Publications by authors named "Michael J R Edwards"

28 Publications

  • Page 1 of 1

Cast-OFF Trial: One Versus 4 to 5 Weeks of Plaster Cast Immobilization for Nonreduced Distal Radius Fractures: A Randomized Clinical Feasibility Trial.

Hand (N Y) 2021 Sep 27:15589447211044775. Epub 2021 Sep 27.

Radboud University Medical Center, Nijmegen, The Netherlands.

Background: Distal radius fracture is a common fracture of which the incidence appears to be increasing worldwide. This pilot study investigated whether 1 week of plaster cast is feasible for nonreduced (stable fractures including nondisplaced and displaced fractures) distal radius fractures.

Methods: The study was a multicenter randomized clinical feasibility trial including patients from regional acute care providers. Patients with a nonreduced distal radius fracture were included in the study. Nonreduced fractures meant intra-articular or extra-articular fractures and including nondisplaced and minimal displaced fractures (dorsal angulation less than 5°-10°, maximum radial shortening of 2 mm, and maximum radial shift of 2 mm) not needing a reduction. Forty Patients were included and randomized. After 1 week of plaster cast, patients were randomized to 1 of the 2 treatment groups: plaster cast removed (intervention group) versus 4 to 5 weeks of plaster cast (control group).

Results: The analysis shows no significant differences between the 2 groups in having less pain, better function after 6 weeks, and better overall patient satisfaction. No difference was shown in secondary displacement between the 2 groups (control 1 vs intervention 0).

Conclusion: One week of plaster cast treatment for nonreduced distal radius fracture is feasible, preferred by patients, with at least the same functional outcome and pain scores.

Level Of Evidence: According to the Oxford 2011 level of evidence, the level of evidence of this study is 2.
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http://dx.doi.org/10.1177/15589447211044775DOI Listing
September 2021

Design recommendations for exoskeletons: Perspectives of individuals with spinal cord injury.

J Spinal Cord Med 2021 Jun 1:1-6. Epub 2021 Jun 1.

Department of Trauma Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

Objective: This study investigated the expectations of individuals with spinal cord injury (SCI) regarding exoskeletons.

Design: The survey consisted out of questions regarding multiple aspects of exoskeleton technology.

Setting: An online survey was distributed via the monthly newsletter of the Dutch Patient Association for Spinal Cord Injury (SCI).

Participants: Individuals with SCI who are members of the Dutch Patient Association for SCI.

Outcome Measures: General impression of exoskeleton technology, expectations regarding capabilities and user-friendliness, training expectations and experiences, future perspectives and points of improvement.

Results: The survey was filled out by 95 individuals with SCI, exoskeletons were considered positive and desirable by 74.7%. About 11 percent (10.5%) thought one could ambulate faster, or just as fast, while wearing an exoskeleton as able-bodied people. Furthermore, 18.9% expected not to use a wheelchair or walking aids while ambulating with the exoskeleton. Twenty-five percent believed that exoskeletons could replace wheelchairs. Some main points of improvement included being able to wear the exoskeleton in a wheelchair and while driving a car, not needing crutches while ambulating, and being able to put the exoskeleton on by oneself.

Conclusion: Individuals with SCI considered exoskeletons as a positive and desirable innovation. But based on the findings from the surveys, major points of improvement are necessary for exoskeletons to replace wheelchairs in the future. For future exoskeleton development, we recommend involvement of individuals with SCI to meet user expectations and improve in functionality, usability and quality of exoskeletons.
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http://dx.doi.org/10.1080/10790268.2021.1926177DOI Listing
June 2021

The impact of regionalized trauma care on the distribution of severely injured patients in the Netherlands.

Eur J Trauma Emerg Surg 2021 Mar 12. Epub 2021 Mar 12.

Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.

Background: Twenty years ago, an inclusive trauma system was implemented in the Netherlands. The goal of this study was to evaluate the impact of structured trauma care on the concentration of severely injured patients over time.

Methods: All severely injured patients (Injury Severity Score [ISS] ≥ 16) documented in the Dutch Trauma Registry (DTR) in the calendar period 2008-2018 were included for analysis. We compared severely injured patients, with and without severe neurotrauma, directly brought to trauma centers (TC) and non-trauma centers (NTC). The proportion of patients being directly transported to a trauma center was determined, as was the total Abbreviated Injury Score (AIS), and ISS.

Results: The documented number of severely injured patients increased from 2350 in 2008 to 4694 in 2018. During this period, on average, 70% of these patients were directly admitted to a TC (range 63-74%). Patients without severe neurotrauma had a lower chance of being brought to a TC compared to those with severe neurotrauma. Patients directly presented to a TC were more severely injured, reflected by a higher total AIS and ISS, than those directly transported to a NTC.

Conclusion: Since the introduction of a well-organized trauma system in the Netherlands, trauma care has become progressively centralized, with more severely injured patients being directly presented to a TC. However, still 30% of these patients is initially brought to a NTC. Future research should focus on improving pre-hospital triage to facilitate swift transfer of the right patient to the right hospital.
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http://dx.doi.org/10.1007/s00068-021-01615-1DOI Listing
March 2021

Satisfaction with Alignment After Reduction of a Displaced Distal Radial Fracture.

J Bone Joint Surg Am 2021 03;103(6):483-488

Department of Plastic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands.

Background: Alignment adequate to offer nonoperative treatment after reduction of a distal radial fracture is a matter of opinion. This study addressed factors associated with interobserver reliability of satisfaction with alignment after the reduction of a distal radial fracture.

Methods: A survey sent to members of the Science of Variation Group divided the participants into 4 groups that each rated 24 sets of radiographs of adult patients with a distal radial fracture before and after manipulative reduction and cast or splint immobilization. This resulted in a total of 96 fractures rated by 111 participants. Observers indicated whether they were satisfied with the reduction, meaning that nonoperative treatment was an option, or not, meaning that they recommend surgery. The Fleiss kappa was used to measure reliability.

Results: There was fair reliability of satisfaction with reduction of a distal radial fracture (kappa, 0.34 [95% confidence interval (CI), 0.28 to 0.41]). No surgeon factors were associated with variations in reliability. Multivariable linear regression analysis indicated that every degree decrease in dorsal angulation of the distal part of the radius on the lateral radiograph increased satisfaction by a mean of 1% (beta, -0.01 [95% CI, -0.02 to -0.006]; p = 0.001); each millimeter decrease in the anterior-to-posterior distance between the dorsal and volar articular margins on the lateral radiograph increased satisfaction by 3% (beta, -0.03 [95% CI, -0.04 to -0.005]; p = 0.014), and each millimeter decrease in ulnar positive variance increased satisfaction by 6% (beta, -0.06 [95% CI, -0.08 to -0.03]; p < 0.001), accounting for 44% of the observed variation.

Conclusions: Surgeons are influenced by radiographic deformity, but do not agree on adequate alignment after reduction of a distal radial fracture.

Clinical Relevance: Greater involvement of patients in decisions with regard to acceptable deformity has the potential to decrease treatment variation.
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http://dx.doi.org/10.2106/JBJS.20.00482DOI Listing
March 2021

Evaluation of the Berlin polytrauma definition: A Dutch nationwide observational study.

J Trauma Acute Care Surg 2021 04;90(4):694-699

From the Dutch Network for Emergency Care (M.L.S.D., L.M.S.), Utrecht; Department of Medical Statistics (E.W.v.Z.), Leiden University Medical Center, Leiden; Department of Surgery (F.W.B.), Amsterdam University Medical Center, VU, Amsterdam; Department of Trauma Surgery (M.J.R.E.), Radboud University Medical Center, Nijmegen; Trauma Research Unit, Department of Surgery (D.d.H.), Erasmus MC, University Medical Center Rotterdam, Rotterdam; Brabant Trauma Registry (M.A.C.d.J.), Network Emergency Care Brabant, Tilburg; Department of Surgery (P.A.L.), Amsterdam University Medical Center, AMC, Amsterdam; Department of Surgery (M.P.), Maastricht University Medical Center, Maastricht; Department of Trauma Surgery (I.B.S.), Leiden University Medical Center, Leiden; Department of Trauma Surgery (R.S.), Isala Hospitals, Zwolle; Department of Trauma Surgery (K.W.W.), University Medical Center Groningen, Groningen; Department of Trauma Surgery (R.J.d.W.), Medical Spectrum Twente, Enschede; Department of Surgery Elisabeth Two Cities Hospital (S.W.A.M.v.Z.), Tilburg; and Department of Surgery (L.P.H.L.), University Medical Center Utrecht, Utrecht, the Netherlands.

Background: The Berlin polytrauma definition (BPD) was established to identify multiple injury patients with a high risk of mortality. The definition includes injuries with an Abbreviated Injury Scale score of ≥3 in ≥2 body regions (2AIS ≥3) combined with the presence of ≥1 physiological risk factors (PRFs). The PRFs are based on age, Glasgow Coma Scale, hypotension, acidosis, and coagulopathy at specific cutoff values. This study evaluates and compares the BPD with two other multiple injury definitions used to identify patients with high resource utilization and mortality risk, using data from the Dutch National Trauma Register (DNTR).

Methods: The evaluation was performed based on 2015 to 2018 DNTR data. First, patient characteristics for 2AIS ≥3, Injury Severity Score (ISS) of ≥16, and BPD patients were compared. Second, the PRFs prevalence and odds ratios of mortality for 2AIS ≥3 patients were compared with those from the Deutsche Gesellschaft für Unfallchirurgie Trauma Register. Subsequently, the association between PRF and mortality was assessed for 2AIS ≥3-DNTR patients and compared with those with an ISS of ≥16.

Results: The DNTR recorded 300,649 acute trauma admissions. A total of 15,711 patients sustained an ISS of ≥16, and 6,263 patients had suffered a 2AIS ≥3 injury. All individual PRFs were associated with a mortality of >30% in 2AIS ≥3-DNTR patients. The increase in PRFs was associated with a significant increase in mortality for both 2AIS ≥3 and ISS ≥16 patients. A total of 4,264 patients met the BPDs criteria. Overall mortality (27.2%), intensive care unit admission (71.2%), and length of stay were the highest for the BPD group.

Conclusion: This study confirms that the BPD identifies high-risk patients in a population-based registry. The addition of PRFs to the anatomical injury scores improves the identification of severely injured patients with a high risk of mortality. Compared with the ISS ≥16 and 2AIS ≥3 multiple injury definitions, the BPD showed to improve the accuracy of capturing patients with a high medical resource need and mortality rate.

Level Of Evidence: Epidemiological study, level III.
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http://dx.doi.org/10.1097/TA.0000000000003071DOI Listing
April 2021

Reliability of recommendations to reduce a fracture of the distal radius.

Acta Orthop 2021 04 13;92(2):131-136. Epub 2020 Nov 13.

Department of Plastic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.

Background and purpose - It is unclear what degree of malalignment of a fracture of the distal radius benefits from reduction. This study addressed the following questions: (1) What is the interobserver reliability of surgeons concerning the recommendation for a reduction for dorsally displaced distal radius fractures? (2) Do expert-based criteria for reduction improve reliability or not?Methods - We sent out 2 surveys to a group of international hand and fracture surgeons. On the first survey, 80 surgeons viewed radiographs of 95 dorsally displaced (0° to 25°) fractures of the distal radius. The second survey randomized 68 participants to either receive or not receive expert-based criteria for when to reduce a fracture and then viewed 20 radiographs of fractures with dorsal angulation between 5° and 15°. All participants needed to indicate whether they would advise a reduction or not.Results - In the 1st study, the interrater reliability of advising a reduction was fair (kappa 0.31). Multivariable linear regression analyses indicated that each additional degree of dorsal angulation increased the chance of recommending a reduction by 3%. In the 2nd study, reading criteria for reduction did not increase interobserver reliability for recommending a reduction.Interpretation - There is notable variation in recommendations for reduction that is not accounted for by surgeon or patient factors and is not diminished by exposure to expert criteria. Surgeons should be aware of their biases and develop strategies to inform patients and share the decision regarding whether to reduce a fracture of the distal radius.
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http://dx.doi.org/10.1080/17453674.2020.1846853DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8158196PMC
April 2021

Accuracy of pre-hospital trauma triage and field triage decision rules in children (P2-T2 study): an observational study.

Lancet Child Adolesc Health 2020 04 1;4(4):290-298. Epub 2020 Feb 1.

Department of Surgery, University Medical Centre Utrecht, Utrecht, Netherlands; Department of Surgery, Diakonessenhuis Utrecht/Zeist/Doorn, Utrecht, Netherlands.

Background: Adequate pre-hospital trauma triage is crucial to enable optimal care in inclusive trauma systems. Transport of children in need of specialised trauma care to lower-level trauma centres is associated with adverse patient outcomes. We aimed to evaluate the diagnostic accuracy of paediatric field triage based on patient destination and triage tools.

Methods: We did a multisite observational study (P2-T2) of all children (aged <16 years) transported with high priority by ambulance from the scene of injury to any emergency department in seven of 11 inclusive trauma regions in the Netherlands. Diagnostic accuracy based on the initial transport destination was evaluated in terms of undertriage rate (ie, the proportion of patients in need of specialised trauma care who were initially transported to a lower-level paediatric or adult trauma centre) and overtriage rate (ie, the proportion of patients not requiring specialised trauma care who were transported to a level-I [highest level] paediatric trauma centre). The Dutch National Protocol of Ambulance Services and Field Triage Decision Scheme triage protocols were externally validated using data from this cohort against an anatomical (Injury Severity Score [ISS] ≥16) and a resource-based reference standard.

Findings: Between Jan 1, 2015, and Dec 31, 2017, 12 915 children (median age 10·3 years, IQR 4·2-13·6) were transported to the emergency department with injuries. 4091 (31·7%) patients were admitted to hospital, of whom 129 (3·2%) patients had an ISS of 16 or greater and 227 (5·5%) patients used critical resources within a limited timeframe. Ten patients died within 24 h of arrival at the emergency department. Based on the primary reference standard (ISS ≥16), the undertriage rate was 16·3% (95% CI 10·8-23·7) and the overtriage rate was 21·2% (20·5-22·0). The National Protocol of Ambulance Services had a sensitivity of 53·5% (95% CI 43·9-62·9) and a specificity of 94·0% (93·4-94·6), and the Field Triage Decision Scheme had a sensitivity of 64·5% (54·1-74·1) and a specificity of 84·3% (83·1-85·5).

Interpretation: Too many children in need of specialised care were transported to lower-level paediatric or adult trauma centres, which is associated with increased mortality and morbidity. Current protocols cannot accurately discriminate between patients at low and high risk, and highly sensitive and child-specific triage tools need to be developed to ensure the right patient is transported to the right hospital.

Funding: The Netherlands Organisation for Health Research and Development, Innovation Fund Health Insurers.
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http://dx.doi.org/10.1016/S2352-4642(19)30431-6DOI Listing
April 2020

Refining the criteria for immediate total-body CT after severe trauma.

Eur Radiol 2020 May 23;30(5):2955-2963. Epub 2020 Jan 23.

Trauma Unit, Department of Surgery, Amsterdam University Medical Centers, location AMC, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.

Objectives: Initial trauma care could potentially be improved when conventional imaging and selective CT scanning is omitted and replaced by immediate total-body CT (iTBCT) scanning. Because of the potentially increased radiation exposure by this diagnostic approach, proper selection of the severely injured patients is mandatory.

Methods: In the REACT-2 trial, severe trauma patients were randomized to iTBCT or conventional imaging and selective CT based on predefined criteria regarding compromised vital parameters, clinical suspicion of severe injuries, or high-risk trauma mechanisms in five trauma centers. By logistic regression analysis with backward selection on the 15 study inclusion criteria, a revised set of criteria was derived and subsequently tested for prediction of severe injury and shifts in radiation exposure.

Results: In total, 1083 patients were enrolled with median ISS of 20 (IQR 9-29) and median GCS of 13 (IQR 3-15). Backward logistic regression resulted in a revised set consisting of nine original and one adjusted criteria. Positive predictive value improved from 76% (95% CI 74-79%) to 82% (95% CI 80-85%). Sensitivity decreased by 9% (95% CI 7-11%). The area under the receiver operating characteristics curve remained equal and was 0.80 (95% CI 0.77-0.83), original set 0.80 (95% CI 0.77-0.83). The revised set retains 8.78 mSv (95% CI 6.01-11.56) for 36% of the non-severely injured patients.

Conclusions: Selection criteria for iTBCT can be reduced from 15 to 10 clinically criteria. This improves the positive predictive value for severe injury and reduces radiation exposure for less severely injured patients.

Key Points: • Selection criteria for iTBCT can be reduced to 10 clinically useful criteria. • This reduces radiation exposure in 36% of less severely injured patients. • Overall discriminative capacity for selection of severely injured patients remained equal.
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http://dx.doi.org/10.1007/s00330-019-06503-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7160085PMC
May 2020

Treatment of Distal Radius Fracture: Does Early Activity Postinjury Lead to a Lower Incidence of Complex Regional Pain Syndrome?

Hand (N Y) 2020 Jan 9:1558944719895782. Epub 2020 Jan 9.

Radboud University Medical Center, Nijmegen, The Netherlands.

The optimal treatment for a distal radius fracture (DRF) remains an ongoing discussion. This study observed whether early activity postinjury can lead to the prevention of type 1 complex regional pain syndrome (CRPS-1). Patients who underwent nonoperative treatment for a DRF were invited to participate in this study. Patients followed an exercise program with progressive loading exercises at home immediately after cast removal. After a minimum of 3 months, patients were interviewed by telephone to determine the presence of disproportionate pain. If present, the patients were seen during a clinical consultation to determine whether they had CRPS-1, using the Budapest Diagnostic Criteria. Of the 129 patients included in this study, 12 reported disproportionate pain, and none were diagnosed with CRPS-1. The incidence of CRPS-1 was zero in this study. A more active treatment approach seems to lower the incidence of CRPS-1. A larger randomized study is necessary to strengthen the evidence.
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http://dx.doi.org/10.1177/1558944719895782DOI Listing
January 2020

Highest ambulatory speed using Lokomat gait training for individuals with a motor-complete spinal cord injury: a clinical pilot study.

Acta Neurochir (Wien) 2020 04 24;162(4):951-956. Epub 2019 Dec 24.

Department of Orthopedic Surgery, Radboudumc, Nijmegen, the Netherlands.

Background: Motor impairment and loss of ambulatory function are major consequences of a spinal cord injury (SCI). Exoskeletons are robotic devices that allow SCI patients with limited ambulatory function to walk. The mean walking speed of SCI patients using an exoskeleton is low: 0.26 m/s. Moreover, literature shows that a minimum speed of 0.59 m/s is required to replace wheelchairs in the community.

Objective: To investigate the highest ambulatory speed for SCI patients in a Lokomat.

Methods: This clinical pilot study took place in the Rehabilitation Center Kladruby, in Kladruby (Czech Republic). Six persons with motor-complete sub-acute SCI were recruited. Measurements were taken at baseline and directly after a 30 min Lokomat training. The highest achieved walking speed, vital parameters (respiratory frequency, heart rate, and blood pressure), visual analog scale for pain, and modified Ashworth scale for spasticity were recorded for each person.

Results: The highest reached walking speed in the Lokomat was on average 0.63 m/s (SD 0.03 m/s). No negative effects on the vital parameters, pain, or spasticity were observed. A significant decrease in pain after the Lokomat training was observed: 95% CI [0.336, 1.664] (p = 0.012).

Conclusion: This study shows that it is possible for motor-complete SCI individuals to ambulate faster on a Lokomat (on average 0.63 m/s) than what is currently possible with over-ground exoskeletons. No negative effects were observed while ambulating on a Lokomat. Further research investigating walking speed in exoskeletons after SCI is recommended.
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http://dx.doi.org/10.1007/s00701-019-04189-5DOI Listing
April 2020

Rib fixation versus non-operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: a multicenter cohort study.

Eur J Trauma Emerg Surg 2019 Aug 19;45(4):655-663. Epub 2018 Oct 19.

Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

Background: Over the years, a trend has evolved towards operative treatment of flail chest although evidence is limited. Furthermore, little is known about operative treatment for patients with multiple rib fractures without a flail chest. The aim of this study was to compare rib fixation based on a clinical treatment algorithm with nonoperative treatment for both patients with a flail chest or multiple rib fractures.

Methods: All patients with ≥ 3 rib fractures admitted to one of the two contributing hospitals between January 2014 and January 2017 were retrospectively included in this multicenter cohort study. One hospital treated all patients nonoperatively and the other hospital treated patients with rib fixation according to a clinical treatment algorithm. Primary outcome measures were intensive care length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. To control for potential confounding, propensity score matching was applied.

Results: A total of 332 patients were treated according to protocol and available for analysis. The mean age was 56 (SD 17) years old and 257 (77%) patients were male. The overall mean Injury Severity Score was 23 (SD 11) and the average number of rib fractures was 8 (SD 4). There were 92 patients with a flail chest, 37 (40%) had rib fixation and 55 (60%) had non-operative treatment. There were 240 patients with multiple rib fractures, 28 (12%) had rib fixation and 212 (88%) had non-operative treatment. For both patient groups, after propensity score matching, rib fixation was not associated with intensive care unit length of stay (for flail chest patients) nor with hospital length of stay (for multiple rib fracture patients), nor with the secondary outcome measures.

Conclusion: No advantage could be demonstrated for operative fixation of rib fractures. Future studies are needed before rib fixation is embedded or abandoned in clinical practice.
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http://dx.doi.org/10.1007/s00068-018-1037-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689036PMC
August 2019

Emergency Bleeding Control Interventions After Immediate Total-Body CT Scans in Trauma Patients.

World J Surg 2019 Feb;43(2):490-496

Trauma Unit, Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, Netherlands.

Background: Immediate total-body CT (iTBCT) is often used for screening of potential severely injured patients. Patients requiring emergency bleeding control interventions benefit from fast and optimal trauma screening. The aim of this study was to assess whether an initial trauma assessment with iTBCT is associated with lower mortality in patients requiring emergency bleeding control interventions.

Methods: In the REACT-2 trial, patients who sustained major trauma were randomized for iTBCT or for conventional imaging and selective CT scanning (standard workup; STWU) in five trauma centers. Patients who underwent emergency bleeding control interventions following their initial trauma assessment with iTBCT were compared for mortality and clinically relevant time intervals to patients that underwent the initial trauma assessment with the STWU.

Results: In the REACT-2 trial, 1083 patients were enrolled of which 172 (15.9%) underwent emergency bleeding control interventions following their initial trauma assessment. Within these 172 patients, 85 (49.4%) underwent iTBCT as primary diagnostic modality during the initial trauma assessment. In trauma patients requiring emergency bleeding control interventions, in-hospital mortality was 12.9% (95% CI 7.2-21.9%) in the iTBCT group compared to 24.1% (95% CI 16.3-34.2%) in the STWU group (p = 0.059). Time to bleeding control intervention was not reduced; 82 min (IQR 5-121) versus 98 min (IQR 62-147), p = 0.108.

Conclusions: Reduction in mortality in trauma patients requiring emergency bleeding control interventions by iTBCT could not be demonstrated in this study. However, a potentially clinically relevant absolute risk reduction of 11.2% (95% CI - 0.3 to 22.7%) in comparison with STWU was observed.

Trial Registration: ClinicalTrials.gov: NCT01523626.
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http://dx.doi.org/10.1007/s00268-018-4818-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6329725PMC
February 2019

Are on-scene blood transfusions by a helicopter emergency medical service useful and safe? A multicentre case-control study.

Eur J Emerg Med 2019 Apr;26(2):128-132

Department of Trauma Surgery.

Introduction: In the prehospital setting, crystalloid fluids are frequently used, but only erythrocytes are capable of transporting oxygen to tissues. The aim of this study was to establish the efficacy and safety of the prehospital use of uncross matched type O rhesus-negative packed red blood cells (URBC) by the Dutch physician-staffed helicopter emergency medical service. We hypothesized that prehospital URBC transfusions are safe and more effective with respect to survival than resuscitations with crystalloids.

Methods: The effects of prehospital URBC transfusions were studied by comparing a cohort of patients (>18 years) who were treated with a combination of URBC and crystalloid fluids with a matched control group of patients who received crystalloid fluids alone.

Results: Among 73 adults who received prehospital URBC transfusions, 50 (68%) patients were included. No transfusion reactions were observed. No effect of prehospital transfusion on 24-h or 30-day survival was found. Haemoglobin levels at presentation to the emergency department were higher in the URBC cohort. The two groups had similar cumulative erythrocyte requirements within the first 24 h.

Conclusion: Neither survival benefits nor a decreased incidence of shock on admission were observed after prehospital helicopter emergency medical service URBC transfusions. There were no prehospital transfusion reactions in this study; therefore, URBC transfusions were deemed to be safe. A prospective randomized study is warranted to evaluate the effect of early URBC transfusions and transfusions with preheated URBC on the survival of patients with severe prehospital haemorrhagic shock.
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http://dx.doi.org/10.1097/MEJ.0000000000000516DOI Listing
April 2019

Ten Meters Walking Speed in Spinal Cord-Injured Patients: Does Speed Predict Who Walks and Who Rolls?

Neurorehabil Neural Repair 2017 Sep 8;31(9):842-850. Epub 2017 Aug 8.

1 Radboud University Medical Centre, Nijmegen, the Netherlands.

Background: Walking speed is assumed to be a key factor in regaining ambulation after spinal cord injury (SCI). However, from the literature it remains unclear which walking speed usually results in independent community ambulation.

Objective: The primary aim of this study was to determine at which walking speed SCI patients tend to walk in the community instead of using a wheelchair. The secondary aim was to investigate clinical conditions that favor independent ambulation in the community.

Methods: Data from SCI patients were collected retrospectively from the European Multicenter Study about Spinal Cord Injury database. We determined a cutoff walking speed at which the patients tend to walk in the community by plotting a receiver operating characteristics curve, using the Spinal Cord Independence Measure for outdoor mobility. Univariate analyses investigated which factors influence independent community ambulation.

Results: A walking speed of 0.59 m/s is the cutoff between patients who do and do not ambulate independently in the community, with a sensitivity of 91.6% and a specificity of 80.3%. Age, injury severity, and lower limb muscle strength have a significant influence on independent community ambulation.

Conclusions: Patients with an SCI who regain a walking speed of 0.59 m/s tend to achieve a level of walking effectiveness that allows for independent community walking. Although such patients tend to be younger and less severely injured, this walking speed can be a target for locomotor training in rehabilitation and clinical trials that lead to a meaningful outcome level of community walking.
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http://dx.doi.org/10.1177/1545968317723751DOI Listing
September 2017

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial.

Lancet 2016 Aug 28;388(10045):673-83. Epub 2016 Jun 28.

Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands. Electronic address:

Background: Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma.

Methods: We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with traumatic brain injury. The χ(2) test was used to assess differences in mortality. This trial is registered with ClinicalTrials.gov, number NCT01523626.

Findings: Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body CT scanning and 701 to the standard work-up. 541 patients in the immediate total-body CT scanning group and 542 in the standard work-up group were included in the primary analysis. In-hospital mortality did not differ between groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542; p=0.92). In-hospital mortality also did not differ between groups in subgroup analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard work-up 82 [25%] of 331; p=0.46) and traumatic brain injury (68 [38%] of 178 vs 66 [44%] of 151; p=0.31). Three serious adverse events were reported in patients in the total-body CT group (1%), one in the standard work-up group (<1%), and one in a patient who was excluded after random allocation. All five patients died.

Interpretation: Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT.

Funding: ZonMw, the Netherlands Organisation for Health Research and Development.
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http://dx.doi.org/10.1016/S0140-6736(16)30932-1DOI Listing
August 2016

The iTClamp in the management of prehospital haemorrhage.

Injury 2016 May 29;47(5):1012-5. Epub 2015 Dec 29.

Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.

Introduction: Bleeding remains a leading cause of death in trauma patients. The iTClamp is a temporary wound closure device designed to control external bleeding within seconds of injury. We describe our experience using this device on 10 patients in the prehospital environment.

Methods: We have implemented the iTClamp for prehospital use through our physician-staffed helicopter emergency medical service (HEMS). Indications were massive bleeding that could not be controlled with an ordinary compressive bandage or a haemostatic bandage.

Results: Ten patients were treated with the iTClamp. Seven patients had a severe head injury due to various traumas, one patient had a neck injury from a disk cutter, one patient had an open chest wound and one patient had an open femur fracture. After applying the iTClamp, bleeding was controlled in 90% of these patients (n=9), with complete cessation reported in 60% (n=6), partial cessation with adequate control reported in 30% (n=3); in one patient, the bleeding could not be controlled with the iTClamp alone. It took an average of 10s to apply the iTClamp, and the average usage satisfaction score was 7.7.

Conclusion: We conclude that the iTClamp is a safe, fast and useful tool for stopping or controlling external blood loss in our series of prehospital patients. Further studies of the iTClamp are needed to determine which patients might benefit from this device.
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http://dx.doi.org/10.1016/j.injury.2015.12.017DOI Listing
May 2016

[Direct total body CT scan in multi-trauma patients].

Ned Tijdschr Geneeskd 2012 ;156(30):A4897

Academisch Medisch Centrum, afd. Chirurgie, Trauma-unit, Amsterdam, the Netherlands.

Background: Immediate total body computed tomography (CT) scanning has become important in the early diagnostic phase of trauma care because of its high diagnostic accuracy. However, literature provides limited evidence whether immediate total body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total body CT scanning in trauma patients.

Design: The REACT-2 trial is an international, multicenter randomized clinical trial.

Methods: All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. The intervention group will receive a contrast-enhanced total body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness.

Conclusion: The REACT-2 trial is the first multicenter randomized clinical trial that will provide evidence on the value of immediate total body CT scanning during the primary survey of severely injured trauma patients.
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October 2012

An evidence based blunt trauma protocol.

Emerg Med J 2013 Mar 16;30(3):e23. Epub 2012 May 16.

Department of Surgery, Division of trauma surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

Objective: Currently CT is rapidly implemented in the evaluation of trauma patients. In anticipation of a large international multicentre trial, this study's aim was to evaluate the clinical feasibility of a new diagnostic protocol, used for the primary radiological evaluation in adult blunt high-energy trauma patients, especially for the use of CT.

Methods: An evidence-based flow chart was created with criteria based on trauma mechanism, physical examination and laboratory analyses to indicate appropriateness of conventional radiography (CR), sonography and CT of head, cervical spine and trunk. To evaluate this protocol, the authors prospectively included 81 consecutive patients. Collected data included protocol adherence and number and type of performed CR and CT scans. The authors also determined the time needed to perform radiological investigations, adverse events in the CT room and clinically relevant missed injuries after 1-month clinical follow-up.

Results: There was 99% adherence to the protocol concerning CT. Seventy-nine patients (98%) received one or more CT scans: 72 (89%) had thoracoabdominal, 78 (96%) cervical spine and 54 (67%) had cranial CT. In 30 patients, one or more CT scans of body regions could be omitted. In 38%, CR was wrongly omitted or performed incorrectly at a variance with the protocol. No major adverse events occurred in the CT room and no clinically relevant injuries were missed.

Conclusions: The authors introduced a diagnostic protocol that seems feasible and safe for the evaluation of adult blunt high-energy trauma patients. Implementation of this protocol has the potential to reduce unnecessary radiological investigations, especially CT scans.
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http://dx.doi.org/10.1136/emermed-2011-200802DOI Listing
March 2013

Effects on mortality, treatment, and time management as a result of routine use of total body computed tomography in blunt high-energy trauma patients.

J Trauma Acute Care Surg 2012 Mar;72(3):553-9

Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

Background: Currently, total body computed tomography (TBCT) is rapidly implemented in the evaluation of trauma patients. With this review, we aim to evaluate the clinical implications-mortality, change in treatment, and time management-of the routine use of TBCT in adult blunt high-energy trauma patients compared with a conservative approach with the use of conventional radiography, ultrasound, and selective computed tomography.

Methods: A literature search for original studies on TBCT in blunt high-energy trauma patients was performed. Two independent observers included studies concerning mortality, change of treatment, and/or time management as outcome measures. For each article, relevant data were extracted and analyzed. In addition, the quality according to the Oxford levels of evidence was assessed.

Results: From 183 articles initially identified, the observers included nine original studies in consensus. One of three studies described a significant difference in mortality; four described a change of treatment in 2% to 27% of patients because of the use of TBCT. Five studies found a gain in time with the use of immediate routine TBCT. Eight studies scored a level of evidence of 2b and one of 3b.

Conclusion: Current literature has predominantly suboptimal design to prove terminally that the routine use of TBCT results in improved survival of blunt high-energy trauma patients. TBCT can give a change of treatment and improves time intervals in the emergency department as compared with its selective use.
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http://dx.doi.org/10.1097/TA.0b013e31822dd93bDOI Listing
March 2012

A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2).

BMC Emerg Med 2012 Mar 30;12. Epub 2012 Mar 30.

Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.

Background: Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients.

Methods/design: The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness.

Discussion: The REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group.

Trial Registration: ClinicalTrials.gov: (NCT01523626).
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http://dx.doi.org/10.1186/1471-227X-12-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361475PMC
March 2012

Raising arms; at any cost?

J Trauma 2011 Apr;70(4):1016; author reply 1016-7

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http://dx.doi.org/10.1097/TA.0b013e31820d218fDOI Listing
April 2011

Incidental Findings on Routine Thoracoabdominal Computed Tomography in Blunt Trauma Patients.

J Trauma Acute Care Surg 2012 02 29;72(2):416-421. Epub 2011 Apr 29.

From the Departments of Surgery (R.V., J.D., R.V.D., M.J.R.E.), Radiology (H.M.D., D.R.K., M.B.), and Emergency Medicine (A.B.V.), Radboud University Nijmegen Medical Centre, The Netherlands.

BACKGROUND:: Thoracoabdominal MultiDetector-row Computed Tomography (MDCT) is frequently used as a diagnostic tool in trauma patients. One potential side-effect of performing MDCT is the detection of incidental findings and their subsequent consequences on medical treatment. The objective was to evaluate frequency and effects of incidental findings in trauma patients. METHODS:: The reports of 1,047 consecutive blunt trauma patients (mean age, 40 years) who underwent routine contrast-enhanced thoracoabdominal MDCT were evaluated. Incidental findings were categorized by a trauma radiologist into four hierarchic categories based on their clinical consequences. We recorded additional diagnostic workup and treatment performed in conjunction with these incidental findings. RESULTS:: Of the 1,047 patients, 372 (mean age, 56 years; 61% male) had one or more incidental findings on thoracoabdominal MDCT. Complementary investigation or therapy was performed in 72 of these 372 patients; 29 of these patients required additional invasive evaluation or treatment. Nineteen patients underwent surgery due to an incidental finding. Nine patients were diagnosed with a not previously identified malignancy. CONCLUSIONS:: Routine thoracoabdominal MDCT in the evaluation of trauma patients revealed a significant number of incidental findings. Based on radiologic findings it is possible to decide whether additional follow-up or treatment is necessary.
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http://dx.doi.org/10.1097/TA.0b013e3182166b4bDOI Listing
February 2012

Is a pelvic fracture a predictor for thoracolumbar spine fractures after blunt trauma?

J Trauma 2009 Nov;67(5):1027-32

Department of Surgery and Traumatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.

Background: Discussion still remains which polytraumatized patients require radiologic thoracolumbar spine (TL spine) screening. The purpose of this study is to determine whether pelvic fractures are associated with TL spine fractures after a blunt trauma. Additionally, the sensitivity of conventional TL spine radiographs and pelvic radiographs (PXRs) is evaluated.

Methods: We prospectively studied 721 consecutive patients who had sustained a high-energy blunt trauma. The diagnostic workup in these patients included routine conventional radiographs of the pelvis and TL spine followed by a computed tomography (CT) analysis. All patients with pelvic fractures and TL spine fractures identified on conventional radiographs and CT were analyzed. A relative risk (RR) was calculated for the association between pelvic fractures and TL spine fractures. The sensitivity for conventional TL spine radiographs and PXRs in identifying fractures was calculated.

Results: Of the 721 patients studied, 620 were included in our diagnostic high-energy trauma protocol. Of these 620 included patients, 86 (14%) suffered a pelvic fracture and 126 (20%) suffered a TL spine fracture. Thirty-three patients (5%) suffered both a pelvic fracture and a TL spine fracture. The RR for a TL spine fracture in the presence of a pelvic fracture identified on PXR is 2.14 (95% confidence interval, 1.54-2.98) and identified on CT this RR is 2.20 (95% confidence interval, 1.59-3.05). However, this association diminishes to a nonsignificant level when the transverse process and spinous process fractures are excluded. Overall sensitivity for conventional TL spine radiographs and PXRs is 22% and 69%, respectively.

Conclusion: Our data suggest that a pelvic fracture is not a predictor for clinically relevant TL spine fractures. Furthermore, our data confirm the superior sensitivity of CT for detecting TL spine injury and pelvic fractures.
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http://dx.doi.org/10.1097/TA.0b013e31818cb261DOI Listing
November 2009

Criteria for the selective use of chest computed tomography in blunt trauma patients.

Eur Radiol 2010 Apr 17;20(4):818-28. Epub 2009 Sep 17.

Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.

Purpose: The purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury.

Methods: This observational study prospectively included consecutive patients (>or=16 years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre.

Results: We included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age >or=55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess <-3 mmol/l and haemoglobin <6 mmol/l). Of 855 patients with >or=1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant.

Conclusion: Omission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected.
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http://dx.doi.org/10.1007/s00330-009-1608-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2835690PMC
April 2010

Arm raising at exposure-controlled multidetector trauma CT of thoracoabdominal region: higher image quality, lower radiation dose.

Radiology 2008 Nov;249(2):661-70

Department of Diagnostic Imaging, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.

Purpose: To evaluate the effect of arm position on image quality and effective radiation dose in an automatic exposure-controlled (AEC) multidetector thoracoabdominal computed tomography (CT) protocol in trauma patients.

Materials And Methods: This retrospective study of the data of 177 trauma patients (117 male; median age, 39 years) was approved by the institutional ethics board, with informed patient consent waived. Patients underwent scanning by using an AEC 16-detector thoracoabdominal CT protocol in which both arms were raised above the shoulder region (standard-position group, 132 patients), one arm was raised and the other was down (one-arm group, 27 patients), or both arms were down (two-arm group, 18 patients). Objective and subjective image quality was assessed. Individual effective radiation dose was calculated from the effective tube current-time product per exposed section. For this purpose, section location-dependent conversion factors were derived by using a CT dosimetry calculator. The effect of arm position on effective dose was quantified by using linear regression analysis with correction for patient volume and attenuation.

Results: Compared with the image quality in the standard-position group, the image quality in the one- and two-arm groups was decreased but within acceptable diagnostic limits. The median corrected effective dose in the standard-position group was 18.6 mSv; the dose in the one-arm group was 18% (95% confidence interval: 11%, 25%) higher than this, and that in the two-arm group was 45% (95% confidence interval: 34%, 57%) higher.

Conclusion: Omitting arm raising results in lower but acceptable image quality and a substantially higher effective radiation dose. Hence, effort should be made to position the arms above the shoulder when scanning trauma patients. Clinical trial registration no. NCT00228111.
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http://dx.doi.org/10.1148/radiol.2492080169DOI Listing
November 2008

Added value of routine chest MDCT after blunt trauma: evaluation of additional findings and impact on patient management.

AJR Am J Roentgenol 2008 Jun;190(6):1591-8

Department of Diagnostic Imaging, Radboud University Nijmegen Medical Centre, Internal number (Huispost) 667, Geert Groote plein 10, 6500 HB Nijmegen, The Netherlands.

Objective: The objective of our study was to evaluate the added value of a low-threshold routine thoracic MDCT algorithm compared with a selective MDCT algorithm in adult blunt trauma patients.

Subjects And Methods: A prospective cohort study was conducted in 464 consecutive blunt trauma patients who met criteria indicative of severe blunt trauma (66% male; age range, 16-93 years; median injury severity score, 13). After clinical evaluation and conventional radiography of the chest and thoracic spine, all patients underwent routine thoracic MDCT with an IV contrast agent (routine MDCT algorithm). Within this routine MDCT group, a subgroup was prospectively defined with abnormal or inconclusive clinical or conventional radiography evaluation (selective MDCT group). Two investigators determined the type, extent, and clinical impact of additional injuries found on MDCT as compared to conventional radiography for both MDCT groups.

Results: Of all 464 patients within the routine MDCT group, 164 patients underwent selective MDCT, which resulted in detection of additional diagnoses compared with conventional radiography in 97 (59%) patients. The routine MDCT algorithm detected additional diagnoses compared with conventional radiography in 201 of 464 patients (43%). Compared with the selective MDCT algorithm, this was an absolute increase of 104 of 464 (22%) extra patients, resulting in a change in patient management in 34 (7%; 95% CI, 5-9.7%), mostly because of additional findings of pulmonary and mediastinal injury.

Conclusion: Routine MDCT has relatively lower, though still substantial, added diagnostic value compared with selective MDCT of the chest.
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http://dx.doi.org/10.2214/AJR.07.3277DOI Listing
June 2008

Comparison of current injury scales for survival chance estimation: an evaluation comparing the predictive performance of the ISS, NISS, and AP scores in a Dutch local trauma registration.

J Trauma 2005 Mar;58(3):596-604

Department of Anesthesiology, Erasmus MC Rotterdam, The Netherlands.

Background: Prediction of survival chances for trauma patients is a basic requirement for evaluation of trauma care. The current methods are the Trauma and Injury Severity Score (TRISS) and A Severity Characterization of Trauma (ASCOT). Scales for scoring injury severity are part of these methods. This study compared three injury scales, the Injury Severity Score (ISS), the New ISS (NISS), and the Anatomic Profile (AP), in three otherwise identical predictive models.

Methods: Records of the Rotterdam Trauma Center were analyzed using logistic regression. The variables used in the models were age (as a linear variable), the corrected Revised Trauma Score (RTS), a denominator for blunt or penetrating trauma, and one of the three injury scales. The original TRISS and ASCOT models also were evaluated. The resulting models were compared in terms of their discriminative power, as indicated by the receiver-operator characteristic (ROC), and calibration (Hosmer-Lemeshow [HL]) for the entire range of injury severity.

Results: For this study, 1,102 patients, with an average ISS of 15, met the inclusion criteria. The TRISS and ASCOT models, using original coefficients, showed excellent discriminative power (ROC, 0.94 and 0.96, respectively), but insufficient fits (HL, p = 0.001 and p = 0.03, respectively). The three fitted models also had excellent discriminative abilities (ROC, 0.95, 0.97, and 0.96, respectively). The custom ISS model was unable to fit the entire range of survival chances sufficiently (p = 0.01). Models using the NISS and AP scales provided adequate fits to the actual survival chances of the population (HL, 0.32 and 0.12, respectively).

Conclusions: The AP and NISS scores particularly both managed to outperform the ISS score in correctly predicting survival chances among a Dutch trauma population. Trauma registries stratifying injuries by the ISS score should evaluate the use of the NISS and AP scores.
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http://dx.doi.org/10.1097/01.ta.0000152551.39400.6fDOI Listing
March 2005
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