Trauma mechanisms and injury patterns after E-scooter related incidents since their introduction in Berlin – a prospective multicenter observational study

Mit der Einführung elektrisch angetriebener Tretroller (E-Scooter) in den deutschen Großstädten bestand aufgrund ihrer hohen Verfügbarkeit und der leichten Zugänglichkeit eine innovative Fortbewegungsmöglichkeit im urbanen Straßenverkehr. Neben ihrer schnellen Implementierung in das Stadtbild, dem Nutzen als alternatives Fortbewegungsmittel und der Fahrfreude unter den Nutzern, konnte in den Notaufnahmen eine Vielzahl neuer und zusätzlicher Verletzungen zu den bisher bekannten Rettungsstellenvorstellungen erfasst werden. Bisherige wissenschaftliche Untersuchungen zu Unfallmechanismen und spezifischen Traumafolgen waren unzureichend und beruhten meist auf retrospektiven Daten aus dem nicht-europäischen Ausland. Ziel dieser Arbeit ist die Analyse der Umstände, Ursachen sowie den Folgen der E-Scooter Unfälle und den damit einhergehenden Verletzungsmustern. So wurden alle Patienten nach E-Scooter assoziierten Unfällen mit ihrer Straßenverkehrszulassung von Juli bis Dezember 2019 an den innenstädtischen Notaufnahmen der Charité – Universitätsmedizin Berlin Campus Mitte und Campus Virchow-Klinikum, am Bundeswehrkrankenhaus Berlin und an der Evangelischen Elisabeth Klinik eingeschlossen. Die prospektive Datenerhebung beinhaltete patienten- und unfallspezifische Angaben, Informationen zu Verletzungsmustern, deren Therapie und den freiwilligen Angaben zum Gebrauch oder zu Vorerfahrungen mit E-Scootern. Innerhalb von sechs Monaten konnten 248 Patienten (129 Männer; medianes Alter 29 Jahre (Q1-Q3: 23 – 39 Jahre)) erfasst werden. Touristen waren in 41% und Kinder in 4% betroffen. Die meisten Unfälle ereigneten sich zur späten Abendzeit (22%) und am Wochenende (56%). In der Befragung besaßen 68% einen Führerschein und 48% hatten bereits Vorerfahrungen mit E-Scootern. Das multifokale Verletzungsmuster betraf insbesondere die unteren (42%) und oberen (37%) Extremitäten sowie den Kopf (40%). Alkoholisierte Fahrten stellten einen besonderen Risikofaktor für Schädel-Hirn-Traumata dar (p<0,001). Die stationäre Aufnahmerate betrug 25%, eine operative Versorgung war in 23% erforderlich. Am häufigsten traten Weichteilverletzungen (85%) sowie Frakturen der oberen Extremitäten (17%) auf. Das Balancieren des Gleichgewichts auf der schmalen Stehplattform bei hohen Geschwindigkeiten und die kleinen Räder stellen ein Risiko für frontale Stürze, ohne externe Einflüsse dar. Eine Reduktion von E-Scooter Unfällen und den damit verbundenen typischen Verletzungsmustern könnte durch technische Modifikationen der Fahrzeuge seitens der Hersteller, einem absoluten Alkoholverbot, dem Tragen von Helmen und der Durchsetzung der Nutzungsregeln mit einhergehenden Kontrollen erreicht werden.With the introduction of E-scooters in large German cities, an innovative vehicle entered the urban road traffic due to their high availability and easy accessibility. Besides their rapid implementation into the cityscape, usefulness as alternative means of transportation, and due to their driving pleasure among users, a variety of new and additional injuries could be detected in the emergency departments. However, scientific studies on accident mechanisms and trauma-specific consequences were sparse and mostly based on retrospective data from non-European countries. The aim of this investigation is the detailed analysis of the circumstances, causes as well as the consequences of the E-scooter accidents and their related injury patterns. All E-scooter-associated accidents since their road permission from July to December 2019 were included at the inner-city emergency departments of Charité - Universitätsmedizin Berlin Campus Mitte and Campus Virchow-Klinikum, Bundeswehrkrankenhaus Berlin, and Evangelische Elisabeth Klinik. Prospective data collection included patient- and accident-specific information, injury patterns, therapy, and voluntary information on E-scooter use or previous experience. A total of 248 patients (129 men; median age 29 years (Q1-Q3: 23 – 39 years)) were recorded within six months. Tourists were involved in 41% and children in 4%. Most accidents occurred at the evening (22%) and at weekends (56%). 68% reported having a driver's license, and 48% had previous experience with E-scooters. The multifocal injury pattern particularly involved the lower (42%) and upper (37%) extremities and the head (40%). Alcohol-impaired driving was a risk factor for traumatic brain injury. The inpatient admission rate was 25%, and surgery was required in 23%. Soft tissue injuries (85%) and upper extremity fractures (17%) were most common. Balancing on the narrow standing platform at high speeds and the small wheels lead to many frontal falls without external influences. A decrease of E-scooter related accidents and the associated typical injury patterns could be achieved through technical modifications to the vehicles by the manufacturers, an alcohol ban, the wearing of helmets and stricter enforcement of rules with accompanying controls

Hypothermic oxygenated machine perfusion for extended criteria donor allografts: Preliminary experience with extended organ preservation times in the setting of organ reallocation

Background: In times of critical organ shortage, poor organ pool utilization and increased use of extended-criteria donor (ECD) allografts remain a major problem. Hypothermic oxygenated machine perfusion (HOPE) has emerged as a promising and feasible strategy in ECD liver transplantation (LT). However, potential safety limits regarding the duration of perfusion are yet to be explored. Besides marginal allograft quality (steatosis), prolonged cold ischemia time remains the most important factor for a high number of liver allografts being declined for transplantation. Patients and methods: Two ECD-allografts were each allocated to two recipients, who proved to be unsuitable to receive the assigned allograft upon arrival at the transplant center. The organs were reallocated by Eurotransplant and accepted by our center for two different backup patients. During that time, HOPE was commenced and continued until the recipient hepatectomy was completed. Postoperative allograft function was assessed by serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), bilirubin, and International Normalized Ratio. Incidence of early allograft dysfunction (EAD), postoperative complications, and length of hospital stay were analyzed. Results: HOPE was applied for 4 h 35 min and 4 h 20 min, resulting in a total cold preservation time of 17 h 29 min and 15 h 20 min, respectively. Both recipients displayed decreasing serum transaminases and bilirubin levels postoperatively. No EAD or major postoperative complications occurred in either patient. Serum ALT and AST levels were within the normal range at discharge. Conclusions: Extended HOPE enables the safe extension of preservation time for up to 18 h in human LT. End-ischemic HOPE may significantly improve organ pool utilization, while simultaneously facilitating operating room logistics and preventing organ injury

How to Estimate the Probability of Tolerance Long-Term in Liver Transplant Recipients

Background: Operational tolerance as the ability to accept the liver transplant without pharmacological immunosuppression is a common phenomenon in the long-term course. However, it is currently underutilized due to a lack of simple diagnostic support and fear of rejection despite its recognized benefits. In the present work, we present a simple score based on clinical parameters to estimate the probability of tolerance. Patients and methods: In order to estimate the probability of tolerance, clinical parameters from 82 patients after LT who underwent weaning from the IS for various reasons at our transplant center were extracted from a prospectively organized database and analyzed retrospectively. Univariate testing as well as multivariable logistic regression analysis were performed to assess the association of clinical variables with tolerance in the real-world setting. Results: The most important factors associated with tolerance after multivariable logistic regression were IS monotherapy, male sex, history of hepatocellular carcinoma pretransplant, time since LT, and lack of rejection. These five predictors were retained in an approximate model that could be presented as a simple scoring system to estimate the clinical probability of tolerance or IS dispensability with good predictive performance (AUC = 0.89). Conclusion: In parallel with the existence of a tremendous need for further research on tolerance mechanisms, the presented score, after validation in a larger collective preferably in a multicenter setting, could be easily and safely applied in the real world and already now address all three levels of prevention in LT patients over the long-term course

Is There a Gender Difference in Clinical Presentation of Renal Hyperparathyroidism and Outcome after Parathyroidectomy?

Introduction: Gender has been proven to influence the pathophysiology and treatment of numerous diseases, including kidney diseases and hormonal dysfunction like hyperparathyroidism. Thus, higher parathormone levels have been demonstrated in women with end-stage kidney disease, when compared to men. Objectives: We questioned whether female gender is associated with an increased risk for parathyroid nodular hyperplasia and necessary parathyroidectomy in dialysis patients and assessed demographics as well as outcome data for women and men undergoing parathyroidectomy for renal hyperparathyroidism. Patients and Methods: One hundred and thirty patients (men = 75, female = 55) with end-stage renal disease on chronic dialysis and advanced secondary hyperparathyroidism who underwent parathyroidectomy between 2008 and 2014 at our center were analyzed retrospectively. Perioperative characteristics and short-term outcome were evaluated with respect to biological gender. Results: No differences could be demonstrated for patient demography, comorbidities and the perioperative course between males and females. Only preoperative calcium levels were lower in female than in male patients (2.3 +/- 0.19 vs. 2.3 +/- 0.26, p = 0.04). There were more women, however, with cerebrovascular complications during follow-up (p = 0.04). There was no postoperative mortality, and all complications and comorbidities with exception of cerebrovascular diseases were equally distributed between female and male patients. Conclusion: Overall, we could not demonstrate many significant differences between male and female patients with end-stage renal diseases, chronic dialysis and operated secondary hyperparathyroidism. Only preoperative electrolyte levels were higher in male than in female patients, and cerebrovascular complications developed more often in females than in males during long-term follow-up

A Reduction of Calcineurin Inhibitors May Improve Survival in Patients with De Novo Colorectal Cancer after Liver Transplantation

Background and Objectives: After liver transplantation (LT), long-term immunosuppression (IS) is essential. IS is associated with de novo malignancies, and the incidence of colorectal cancer (CRC) is increased in LT patients. We assessed course of disease in patients with de novo CRC after LT with focus of IS and impact on survival in a retrospective, single-center study. Materials and&nbsp;Methods: All patients diagnosed with CRC after LT between 1988 and 2019 were included. The management of IS regimen following diagnosis and the oncological treatment approach were analyzed: Kaplan&ndash;Meier analysis as well as univariate and multivariate analysis were performed. Results: A total of 33 out of 2744 patients were diagnosed with CRC after LT. Two groups were identified: patients with restrictive IS management undergoing dose reduction (RIM group, n = 20) and those with unaltered regimen (maintenance group, n = 13). The groups did not differ in clinical and oncological characteristics. Statistically significant improved survival was found in Kaplan&ndash;Meier analysis for patients in the RIM group with 83.46 (8.4&ndash;193.1) months in RIM and 24.8 (0.5&ndash;298.9) months in the maintenance group (log rank = 0.02) and showed a trend in multivariate cox regression (p = 0.054, HR = 14.3, CI = 0.96&ndash;213.67). Conclusions: Immunosuppressive therapy should be reduced further in patients suffering from CRC after LT in an individualized manner to enable optimal oncological therapy and enable improved survival

The Role of Immunosuppression for Recurrent Cholangiocellular Carcinoma after Liver Transplantation

Liver transplantation (LT) for cholangiocarcinoma (CCA), or biliary tract cancer (BTC), remains controversial regarding high recurrence rates and poor prognosis. Oncological follow-up may benefit from tumor-inhibiting properties of mTOR inhibitors (mTORI), shown with improved survival for recurrent hepatocellular carcinoma (HCC) patients after LT. The aim of this study was to investigate the recurrence and survival in relation to tumor type and type of immunosuppression (IS). LT patients with CCA or mixed HCC/CCA (mHCC/CCA) (n = 67) were retrospectively analyzed. Endpoints were the time from LT to recurrence (n = 44) and survival after recurrence. Statistically significant impairment in survival for recurrent CCA (rCCA) was shown in patients not eligible for surgical resection (HR 2.46 (CI: 1.2&ndash;5.1; p = 0.02). Histological proven grading &gt;1 and N1 status at initial transplantation were associated with impaired survival (HR 0.13 (CI: 0.03&ndash;0.58); p &lt; 0.01 and HR 3.4 (CI: 1.0&ndash;11.65); p = 0.05). Reduced IS after tumor recurrence improved survival (HR 4.2/CI: 1.3&ndash;13.6; p = 0.02). MTORI initiation before recurrence or after had no significant impact on survival. Our data thereby indicate, similar to findings in recurrent HCC after LT, that patients with rCCA after LT benefit from a reduction in IS upon recurrence

Reducing Immunosuppression in Patients with De Novo Lung Carcinoma after Liver Transplantation Could Significantly Prolong Survival

(1) Background: Liver transplantation (LT) is an established treatment for selected patients with end-stage liver disease resulting in a subsequent need for long-term immunosuppressive therapy. With cumulative exposure to immunosuppression (IS), the risk for the development of de novo lung carcinoma increases. Due to limited therapy options and prognosis after diagnosis of lung cancer, the question of the mode and extent of IS in this particular situation is raised. (2) Methods: All patients diagnosed with de novo lung cancer in the follow-up after LT were identified from the institution&rsquo;s register of liver allograft recipients (Charit&eacute;&mdash;Universit&auml;tsmedizin Berlin, Germany) transplanted between 1988 and 2021. Survival analysis was performed based on the IS therapy following diagnosis of lung cancer and the oncological treatment approach. (3) Results: Among 3207 adult LTs performed in 2644 patients at our institution, 62 patients (2.3%) developed de novo lung carcinoma following LT. Lung cancer was diagnosed at a median interval of 9.7 years after LT (range 0.7&ndash;27.0 years). Median survival after diagnosis of lung carcinoma was 13.2 months (range 0&ndash;196 months). Surgical approach with curative intent significantly prolonged survival rates compared to palliative treatment (median 67.4 months vs. 6.4 months). Reduction of IS facilitated a significant improvement in survival (median 38.6 months vs. 6.7 months). In six patients (9.7%) complete IS weaning was achieved with unimpaired liver allograft function. (4) Conclusion: Reduction of IS therapy after the diagnosis of de novo lung cancer in LT patients is associated with prolonged survival. The risk of acute rejection does not appear to be increased with restrictive IS management. Therefore, strict reduction of IS should be an early intervention following diagnosis. In addition, surgical resection should be attempted, if technically feasible and oncologically meaningful

Body composition is associated with disease aetiology and prognosis in patients undergoing resection of intrahepatic cholangiocarcinoma

Abstract Background Body composition alterations are frequent in patients with cancer or chronic liver disease, but their prognostic value remains unclear in many cancer entities. Objective We investigated the impact of disease aetiology and body composition after surgery for intrahepatic cholangiocarcinoma (iCCA), a rare and understudied cancer entity in European and North American cohorts. Methods Computer tomography‐based assessment of body composition at the level of the third lumbar vertebra was performed in 173 patients undergoing curative‐intent liver resection for iCCA at the Department of Surgery, Charité – Universitätsmedizin Berlin. Muscle mass and ‐composition as well as subcutaneous and visceral adipose tissue quantity were determined semi‐automatically. (Secondary) sarcopenia, sarcopenic obesity, myosteatosis, visceral and subcutaneous obesity were correlated to clinicopathological data. Results Sarcopenia was associated with post‐operative morbidity (intraoperative transfusions [p = 0.027], Clavien–Dindo ≥ IIIb complications [p = 0.030], post‐operative comprehensive complication index, CCI [p  65, fresh frozen plasma transfusions) as independently prognostic for overall survival. Conclusion This study evidenced a high prevalence of MAFLD in iCCA, suggesting its potential contribution to disease aetiology. Alterations of muscle mass and adipose tissue were more frequent in patients with MAFLD