Amy C. Gunning

Operative or conservative treatment in patients with Rockwood type III acromioclavicular dislocation: a systematic review and update of current literature

PurposeDespite previous studies the management of Rockwood type III acromioclavicular (AC) dislocations remains controversial and the debate continues about whether patients with Rockwood type III AC injuries should be treated conservatively or operatively. In this study, we will review the current literature and present an overview of the outcome of conservative versus operative treatment of Rockwood type III dislocations.MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was used to conduct this review. A systematic search was performed in the Pubmed, Cochrane library, Embase, Scopus and Cumulative Index to Nursing and Allied Health Literature databases. Titles and abstracts were screened using predefined criteria and articles were critically appraised on relevance and validity.ResultsAfter critical appraisal eight articles were included in the study. The objective and subjective shoulder function outcome was better in the operative group, especially in young adults, though the rate of complications and radiographic abnormalities were higher. The rehabilitation time was shorter in the conservative group, however the cosmetic outcome was worse.ConclusionsThis review showed no conclusive evidence for the treatment of Rockwood type III AC dislocations. Overall, physically active young adults seem to have a slight advantage in outcome when treated operatively.

Applicability of the predictors of the historical trauma score in the present Dutch trauma population: Modelling the TRISS predictors

BACKGROUND The extensively used trauma scores to evaluate trauma center performances have been derived decades ago. This leaves its applicability in the current trauma population a subject of discussion. In this study, we evaluate the applicability of the current trauma scores in today’s trauma population. METHODS This study was performed in the central trauma region (Utrecht) of the Netherlands. Data from all admitted trauma patients were collected and split according to trauma mechanism, that is, blunt or penetrating trauma. The number of events in the penetrating trauma population was too small to derive or validate a model. We have validated the original predictors and their coefficients (i.e., Revised Trauma Score [RTS], Injury Severity Score [ISS] and age index) in a regional trauma population and derived a new model in a Level I trauma population. The model was checked for its quality and internally validated using bootstrapping methods. RESULTS Regional data set included 10,235 patients, 9,903 (96.8%) of whom with blunt and 332 (3.2%) with penetrating trauma. Level I data set included 4,649 patients, of whom 4,373 (94.1%) with blunt and 276 (5.9%) with penetrating trauma. In the regional data set, the external validation showed an R2 of 0.293, a good fit (p = 0.168), and an area under the curve of 0.851. The new model in the Level I data set resulted in Glasgow Coma Scale (GCS) score, ISS, age index, and systolic blood pressure (SBP) in the model (R2 = 0.516; a good fit test, p = 0.104; and AUC, 0.939). The Wald test of the SBP in this model was 6.46. CONCLUSION We conclude that the current trauma predictors are applicable in a regional mixed trauma population, but not in a Level I trauma population. The physiologic parameters, SBP and RR, must be excluded from the current model, and new coefficients should be calculated to maintain accurate predictions in a Level I trauma population. LEVEL OF EVIDENCE Prognostic study, level III.

Accuracy of prehospital triage protocols in selecting severely injured patients : A systematic review

BACKGROUND Prehospital trauma triage ensures proper transport of patients at risk of severe injury to hospitals with an appropriate corresponding level of trauma care. Incorrect triage results in undertriage and overtriage. The American College of Surgeons Committee on Trauma recommends an undertriage rate below 5% and an overtriage rate below 50% for prehospital trauma triage protocols. To find the most accurate prehospital trauma triage protocol, a clear overview of all currently available protocols and corresponding outcomes is necessary. OBJECTIVES The aim of this systematic review was to evaluate the current literature on all available prehospital trauma triage protocols and determine accuracy of protocol-based triage quality in terms of sensitivity and specificity. METHODS A search of Pubmed, Embase, and Cochrane Library databases was performed to identify all studies describing prehospital trauma triage protocols before November 2016. The search terms included “trauma,” “trauma center,” or “trauma system” combined with “triage,” “undertriage,” or “overtriage.” All studies describing protocol-based triage quality were reviewed. To assess the quality of these type of studies, a new critical appraisal tool was developed. RESULTS In this review, 21 articles were included with numbers of patients ranging from 130 to over 1 million. Significant predictors for severe injury were: vital signs, suspicion of certain anatomic injuries, mechanism of injury, and age. Sensitivity ranged from 10% to 100%; specificity from 9% to 100%. Nearly all protocols had a low sensitivity, thereby failing to identify severely injured patients. Additionally, the critical appraisal showed poor quality of the majority of included studies. CONCLUSION This systematic review shows that nearly all protocols are incapable of identifying severely injured patients. Future studies of high methodological quality should be performed to improve prehospital trauma triage protocols. LEVEL OF EVIDENCE Systematic review, level III.

Patient-reported health-related quality of life after a displaced intra-articular calcaneal fracture: a systematic review

BackgroundA displaced intra-articular calcaneal fracture (DIACF) is known for having a negative influence on the daily activities of patients. A health-related quality of life (HRQoL) outcome instrument is used to quantify the impact of DIACF. It seems that these studies used restrictive inclusion criteria and observe specific patient groups; consequently, an increased risk of bias that results in incorrect estimation of the impact. Therefore, we will systematically review the current literature.Materials and methodsA systematic search was performed in PubMed, Embase and Cochrane library. Inclusion criteria were studies reporting DIACF and HRQoL, measured with SF-36, SF-36v2, EQ-5D or EQ-6D. The identified articles were critically appraised for their relevance and validity. The overall risk of bias was determined. The studies with a low to medium risk of bias were used for data extraction.Results32 articles were available for the critical appraisal. 13 articles had a medium risk of bias. All studies reported the SF-36 and two studies also reported the EQ-5D.ConclusionsThis systematic review indicates that DIACF is a life-changing event for most patients. The HRQoL is substantially lower in comparison to the period before the trauma and to the general population, in particular the subdomains related to the physical domain are affected. In addition, this review reveals that the identified studies have a medium to high risk of bias. Consequently, it is challenging to make reliable and valid conclusions. Therefore, we provided recommendations to decrease the risk of bias in order to improve future research.

Grade of dysplasia and malignant transformation in adults with premalignant laryngeal lesions.

The purpose of this systematic review was to determine the significance of the grade of dysplasia in the development of invasive carcinoma.

Impact of trauma system structure on injury outcomes: a systematic review protocol.

BackgroundInjury represents one of the greatest public health challenges of our time with over 5 million deaths and 100 million people temporarily or permanently disabled every year worldwide. The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, the organisation of trauma care varies significantly across trauma systems and we know little about which components of trauma systems contribute to their effectiveness. The objective of the study described in this protocol is to systematically review evidence of the impact of trauma system components on clinically significant outcomes including mortality, function and disability, quality of life, and resource utilization.MethodsWe will perform a systematic review of studies evaluating the association between at least one trauma system component (e.g. accreditation by a central agency, interfacility transfer agreements) and at least one injury outcome (e.g. mortality, disability, resource use). We will search MEDLINE, EMBASE, COCHRANE central, and BIOSIS/Web of Knowledge databases, thesis holdings, key injury organisation websites and conference proceedings for eligible studies. Pairs of independent reviewers will evaluate studies for eligibility and extract data from included articles. Methodological quality will be evaluated using elements of the ROBINS-I tool and the Cochrane risk of bias tool for non-randomized and randomized studies, respectively. Strength of evidence will be evaluated using the GRADE tool.DiscussionWe expect to advance knowledge on the components of trauma systems that contribute to their effectiveness. This may lead to recommendations on trauma system structure that will help policy-makers make informed decisions as to where resources should be focused. The review may also lead to specific recommendations for future research efforts.Systematic review registrationThis protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 28-06-2016. PROSPERO 2016:CRD42016041336 Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016041336.

Predicting suitability of intramedullary fixation for displaced midshaft clavicle fractures

PurposeImplant-related irritation is a technique-specific complication seen in a substantial number of patients treated with intramedullary nailing for clavicle fractures. The purpose of this study was to identify predictors for developing implant-related irritation in patients with displaced midshaft clavicle fractures treated with elastic stable intramedullary nailing.MethodsA retrospective analysis of the surgical database in two level 2 trauma centers was performed. Patients who underwent intramedullary nailing for displaced midshaft clavicle fractures between 2005 and 2012 in the first hospital were included. Age, gender, fracture comminution and fracture location were assessed as possible predictors for developing irritation using multivariate logistic regression analysis. These predictors were externally validated using data of patients treated in another hospital.ResultsEighty-one patients were included in initial analysis. In the multivariate analysis, comminuted fractures in comparison to non-comminuted fractures (72 vs. 38%, p = 0.027) and fracture location (p < 0.001) were significantly associated with the development of implant-related irritation. In particular, lateral diaphyseal fractures caused irritation compared to fractures on the medial side of the cut-off point (88 vs. 26%). External validation of these predictors in 48 additional patients treated in another hospital showed a similar predictive value of the model and a good fit.ConclusionComminuted and lateral diaphyseal fractures were found to be statistically significant and independent predictors for developing implant-related irritation. We, therefore, believe that intramedullary nailing might not be suitable for these types of fractures. Future studies are needed to determine whether alternative surgical techniques or implants would be more suitable for these specific types of fractures.

Effectiveness of prehospital trauma triage systems in selecting severely injured patients: Is comparative analysis possible?

Introduction In an optimal trauma system, prehospital trauma triage ensures transport of the right patient to the right hospital. Incorrect triage results in undertriage and overtriage. The aim of this systematic review is to evaluate and compare prehospital trauma triage system quality worldwide and determine effectiveness in terms of undertriage and overtriage for trauma patients. Methods A systematic search of Pubmed/MEDLINE, Embase, and Cochrane Library databases was performed, using “trauma”, “trauma center,” or “trauma system”, combined with “triage”, “undertriage,” or “overtriage”, as search terms. All studies describing ground transport and actual destination hospital of patients with and without severe injuries, using prehospital triage, published before November 2017, were eligible for inclusion. To assess the quality of these studies, a critical appraisal tool was developed. Results A total of 33 articles were included. The percentage of undertriage ranged from 1% to 68%; overtriage from 5% to 99%. Older age and increased geographical distance were associated with undertriage. Mortality was lower for severely injured patients transferred to a higher‐level trauma center. The majority of the included studies were of poor methodological quality. The studies of good quality showed poor performance of the triage protocol, but additional value of EMS provider judgment in the identification of severely injured patients. Conclusion In most of the evaluated trauma systems, a substantial part of the severely injured patients is not transported to the appropriate level trauma center. Future research should come up with new innovative ways to improve the quality of prehospital triage in trauma patients.