Alcohol consumption, blood alcohol concentration level and guideline compliance in hospital referred patients with minimal, mild and moderate head injuries

<p>Abstract</p> <p>Background</p> <p>In 2000 the Scandinavian Neurotrauma Committee published guidelines for safe and cost-effective management of minimal, mild and moderate head injured patients.</p> <p>The aims of this study were to investigate to what extent the head injury population is under the influence of alcohol, and to evaluate whether the physicians' compliance to the guidelines is affected when patients are influenced by alcohol.</p> <p>Methods</p> <p>This study included adult patients (≥15 years) referred to a Norwegian University Hospital with minimal, mild and moderate head injuries classified according to the Head Injury Severity Scale (HISS). Information on alcohol consumption was recorded, and in most of these patients blood alcohol concentration (BAC) was measured. Compliance with the abovementioned guidelines was registered.</p> <p>Results</p> <p>The study includes 860 patients. 35.8% of the patients had consumed alcohol, and 92.1% of these patients had a BAC ≥ 1.00‰. Young age, male gender, trauma occurring during the weekends, mild and moderate head injuries were independent factors significantly associated with being under the influence of alcohol. Guideline compliance was 60.5%, and over-triage was the main violation. The guideline compliance showed no significant correlation to alcohol consumption or to BAC-level.</p> <p>Conclusions</p> <p>This study confirms that alcohol consumption is common among patients with head injuries. The physicians' guideline compliance was not affected by the patients' alcohol consumption, and alcohol influence could therefore not explain the low guideline compliance.</p

An observational study of compliance with the Scandinavian guidelines for management of minimal, mild and moderate head injury

<p>Abstract</p> <p>Background</p> <p>The Scandinavian guidelines for management of minimal, mild and moderate head injuries were developed to provide safe and cost effective assessment of head injured patients. In a previous study conducted one year after publication and implementation of the guidelines (2003), we showed low compliance, involving over-triage with computed tomography (CT) and hospital admissions. The aim of the present study was to investigate guideline compliance after an educational intervention.</p> <p>Methods</p> <p>We evaluated guideline compliance in the management of head injured patients referred to the University Hospital of Stavanger, Norway. The findings from the previous study in 2003 were communicated to the hospitals physicians, and a feed-back loop training program for guideline implementation was conducted. All patients managed during the months January through June in the years 2005, 2007 and 2009 were then identified with an electronic search in the hospitals patient administrative database, and the patient files were reviewed. Patients were classified according to the Head Injury Severity Scale, and the management was classified as compliant or not with the guideline.</p> <p>Results</p> <p>The 1 180 patients were 759 (64%) males and 421 (36%) females with a mean age of 31.5 (range 0-97) years. Over all, 738 (63%) patients were managed in accordance with the guidelines and 442 (37%) were not. Compliance was not significantly different between minimal (56%) and mild (59%) injuries, while most moderate (93%) injuries were managed in accordance with the guidelines (p < 0.05). Noncompliance was caused by overtriage in 362 cases (30%) and undertriage in 80 (7%). Guideline compliance was 54% in 2005, 71% in 2007, and 64% in 2009.</p> <p>Conclusions</p> <p>This study shows higher guideline compliance after an educational intervention involving feed-back on performance. A substantial number of patients are exposed to over-triage, involving unnecessary radiation from CT examinations, and unnecessary costs from hospital admissions.</p

Vaktpostlymfeknuteoperasjon ved brystkreft

Sentinel Lymph Node Biopsy in Breast Cancer Ellen Schlichting, Marianne Efskind Harr, Torill Sauer, Almira Babovic, Rolf Kåresen Background Sentinel lymph node (SN) biopsy is a highly accurate technique for identifying axillary metastases from a primary breast carcinoma. Material and methods Between 2000 and 2005, SN biopsy was performed in 1409 patients with breast carcinoma or ductal carcinoma in situ grade 3. Peritumoral radiocolloid (60-80 MBq 99 Tc-Nanocoll) was injected the day before operation and blue dye was injected around the tumor peroperatively. Results SN was detected in 90,2% of the operations. Training of the individual surgeon influenced the detection rate. Metastases to SN were detected in 25% of the patients. Of the 319 patients with a positive SN, 51,7% had no further positive nodes in the axilla. Patients with a tumor less than 20 mm had metastases in 21,6% of the SN, while tumors larger than 20 mm were positive in 31,8% of the patients. Age below 50 years was associated with a positive SN in 35,3%, while age above 50 years reduced the incidence of positive SN to 21,9%. Mean age was 58 years. The mean tumor size was 16,6 mm. Tumors were located in the upper, outer quadrant in 59%. There were three patients with local recurrence in the axilla early in the series. Ductal carcinoma in situ grade 3 was diagnosed preoperatively in 109 patients (cytology), 88 had this diagnosis after histology (the rest had combinations with cancer or in situ lesions with another grade). Axillary metastases were found in 4.8% of these patients. Two out of 19 patients had metastases to parasternal SN. Interpretation SN biopsy has a proven valid in the staging of the axilla in patients with breast cancer and have replaced routine axillary clearance. The method should also be considered in patients with high-grade DCIS

Management and long-term outcome of type II acute odontoid fractures: a population-based consecutive series of 282 patients

BACKGROUND CONTEXT The surgical fixation rate of type II odontoid fracture (OFx) in the elderly (≥65 years) is much lower than expected if the treatment adheres to current general treatment recommendations. Outcome data after conservative treatment for elderly patients with these fractures are sparse. PURPOSE The main aim of this study was to determine the long-term outcome after conservative and surgical treatments of type II OFx (all age-groups) to evaluate whether nonoperative treatment yields an acceptable outcome. STUDY DESIGN/SETTING Retrospective study based on a prospective database. PATIENT SAMPLE Two hundred eighty-two consecutive patients with type II OFx treated at Oslo University Hospital over an 8-year period. OUTCOME MEASURES Long-term rates of bony fusion, fibrous union, pseudarthrosis, crossover from primary conservative treatment to surgical fixation, new-onset spinal cord injury (SCI), and neck pain were the outcome measures used. METHODS The present study was based on data extracted from our quality control database for acute cervical spine fractures. All ages were included. In addition, long-term follow-up of alive patients was performed during the years 2018–2019. The follow-up included neurological examination, radiological examination, and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new-onset SCI, neck pain, and Neck Disability Index (NDI score). Data are described by counts, percentages, medians, means, ranges and standard deviations where appropriate. For statistical analyses the Mann-Whitney U test, Wilcoxon signed-rank test, and t tests were used. RESULTS During the eight-year study period, we registered 282 consecutive patients with type II OFx; 54% were males, patient age ranged from 15 to 101 years, 84% were ≥65 years of age (WHO definition of elderly), and 51% were ≥80 years of age. Severe comorbidities (American Society of Anesthesiologists, ASA ≥3) were seen in 67%, whereas nonindependent living was registered in 32%. Severe comorbidities and nonindependent living were significantly associated with increasing age (p<.001). SCI secondary to the OFx was seen in 5.3%. Primary treatment of the OFx was conservative (external immobilization alone) in 193 patients (68.4%), open surgical fixation in 87 patients (30.9%), and no treatment in two critically injured patients. At the time of long-term follow-up, 125 patients had died, nine patients declined the invitation to follow-up, and five patients did not respond. Thus, 143 patients were available for follow-up with a median follow-up time of 39 months (range 5–115 months). At long-term follow-up, the fusion status was bony fusion in 39.2% of patients, fibrous union in 57.3%, and pseudarthrosis in 3.5%. The proportion of bony fusion was significantly higher in the primary surgical fixation group (p=.005). No patients had new-onset SCI presenting after the start of primary treatment. The proportion of crossover from primary external immobilization to surgery was 14.4%, whereas proportion of revision surgery in the primary surgical group was 9.5%. There was no significant difference between the primary surgical fixation group and the primary conservative treatment group at long-term follow-up with respect to the proportion of pseudarthrosis and degree of neck pain. CONCLUSIONS Primary conservative treatment of elderly patients with type II OFx appears to be safe and should be regarded a viable treatment option

Favorable prognosis with nonsurgical management of type III acute odontoid fractures: a consecutive series of 212 patients

BACKGROUND CONTEXT The recommended primary treatment for type III odontoid fractures (OFx) is external immobilization, except for patients having major displacement of the odontoid fragment. The bony fusion rate of type III OFx has been reported to be >85%. High compliance to treatment recommendations is favorable only if the treatment leads to a good outcome. PURPOSE The primary aim of this study was to determine the long-term outcome after conservative and surgical treatment of type III OFx and to reaffirm that primary external immobilization is the best treatment for most type III fractures. STUDY DESIGN/SETTING Retrospective study based on a prospective database. PATIENT SAMPLE Two hundred twelve consecutive patients with type III OFx treated at Oslo University Hospital over an 8-year period (2009–2017). OUTCOME MEASURES Long-term rates of bony fusion, crossover from primary conservative treatment to surgical fixation, new onset spinal cord injury (SCI), severe persistent neck pain (visual analogue scale - VAS), and persistent disability measured with Neck Disability index (NDI). METHODS The present study was based on data extracted from our quality control database for acute cervical spine fractures from a general population. During the years 2018 to 2019 long-term follow-up of alive patients was performed (median follow-up time was 38.0 months; range 3.0–108.0 months). The follow-up included neurological examination, radiological examination and scoring of bony fusion status, crossover from primary conservative treatment to surgical fixation, new onset SCI, neck pain, and Neck Disability Index (NDI score). RESULTS In this consecutive series of 212 patients with type III acute OFx, median patient age was 72 years, 56% had severe preinjury comorbidities (ASA score ≥3) and 22% lived dependently. Severe comorbidities and dependent living were significantly associated with increasing age (p<.001). The trauma mechanism was fall injury in 82%. The median age of patients injured by falls was significantly higher than in patients with a nonfall injury (p<.001). At the time of diagnosis, 4% had an OFx related SCI. Primary treatment was external immobilization alone in 95.3% and open surgical fixation in 4.7%. Patients treated with primary external immobilization alone presented with significantly less translation of the odontoid fragment (p<.001) and less angulation of the odontoid fragment (p=.025) than patients treated with primary surgery. Subsequent crossover to surgical fixation was performed in 5.4%. At long-term follow-up, 95.7% of patients had bony fusion of the OFx, 80.5% had minimal/no neck pain, and none developed new onset SCI. There was no significant difference in long-term follow-up VAS (p=.444) or NDI (p=.562) between the primary external immobilization group and the primary surgical group. CONCLUSION This study reaffirms that nonsurgical treatment remains the preferable option in the majority of patients with type III OFx