailty requiring an adjusted treatment approach. In this study, we establish an overview of changes we observed in demographics of older severe trauma patients from 2002 to 2017.

Methods

A descriptive analysis of the data from the TraumaRegister DGU^® (TR-DGU) was performed. Patients admitted to a level one trauma center in Germany, Austria and Switzerland between 2002 and 2017, aged 60 years or older and with an injury severity score (ISS) over 15 were included. Patients were stratified into subgroups based on the admission: 2002–2005 (1), 2006–2009 (2), 2010–2013 (3) and 2014–2017 (4). Trauma and patient characteristics, diagnostics, treatment and outcome were compared.

Results

In total 27,049 patients with an average age of 73.9 years met the inclusion criteria. The majority were males (64%), and the mean ISS was 27.4. The proportion of patients 60 years or older [(23% (1) to 40% (4)] rose considerably over time. Trauma mechanisms changed over time and more specifically low falls (< 3 m) rose from 17.6% (1) to 40.1% (4). Altered injury patterns were also identified. Length-of-stay decreased from 28.9 (1) to 19.5 days (4) and the length-of-stay on ICU decreased from 17.1 (1) to 12.7 days (4). Mortality decreased from 40.5% (1) to 31.8% (4).

Conclusion

Length of stay and mortality decreased despite an increase in patient age. We ascribe this observation mainly to increased use of diagnostic tools, improved treatment algorithms, and the implementation of specialized trauma centers for older patients allowing interdisciplinary care.

Virtual Monoenergetic Images from Spectral Detector CT Enable Radiation Dose Reduction in Unenhanced Cranial CT

BACKGROUND AND PURPOSE

Our aim was to evaluate whether improved gray-white matter differentiation in cranial CT by means of 65- keV virtual monoenergetic images enables a radiation dose reduction compared to conventional images.

MATERIALS AND METHODS

One hundred forty consecutive patients undergoing 171 spectral detector CTs of the head between February and November 2017 (56 ± 19 years of age; male/female ratio, 56%/44%) were retrospectively included. The tube current-time product was reduced during the study period, resulting in 61, 55, and 55 patients being examined with 320, 290, and 260 mAs, respectively. All other scanning parameters were kept identical. The volume CT dose index was recorded. ROIs were placed in gray and white matter on conventional images and copied to identical positions in 65- keV virtual monoenergetic images. The contrast-to-noise ratio was calculated. Two radiologists blinded to the reconstruction technique evaluated image quality on a 5-point Likert-scale. Statistical assessment was performed using ANOVA and Wilcoxon test adjusted for multiple comparisons.

RESULTS

The mean volume CT dose index was 55, 49.8, and 44.7 mGy using 320, 290, and 260 mAs, respectively. Irrespective of the volume CT dose index, noise was significantly lower in 65- keV virtual monoenergetic images compared with conventional images (65- keV virtual monoenergetic images/conventional images: extraocular muscle with 49.8 mGy, 3.7 ± 1.3/5.6 ± 1.6 HU, P < .001). Noise slightly increased with a reduced radiation dose (eg, extraocular muscle in conventional images: 5.3 ± 1.4/5.6 ± 1.6/6.1 ± 2.1 HU). Overall, the contrast-to-noise ratio in 65- keV virtual monoenergetic images was superior to that in conventional images irrespective of the volume CT dose index (P < .001). Particularly, 65-keV virtual monoenergetic images with 44.7 mGy showed significantly lower noise and a higher contrast-to-noise ratio than conventional images with 55 mGy (P < .001). Subjective analysis confirmed better image quality in 65- keV virtual monoenergetic images, even using 44.7 mGy.

CONCLUSIONS

The 65-keV virtual monoenergetic images from spectral detector CT allow radiation dose reduction in cranial CT. While this proof of concept included a radiation dose reduction of 19%, our data suggest that even greater reduction appears achievable.

Reduction of artifacts caused by orthopedic hardware in the spine in spectral detector CT examinations using virtual monoenergetic image reconstructions and metal-artifact-reduction algorithms

OBJECTIVE

Aim of this study was to assess the artifact reduction in patients with orthopedic hardware in the spine as provided by (1) metal-artifact-reduction algorithms (O-MAR) and (2) virtual monoenergetic images (MonoE) as provided by spectral detector CT (SDCT) compared to conventional iterative reconstruction (CI).

METHODS

In all, 28 consecutive patients with orthopedic hardware in the spine who underwent SDCT-examinations were included. CI, O-MAR and MonoE (40-200 keV) images were reconstructed. Attenuation (HU) and noise (SD) were measured in order to calculate signal-to-noise ratio (SNR) of paravertebral muscle and spinal canal. Subjective image quality was assessed by two radiologists in terms of image quality and extent of artifact reduction.

RESULTS

O-MAR and high-keV MonoE showed significant decrease of hypodense artifacts in terms of higher attenuation as compared to CI (CI vs O-MAR, 200 keV MonoE: -396.5HU vs. -115.2HU, -48.1HU; both p ≤ 0.001). Further, artifacts as depicted by noise were reduced in O-MAR and high-keV MonoE as compared to CI in (1) paravertebral muscle and (2) spinal canal-CI vs. O-MAR/200 keV: (1) 34.7 ± 19.0 HU vs. 26.4 ± 14.4 HU, p ≤ 0.05/27.4 ± 16.1, n.s.; (2) 103.4 ± 61.3 HU vs. 72.6 ± 62.6 HU/60.9 ± 40.1 HU, both p ≤ 0.001. Subjectively both O-MAR and high-keV images yielded an artifact reduction in up to 24/28 patients.

CONCLUSION

Both, O-MAR and high-keV MonoE reconstructions as provided by SDCT lead to objective and subjective artifact reduction, thus the combination of O-MAR and MonoE seems promising for further reduction.

[Abdominal injuries in polytraumatized adults : Systematic review]

Abdominal injuries are potentially life-threatening and occur in 20-25% of all polytraumatized patients. Blunt trauma is the main mechanism. The liver and spleen are most commonly injured and much less often the intestines. The clinical evaluation proves equivocal in many cases; therefore, the gold standard is computed tomography (CT), which has been increasingly used even in hemodynamically weakly stable or sometimes even unstable patients because it promptly provides precise diagnostic findings, which present the basis for successful therapy. Hemodynamically unstable patients always need an exploratory laparotomy (EL). An EL should also be carried out with a positive focused assessment with sonography for trauma (FAST) or CT for severe parenchymal lesions, hollow organ lesions, intraperitoneal bladder lesions, peritonitis and organ evisceration, impalement injuries and lesions of the abdominal fascia. Hemodynamically stable patients without signs of peritonitis and a lack of such findings can often be treated conservatively irrespective of the extent of an injury. Angiography (and if needed embolization) can additionally be diagnostically and therapeutically utilized.

Influence of surgeon, patient and radiographic factors on distal radius fracture treatment

The purpose of this study was to evaluate surgeon, patient, and radiographic factors influencing the recommendation for operative treatment in distal radius fractures. In a web-based study 252 orthopaedic surgeons from a variety of countries reviewed 30 consecutive sets of radiographs of patients that presented to our emergency department with a fracture of the distal radius. Surgeons were randomly assigned to receive either 'Radiographs only' or 'Radiographs and clinical information'. Surgery was recommended on average 52% of the time whether or not surgeons received clinical information. Female surgeons, surgeons with less than 21 years of experience, and hand surgeons were more likely to recommend operative treatment, but these factors explained only 1% of the variation. Radiographic criteria (intra-articular fractures, ulnar styloid fractures, dorsal comminution, dorsal tilt, and ulnar variance) explained 49% of the variation. The overall agreement on treatment was moderate and slightly higher among surgeons that received radiographs alone. Level of evidence: Level II, therapeutic; not a clinical study.

The role of arthrodesis of the wrist in spastic disorders

We investigated the functional and radiographic outcome of wrist arthrodesis in 11 adults with spastic wrist deformities, carried out by one surgeon between 2003 and 2012. The underlying cause of spasticity was a cerebrovascular insult in five, traumatic brain injury in four, and cerebral palsy in two patients. A dorsal plate and local bone graft was used in all patients. The mean radiographic flexion deformity significantly improved from 67° pre-operatively to 4° of dorsal angulation post-operatively. Thumb-in-palm deformity was more pronounced in three patients after the operation. The functional House score improved in all patients an average of two levels (range 1-3).

Risk factors for return with a second trigger digit

The purpose of this study was to determine predictors of return to the same practice with a second idiopathic trigger digit. A total of 2234 patients with Quinnell grade 2 or greater (objective triggering) of one or more digits were retrospectively analysed. A total of 490 of 2234 (22%) patients returned to the same practice with a second trigger digit, with an average follow-up time of 2.1 years (range, 7 days to 10 years). Predictors of return with a second trigger digit included carpal tunnel syndrome, Type 1 diabetes mellitus and duration of follow-up in years. Patients diagnosed with idiopathic trigger digit can be advised that about one in five will return to the same practice with another trigger digit, with approximately double the risk in patients that have carpal tunnel syndrome or Type 1 diabetes.

In vitro and ex vivo toxicological testing of sildenafil-loaded solid lipid nanoparticles

The aim of this study was to investigate the potential cytotoxicity of solid lipid nanoparticles (SLN) loaded with sildenafil. The SLNs were tested as a new drug delivery system (DDS) for the inhalable treatment of pulmonary hypertension in human lungs. Solubility of sildenafil in SLN lipid matrix (30:70 phospholipid:triglyceride) was determined to 1% sildenafil base and 0.1% sildenafil citrate, respectively. Sildenafil-loaded SLN with particle size of approximately 180 nm and monomodal particle size distribution were successfully manufactured using a novel microchannel homogenization method and were stable up to three months. Sildenafil-loaded SLN were then used in in vitro and ex vivo models representing lung and heart tissue. For in vitro models, human alveolar epithelial cell line (A459) and mouse heart endothelium cell line (MHEC5-T) were used. For ex vivo models, rat precision cut lung slices (PCLS) and rat heart slices (PCHS) were used. All the models were treated with plain SLN and sildenafil-loaded SLN in a concentration range of 0-5000 µg/ml of lipid matrix. The toxicity was evaluated in vitro and ex vivo by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Median lethal dose 50% (LD50) values for A549 cells and PCLS were found to be in the range of 1200-1900 µg/ml while for MHEC5-T cells and precision cut heart slices values were found between 1500 and 2800 µg/ml. PCHS showed slightly higher LD50 values in comparison to PCLS. Considering the toxicological aspects, sildenafil-loaded SLN could have potential in the treatment of pulmonary hypertension via inhalation route.

Fixation of osteoporotic fractures in the upper limb with a locking compression plate

Locking Compression Plate (LCP) has the advantageous feature that screws can be locked in the plate leaving an angular stable construct. There is no need to have contact between the plate and the bone to achieve stability resulting from friction of the plate-bone-construct. Therefore the plate does not need to be contoured exactly to the bone and the healing bone's periosteal blood supply is not affected. The LCP is used as a bridging plate to gain relative stability in multi-fragmentary, diaphyseal or metaphyseal fractures. Depending on the fracture, the combination hole can also allow the LCP to achieve absolute stability similar to conventional fixation techniques. Osteoporotic fractures have significant impact on morbidity and mortality. Proximal humeral and distal radius fractures are typical examples. These osteoporotic and often comminuted fractures are ideal settings/indications for LCP utilization in the upper extremity. However, the data quality is due to mostly small study populations not so powerful. Unquestionably there has been a clear and fashionable trend to choose operative treatment for these fractures, because the angular stability allows stable fixation and early functional mobilization.

Current concepts review: carpal injuries - fractures, ligaments, dislocations

An overview about current concepts in treating carpal injuries is presented. These injuries are more commonly seen in young, active individuals after a fall on an outstretched hand. Conventional radiographs and a thorough examination are important. The scaphoid is the most affected bone. Scaphoid fractures can be classified in accordance to OTA, AO, and other classification systems, but mostly to Herbert. It can be treated non-operatively if undisplaced, however a percutaneous internal fixation can be discussed to achieve earlier return to work and shorter time to union, but hazarding the consequences of an operation. Unstable, proximal pole, or delayed diagnosed scaphoid fractures should be treated surgically. Nonunion is seen in 5 - 40% of scaphoid fractures depending mainly on displacement and localization of the fracture. The gold standard in non-osteoarthritic scaphoid nonunion is debridement of the nonunion site, bone grafting, realignment, stable fixation and rehabilitation. The treatment of scaphoid-nonunion advanced collapse is more complex. Proximal row carpectomy or arthrodesis (four-corner or complete wrist) can be mandatory. Other carpal bone fractures are rare. Perilunate dislocations are also uncommon but can be disabling. They usually originate in high-energy trauma. The Mayfield stages help to understand the injury pattern. Open reduction through both volar and dorsal approaches, repair of the volar capsule as well as volar and dorsal ligaments, and internal fixation is commonly the standard treatment. However osteoarthritis and carpal instability are often encountered.

[Ascites and hematuria after falling in an alcoholic patient]

Isolated ruptures of the urinary bladder following minor traumas are a rare abdominal lesion. Diagnosis and treatment are a challenge to emergency physicians and surgeons. This case shows a 46-year-old patient admitted for a minor brain injury after falling during an episode of alcoholic intoxication. Ultrasound and CT scan of the abdomen showed intraabdominal fluid without a parenchymatous lesion. Also a hematuria was significant. The retrograde cystography showed intraabdominal contrast agent. The rupture of the urinary bladder was confirmed by laparoscopy and was intracorporal sutured in double layer technique. Without any postoperative complications the patient was discharged after 4 days. The retrograde cystography after 10 days showed no leckage and the urinary catheter could be removed.

Toll-like receptor 7 and MyD88 knockdown by lentivirus-mediated RNA interference to porcine dendritic cell subsets

Sensing of viruses by dendritic cell (DC) pathogen recognition receptors (PRRs) represents a critical event during innate antiviral immune responses. Identification of these PRRs has often posed a problem due to difficulties in performing gene function studies in the naturally targeted hosts. Consequently, we developed a lentivirus (LV)-based strategy for specific gene knockdown in porcine DC. Short hairpin RNAs (shRNAs) were designed, targeting toll-like receptor 7 (TLR7) and the adaptor protein MyD88. As cellular targets, monocyte-derived DC (MoDC) and Flt3 ligand-induced DC (Flt3L-DC), DC precursors including monocytes and haematopoietic stem cells (HSCs) as well as plasmacytoid DCs (pDCs) were employed. Transduction efficiencies ranged from 40 to 95%. The LV-mediated shRNA delivery was functionally active, reducing TLR7 and MyD88 mRNA in MoDC and conventional Flt3L-DC, and blunting the responsiveness to TLR7 ligands in Flt3L-DC. Although infection of MoDC by the LV did neither influence MHC class II and CD80/86 expressions, nor cytokine responses, the infection of Flt3L-DC induced a phenotypic maturation. Furthermore, the interaction of the LV with pDC induced high levels of interferon-alpha. Taken together, these studies characterize the interaction of the LV with different DC subsets and demonstrate the suitability of LV-mediated small interfering RNA delivery for targeting PRR knockout for MoDC and conventional Flt3L-DC.

[Fall from a height of 13.5 meters of a child without major injuries]

High-velocity traumas, especially falls from a height, are a major cause of morbidity and mortality in children. Despite the height of fall is a poor predictor of major injury, we must be aware of relevant injuries especially of the head and the musculoskeletal system. The aim is to recognize all relevant problems, or better to avoid the fall. We report a case from a fall of 13.5 meters with an ellbow-fracture and contusions of the head.

Porcine dendritic cells generated in vitro: morphological, phenotypic and functional properties

Despite the central role that dendritic cells (DC) play in immune regulation and antigen presentation, little is known about porcine DC. In this study, two sources of DC were employed. Bone marrow haematopoietic cell-derived DC (BM-DC) were generated using granulocyte-macrophage colony-stimulating factor (GM-CSF) in the presence or absence of tumour necrosis factor-alpha (TNF-alpha). Monocyte-derived DC (Momicron-DC) were generated with GM-CSF and interleukin-4 (IL-4). In both systems, non-adherent cells developed with dendritic morphology, expressing high levels of major histocompatibility complex (MHC) class II. The presence of TNF-alpha increased the BM-DC yield, and enhanced T-cell stimulatory capacity. Both BM-DC and Momicron-DC expressed the pan-myeloid marker SWC3, as well as CD1 and CD80/86, but were also CD14+ and CD16+. The CD16 molecule was functional, acting as a low-affinity Fc receptor. In contrast, the CD14 on DC appeared to differ functionally from monocyte CD14: attempts to block CD14, in terms of lipopolysaccharide (LPS)-induced procoagulant activity (PCA), failed. The use of TNF-alpha or LPS for DC maturation induced up-regulation of MHC class II and/or CD80/86, but also CD14. Allogeneic mixed leucocyte reactions and staphylococcal enterotoxin B antigen presentation assays demonstrated that these DC possessed potent T-cell stimulatory capacity. No T helper cell polarization was noted. Both the BM-DC and the Momicron-DC induced a strong interferon-gamma and IL-4 response. Taken together, porcine DC generated in vitro possess certain characteristics relating them to DC from other species including humans, but the continued presence of CD14 and CD16 on mature and immature porcine DC was a notable difference.

Porcine dendritic cells generated in vitro: morphological, phenotypic and functional properties

Despite the central role that dendritic cells (DC) play in immune regulation and antigen presentation, little is known about porcine DC. In this study, two sources of DC were employed. Bone marrow haematopoietic cell-derived DC (BM-DC) were generated using granulocyte-macrophage colony-stimulating factor (GM-CSF) in the presence or absence of tumour necrosis factor-alpha (TNF-alpha). Monocyte-derived DC (Momicron-DC) were generated with GM-CSF and interleukin-4 (IL-4). In both systems, non-adherent cells developed with dendritic morphology, expressing high levels of major histocompatibility complex (MHC) class II. The presence of TNF-alpha increased the BM-DC yield, and enhanced T-cell stimulatory capacity. Both BM-DC and Momicron-DC expressed the pan-myeloid marker SWC3, as well as CD1 and CD80/86, but were also CD14+ and CD16+. The CD16 molecule was functional, acting as a low-affinity Fc receptor. In contrast, the CD14 on DC appeared to differ functionally from monocyte CD14: attempts to block CD14, in terms of lipopolysaccharide (LPS)-induced procoagulant activity (PCA), failed. The use of TNF-alpha or LPS for DC maturation induced up-regulation of MHC class II and/or CD80/86, but also CD14. Allogeneic mixed leucocyte reactions and staphylococcal enterotoxin B antigen presentation assays demonstrated that these DC possessed potent T-cell stimulatory capacity. No T helper cell polarization was noted. Both the BM-DC and the Momicron-DC induced a strong interferon-gamma and IL-4 response. Taken together, porcine DC generated in vitro possess certain characteristics relating them to DC from other species including humans, but the continued presence of CD14 and CD16 on mature and immature porcine DC was a notable difference.