Pre-hospital rescue times and interventions in severe trauma in Germany and the Netherlands:a matched-pairs analysis

Purpose The aim of this study was to compare the pre-hospital treatment of major trauma patients with similar injury patterns in Germany and the Netherlands. Patients and methods This matched-pairs analysis is based on the TraumaRegister DGU (R). The authors compared major trauma patients (ISS >= 16) from 2009 to 2015 treated in Dutch and German Level 1 trauma centers (TC). Endpoints were the pre-hospital times and interventions performed until hospital admission. Additional endpoints included hospital mortality, 24-h mortality and standardized mortality ratio (SMR) which was calculated using the Revised Injury Severity Classification, version II (RISC II). Patients were matched by age, gender, injury pattern, vital status on-scene and involvement into a traffic accident. Three subgroups were formed according to the mode of transportation and level of care provided during transport: Ambulance/Physician, Helicopter/Physician and Ambulance/Emergency Medical Technician. Results Patients were matched into 1094 pairs. German patients arrived at the TC after a mean pre-hospital time of 65.6 (+/- 29.6) min while Dutch patients arrived after 61.4 (+/- 28.7) min. Pre-hospital intubation rate was slightly higher in the Netherlands (44.1% GER vs 50.5% NL). Chest tubes were placed in 3.0% of German patients and 8.3% of Dutch patients. 63.5% of the German patients received analgesia/sedation which was below the rate of Dutch patients (71.1%). The hospital mortality was for 17.6% for German patients and 19.8% for Dutch patients. The SMR was about 1.0 for both groups. Conclusion Multiple differences and some similarities in the treatment of major trauma patients with similar injury patterns were found but no clinically relevant differences in the chosen outcome parameters could be observed

Pre-hospital rescue times and actions in severe trauma. A comparison between two trauma systems:Germany and the Netherlands

Introduction: The aim of this study was to compare the effect of national pre-hospital rescue strategies on the status of severely injured patients at the time of admission to a Trauma Center (TC) in Germany or the Netherlands. Patients and methods: This retrospective database analysis based on the TraumaRegister DGU (R) (TR-DGU) of the German Trauma Society compares the pre-hospital trauma system of Germany with three Trauma Centers (TCs) from the Netherlands. It comprises trauma patients from 2009 to 2012 admitted to a Level I TC, all patients aged 16-80 years primarily admitted with an ISS >= 16 and data available for mode of transport, pre-hospital measures and total pre-hospital time. Additionally three subgroups were formed by mode of transportation and involved personnel: Ambulance/Physician, Helicopter/Physician, Ambulance/EMT. Primary endpoint is the patient's status at the time of admission to the trauma room. Secondary endpoint is hospital mortality. Results: A total of 12,168 patients met the inclusion criteria. Major differences in the injury patterns, pre-hospital rescue time, transport strategy and actions are documented. The mean ISS in the German overall group was 28.6 +/- 12.2 compared to 27.4 +/- 12.8 in the Dutch overall group. In the subgroups the highest injury severity with 29.8 +/- 12.7 for German patients and 31.0 +/- 14.6 for Dutch patients was found in the Helicopter/Physician subgroups and the lowest in patients transported by ambulance under emergency medical technician (EMT) care i.e. 24.2 +/- 8.9 for German patients and 23.6 +/- 10.3 for Dutch patients. The mean total pre-hospital time for patients admitted to Dutch TCs of 53.8 +/- 28.7 min was 15.1 min shorter than for patients transported to German TCs 68.7 +/- 28.6 min. The overall mean pre-hospital volume replacement of 1103 +/- 821 ml for German patients was about twice as high as for Dutch patients (541 +/- 700 ml). In physician led subgroups in the Netherlands higher rates of intubation, catecholamine administration and chest tubes are recorded. The basic vital signs from on-scene to hospital admission did not show relevant changes. Additional parameters available in the trauma room revealed a lower mean Base Excess (BE) for Dutch patients and a diminished mean prothrombin ratio for German patients. No reliable evidence was found that differences in the mortality analysis resulted from different national pre-hospital strategy. Conclusions: Many differences in the national pre-hospital strategy were demonstrated but the effect on patient's status at the time of admission to trauma room remains unclear. A follow-up study, which mitigates the now known injury patterns has to be initiated to further substantiate the findings of this study. (C) 2014 Elsevier Ltd. All rights reserved

The golden hour of shock how time is running out: prehospital time intervals in Germany-a multivariate analysis of 15, 103 patients from the TraumaRegister DGU (R)

Objectives Although prehospital treatment algorithms have changed over the past years, the prehospital time of multiple trauma patients of some 70 min and the on-scene-treatment time (OST) of some 30 min have not changed since 1993. The aim of this study was to critically assess specific interventions and conditions at the scene in relation to their impact on prehospital rescue intervals. Methods We performed a retrospective data analysis of all multiple injured patients from the TraumaRegister DGU (English: German Trauma Society) from January 1993 to December 2010. Exclusion criteria were missing or implausible data regarding prehospital timelines. With OST as an independent variable, different models of multivariate regression were performed to identify parameters with relevant impact on the OST. Results 15 103 datasets were included in this study. Based on the mean OST of 32.7 (+/-18.6) min and a constant absolute term of 16.2 (+/-1.5) min, we identified seven procedures and nine environmental parameters with significant impact on OST. Intubation (9.3+/-0.8 min) and being a car occupant (8.0+/-0.8 min) were associated with the most prolonged OSTs. A Glasgow Coma Scale <= 8 (-4.5+/-0.7 min) and cardiopulmonary resuscitation (-2.8+/-1.7 min) resulted in its most relevant reduction. Admission to a Level III facility led to a reduced overall prehospital time (60.0+/-24.6 min) compared with Level 1 (70.0+/-28.5 min) and II (66.8+/-27.4 min) trauma centres. Conclusions This study identified characteristic interventions and conditions with significant impact on prehospital treatment times. Current treatment concepts should be re-evaluated with respect to these results

Dynamics and durability of HIV-1 neutralization are determined by viral replication

Human immunodeficiency virus type 1 (HIV-1)-neutralizing antibodies (nAbs) that prevent infection are the main goal of HIV vaccine discovery. But as no nAb-eliciting vaccines are yet available, only data from HIV-1 neutralizers-persons with HIV-1 who naturally develop broad and potent nAbs-can inform about the dynamics and durability of nAb responses in humans, knowledge which is crucial for the design of future HIV-1 vaccine regimens. To address this, we assessed HIV-1-neutralizing immunoglobulin G (IgG) from 2,354 persons with HIV-1 on or off antiretroviral therapy (ART). Infection with non-clade B viruses, CD4+ T cell counts <200 µl-1, being off ART and a longer time off ART were independent predictors of a more potent and broad neutralization. In longitudinal analyses, we found nAb half-lives of 9.3 and 16.9 years in individuals with no- or low-level viremia, respectively, and 4.0 years in persons who newly initiated ART. Finally, in a potent HIV-1 neutralizer, we identified lower fractions of serum nAbs and of nAb-encoding memory B cells after ART initiation, suggesting that a decreasing neutralizing serum activity after antigen withdrawal is due to lower levels of nAbs. These results collectively show that HIV-1-neutralizing responses can persist for several years, even at low antigen levels, suggesting that an HIV-1 vaccine may elicit a durable nAb response