Cross-validation of two prognostic trauma scores in severely injured patients

Introduction Trauma scoring systems are important tools for outcome prediction and severity adjustment that informs trauma quality assessment and research. Discrimination and precision of such systems is tested in validation studies. The German TraumaRegister DGU® (TR-DGU) and the Trauma Audit and Research Network (TARN) from the UK agreed on a cross-validation study to validate their prediction scores (RISC II and PS14, respectively). Methods Severe trauma patients with an Injury Severity Score (ISS) ≥ 9 documented in 2015 and 2016 were selected in both registries (primary admissions only). The predictive scores from each registry were applied to the selected data sets. Observed and predicted mortality were compared to assess precision; area under the receiver operating characteristic curve was used for discrimination. Hosmer–Lemeshow statistic was calculated for calibration. A subgroup analysis including patients treated in intensive care unit (ICU) was also carried out. Results From TR-DGU, 40,638 patients were included (mortality 11.7%). The RISC II predicted mortality was 11.2%, while PS14 predicted 16.9% mortality. From TARN, 64,622 patients were included (mortality 9.7%). PS14 predicted 10.6% mortality, while RISC II predicted 17.7%. Despite the identical cutoff of ISS ≥ 9, patient groups from both registries showed considerable difference in need for intensive care (88% versus 18%). Subgroup analysis of patients treated on ICU showed nearly identical values for observed and predicted mortality using RISC II. Discussion Each score performed well within its respective registry, but when applied to the other registry a decrease in performance was observed. Part of this loss of performance could be explained by different development data sets: the RISC II is mainly based on patients treated in an ICU, while the PS14 includes cases mainly cared for outside ICU with more moderate injury severity. This is according to the respective inclusion criteria of the two registries. Conclusion External validations of prediction models between registries are needed, but may show that prediction models are not fully transferable to other health-care settings

Performance of the Hull Salford Cambridge Decision Rule (HSC DR) for early discharge of patients with findings on CT scan of the brain : a CENTER-TBI validation study

Background: There is international variation in hospital admission practices for patients with mild traumatic brain injury (TBI) and injuries on CT scan. Only a small proportion of patients require neurosurgical intervention, while many guidelines recommend routine admission of all patients. We aim to validate the Hull Salford Cambridge Decision Rule (HSC DR) and the Brain Injury Guidelines (BIG) criteria to select low-risk patients for discharge from the emergency department. Method: A cohort from 18 countries of Glasgow Coma Scale 13–15 patients with injuries on CT imaging was identified from the multicentre Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Study (conducted from 2014 to 2017) for secondary analysis. A composite outcome measure encompassing need for ongoing hospital admission was used, including seizure activity, death, intubation, neurosurgical intervention and neurological deterioration. We assessed the performance of our previously derived prognostic model, the HSC DR and the BIG criteria at predicting deterioration in this validation cohort. Results: Among 1047 patients meeting the inclusion criteria, 267 (26%) deteriorated. Our prognostic model achieved a C-statistic of 0.81 (95% CI: 0.78 to 0.84). The HSC DR achieved a sensitivity of 100% (95% CI: 97% to 100%) and specificity of only 4.7% (95% CI: 3.3% to 6.5%) for deterioration. Using the BIG criteria for discharge from the ED achieved a higher specificity (13.3%, 95% CI: 10.9% to 16.1%) and lower sensitivity (94.6%, 95% CI: 90.5% to 97%), with 12/105 patients recommended for discharge subsequently deteriorating, compared with 0/34 with the HSC DR. Conclusion: Our decision rule would have allowed 3.5% of patients to be discharged, none of whom would have deteriorated. Use of the BIG criteria may select patients for discharge who have too high a risk of subsequent deterioration to be used clinically. Further validation and implementation studies are required to support use in clinical practice

Second-line agents in myositis: 1-year factorial trial of additional immunosuppression in patients who have partially responded to steroids.

Ciclosporin and MTX are used in idiopathic inflammatory myopathies (DM and PM) when patients incompletely respond to glucocorticoids. Their effectiveness is unproved in randomized controlled trials (RCTs). We evaluated their benefits in a placebo-controlled factorial RCT

Comparison of Mortality Following Hospitalisation for Isolated Head Injury in England and Wales, and Victoria, Australia

BACKGROUND: Traumatic brain injury (TBI) remains a leading cause of death and disability. The National Institute for Health and Clinical Excellence (NICE) guidelines recommend transfer of severe TBI cases to neurosurgical centres, irrespective of the need for neurosurgery. This observational study investigated the risk-adjusted mortality of isolated TBI admissions in England/Wales, and Victoria, Australia, and the impact of neurosurgical centre management on outcomes. METHODS: Isolated TBI admissions (>15 years, July 2005-June 2006) were extracted from the hospital discharge datasets for both jurisdictions. Severe isolated TBI (AIS severity >3) admissions were provided by the Trauma Audit and Research Network (TARN) and Victorian State Trauma Registry (VSTR) for England/Wales, and Victoria, respectively. Multivariable logistic regression was used to compare risk-adjusted mortality between jurisdictions. FINDINGS: Mortality was 12% (749/6256) in England/Wales and 9% (91/1048) in Victoria for isolated TBI admissions. Adjusted odds of death in England/Wales were higher compared to Victoria overall (OR 2.0, 95% CI: 1.6, 2.5), and for cases <65 years (OR 2.36, 95% CI: 1.51, 3.69). For severe TBI, mortality was 23% (133/575) for TARN and 20% (68/346) for VSTR, with 72% of TARN and 86% of VSTR cases managed at a neurosurgical centre. The adjusted mortality odds for severe TBI cases in TARN were higher compared to the VSTR (OR 1.45, 95% CI: 0.96, 2.19), but particularly for cases <65 years (OR 2.04, 95% CI: 1.07, 3.90). Neurosurgical centre management modified the effect overall (OR 1.12, 95% CI: 0.73, 1.74) and for cases <65 years (OR 1.53, 95% CI: 0.77, 3.03). CONCLUSION: The risk-adjusted odds of mortality for all isolated TBI admissions, and severe TBI cases, were higher in England/Wales when compared to Victoria. The lower percentage of cases managed at neurosurgical centres in England and Wales was an explanatory factor, supporting the changes made to the NICE guidelines

Evaluating the impact of cycle helmet use on severe traumatic brain injury and death in a national cohort of over 11000 pedal cyclists : a retrospective study from the NHS England trauma audit and research network dataset

Objectives In the last 10 years there has been a significant increase in cycle traffic in the UK, with an associated increase in the overall number of cycling injuries. Despite this, and the significant media, political and public health debate into this issue, there remains an absence of studies from the UK assessing the impact of helmet use on rates of serious injury presenting to the National Health Service (NHS) in cyclists. Setting The NHS England Trauma Audit and Research Network (TARN) Database was interrogated to identify all adult (≥16 years) patients presenting to hospital with cycling-related major injuries, during a period from 14 March 2012 to 30 September 2017 (the last date for which a validated dataset was available). Participants 11 patients met inclusion criteria. Data on the use of cycling helmets were available in 6621 patients. Outcome measures TARN injury descriptors were used to compare patterns of injury, care and mortality in helmeted versus non-helmeted cohorts. Results Data on cycle helmet use were available for 6621 of the 11 192 cycle-related injuries entered onto the TARN Database in the 66 months of this study (93 excluded as not pedal cyclists). There was a significantly higher crude 30-day mortality in un-helmeted cyclists 5.6% (4.8%–6.6%) versus helmeted cyclists 1.8% (1.4%–2.2%) (p<0.001). Cycle helmet use was also associated with a reduction in severe traumatic brain injury (TBI) 19.1% (780, 18.0%–20.4%) versus 47.6% (1211, 45.6%–49.5%) (p<0.001), intensive care unit requirement 19.6% (797, 18.4%–20.8%) versus 27.1% (691, 25.4%–28.9%) (p<0.001) and neurosurgical intervention 2.5% (103, 2.1%–3.1%) versus 8.5% (217, 7.5%–9.7%) (p<0.001). There was a statistically significant increase in chest, spinal, upper and lower limb injury in the helmeted group in comparison to the un-helmeted group (all p<0.001), though in a subsequent analysis of these anatomical injury patterns, those cyclists wearing helmets were still found to have lower rates of TBI. In reviewing TARN injury codes for specific TBI and facial injuries, there was a highly significant decrease in rates of impact injury between cyclists wearing helmets and those not. Conclusions This study suggests that there is a significant correlation between use of cycle helmets and reduction in adjusted mortality and morbidity associated with TBI and facial injury

Acute lower limb compartment syndrome after Cesarean section: a case report

Abstract: Introduction Acute compartment syndrome of the lower limb is a rare but severe intra- and post-partum complication. Prompt diagnosis is essential to avoid permanent functional restriction or even the loss of the affected limb. Clinical signs and symptoms might be nonspecific, especially in the early stages; therefore, knowledge of predisposing risk factors can be helpful. Case presentation We present the case of a 32-year-old Caucasian woman with acute post-partum compartment syndrome. Conclusion: Acute compartment syndrome is an important differential diagnosis for the sudden onset of intra- or post-partum lower-limb pain. Predisposing factors for the manifestation of acute compartment syndrome in an obstetric environment are augmented intra-partum blood loss, prolonged hypotensive episodes and the use of oxytocin to support or induce labor because of its vasoconstrictive properties. Treatment is prompt surgical decompression by performing fasciotomy in any affected muscular compartments

Impact of an injury hospital admission on childhood academic performance: a Welsh population-based data linkage study

Background While injuries can impact on children’s educational achievements (with threats to their development and employment prospects), these risks are poorly quantified. This population-based longitudinal study investigated the impact of an injury-related hospital admission on Welsh children’s academic performance. Methods The Secure Anonymised Information Linkage databank, 55 587 children residing in Wales from 2006 to 2016 who had an injury hospital admission (58.2% males; 16.8% born in most deprived Wales area; 80.1% one injury hospital admission) were linked to data from the Wales Electronic Cohort for Children. The primary outcome was the Core Subject Indicator reflecting educational achievement at key stages 2 (school years 3–6), 3 (school years 7–9) and 4 (school years 10–11). Covariates in models included demographic, birth, injury and school characteristics. Results Educational achievement of children was negatively associated with: pedestrian injuries (adjusted risk ratio, (95% CIs)) (0.87, (0.83 to 0.92)), cyclist (0.96, (0.94 to 0.99)), high fall (0.96, (0.94 to 0.97)), fire/flames/smoke (0.85, (0.73 to 0.99)), cutting/piercing object (0.96, (0.93 to 0.99)), intentional self-harm (0.86, (0.82 to 0.91)), minor traumatic brain injury (0.92, (0.86 to 0.99)), contusion/open wound (0.93, (0.91 to 0.95)), fracture of vertebral column (0.78, (0.64 to 0.95)), fracture of femur (0.88, (0.84 to 0.93)), internal abdomen/pelvic haemorrhage (0.82, (0.69 to 0.97)), superficial injury (0.94, (0.92 to 0.97)), young maternal age (<18 years: 0.91, (0.88 to 0.94); 19–24 years: 0.94, (0.93 to 0.96)); area based socioeconomic status (0.98, (0.97 to 0.98)); moving to a more deprived area (0.95, (0.93 to 0.97)); requiring special educational needs (0.46, (0.44 to 0.47)). Positive associations were: being female (1.04, (1.03 to 1.06)); larger pupil school sizes and maternal age 30+ years. Conclusion This study highlights the importance on a child’s education of preventing injuries and implementing intervention programmes that support injured children. Greater attention is needed on equity-focused educational support and social policies addressing needs of children at risk of underachievement, including those from families experiencing poverty

Low-value clinical practices in injury care: a scoping review and expert consultation survey

BACKGROUND: Tests and treatments that are not supported by evidence and could expose patients to unnecessary harm, referred to here as low-value clinical practices, consume up to 30% of healthcare resources. Choosing Wisely and other organisations have published lists of clinical practices to be avoided. However, few apply to injury and most are based uniquely on expert consensus. We aimed to identify low-value clinical practices in acute injury care. METHODS: We conducted a scoping review targeting articles, reviews and guidelines that identified low-value clinical practices specific to injury populations. Thirty-six experts rated clinical practices on a 5-point Likert scale from clearly low-value to clearly beneficial. Clinical practices reported as low-value by at least one level I, II or III study and considered clearly or potentially low-value by at least 75% of experts were retained as candidates for low-value injury care. RESULTS: Of 50,695 citations, 815 studies were included and led to the identification of 150 clinical practices. Of these 63 were considered candidates for low-value injury care; 33 in the emergency room, 9 in trauma surgery, 15 in the intensive care unit and 5 in orthopaedics. We also identified 87 'grey zone' practices, which did not meet our criteria for low-value care. CONCLUSIONS: We identified 63 low-value clinical practices in acute injury care that are supported by empirical evidence and expert opinion. Conditional on future research, they represent potential targets for guidelines, overuse metrics and de-implementation interventions. We also identified 87 'grey zone' practices, which may be interesting targets for value-based decision-making. Our study represents an important step towards the de-implementation of low-value clinical practices in injury care. LEVEL OF EVIDENCE: III

Epidemiology and predictors of spinal injury in adult major trauma patients: European cohort study

This is a European cohort study on predictors of spinal injury in adult (≥16 years) major trauma patients, using prospectively collected data of the Trauma Audit and Research Network from 1988 to 2009. Predictors for spinal fractures/dislocations or spinal cord injury were determined using univariate and multivariate logistic regression analysis. 250,584 patients were analysed. 24,000 patients (9.6%) sustained spinal fractures/dislocations alone and 4,489 (1.8%) sustained spinal cord injury with or without fractures/dislocations. Spinal injury patients had a median age of 44.5 years (IQR = 28.8–64.0) and Injury Severity Score of 9 (IQR = 4–17). 64.9% were male. 45% of patients suffered associated injuries to other body regions. Age <45 years (≥45 years OR 0.83–0.94), Glasgow Coma Score (GCS) 3–8 (OR 1.10, 95% CI 1.02–1.19), falls >2 m (OR 4.17, 95% CI 3.98–4.37), sports injuries (OR 2.79, 95% CI 2.41–3.23) and road traffic collisions (RTCs) (OR 1.91, 95% CI 1.83–2.00) were predictors for spinal fractures/dislocations. Age <45 years (≥45 years OR 0.78–0.90), male gender (female OR 0.78, 95% CI 0.72–0.85), GCS <15 (OR 1.36–1.93), associated chest injury (OR 1.10, 95% CI 1.01–1.20), sports injuries (OR 3.98, 95% CI 3.04–5.21), falls >2 m (OR 3.60, 95% CI 3.21–4.04), RTCs (OR 2.20, 95% CI 1.96–2.46) and shooting (OR 1.91, 95% CI 1.21–3.00) were predictors for spinal cord injury. Multilevel injury was found in 10.4% of fractures/dislocations and in 1.3% of cord injury patients. As spinal trauma occurred in >10% of major trauma patients, aggressive evaluation of the spine is warranted, especially, in males, patients <45 years, with a GCS <15, concomitant chest injury and/or dangerous injury mechanisms (falls >2 m, sports injuries, RTCs and shooting). Diagnostic imaging of the whole spine and a diligent search for associated injuries are substantial

Characterisation of 22446 patients attending UK emergency departments with suspected COVID-19 infection : observational cohort study

Background Hospital emergency departments play a crucial role in the initial management of suspected COVID-19 infection. We aimed to characterise patients attending emergency departments with suspected COVID-19, including subgroups based on sex, ethnicity and COVID-19 test results. Methods We undertook a mixed prospective and retrospective observational cohort study in 70 emergency departments across the United Kingdom (UK). We collected presenting data from 22446 people attending with suspected COVID-19 between 26 March 2020 and 28 May 2020. Outcomes were admission to hospital, COVID-19 result, organ support (respiratory, cardiovascular or renal), and death, by record review at 30 days. Results Adults were acutely unwell (median NEWS2 score 4) and had high rates of admission (67.1%), COVID-19 positivity (31.2%), organ support (9.8%) and death (15.9%). Children had much lower rates of admission (27.4%), COVID-19 positivity (1.2%), organ support (1.4%) and death (0.3%). Adult men and women presented in similar numbers (10210 versus 10506), but men were more likely to be admitted (72.9% v 61.4%), require organ support (12.2% v 7.7%) and die (18.7% v 13.3%). Black or Asian adults tended to be younger than White adults (median age 54, 50 and 67 years), were less likely to be admitted (60.8%, 57.3%, 69.6%) or die (11.9%, 11.2%, 16.8%), but were more likely to require organ support (15.9%, 14.3%, 8.9%) or have a positive COVID-19 test (40.8%, 42.1%, 30.0%). Adults admitted with confirmed COVID-19 had similar age and comorbidities (except chronic lung disease) to those who did not have COVID-19 confirmed, but were much more likely to need organ support (22.2% v 8.9%) or die (32.7% v 15.9%). Conclusions Important differences exist between patient groups presenting to the emergency department with suspected COVID-19. People with confirmed COVID-19 have a poor prognosis, compared with similar emergency admissions without confirmed COVID-19