Christian Lycke Ellingsen

Epidemiology and Contemporary Patterns of Trauma Deaths: Changing Place, Similar Pace, Older Face

AbstractBackgroundThe epidemiology of trauma deaths in Europe is less than well investigated. Thus, our goal was to study the contemporary patterns of trauma deaths within a defined population with an exceptionally high trauma autopsy rate.MethodsThis was a retrospective evaluation of 260 consecutive trauma autopsies for which we collected demographic, pre-hospital and in-hospital data. Patients were analyzed for injury severity by standard scoring systems (Abbreviated Injury Scale [AIS], Revised Trauma Score [RTS], and Injury Severity Score [ISS]), and the Trauma and Injury Severity Scale [TRISS] methodology.ResultsThe fatal trauma incidence was 10.0 per 100,000 inhabitants (17.4 per 100,000 age-adjusted ≥ 55 years). Blunt mechanism (87%), male gender (75%), and pre-hospital deaths (52%) predominated. Median ISS was 38 (range: 4–75). Younger patients (<55 years) who died in the hospital were more often hypotensive (SBP < 90 mmHg; p = 0.001), in respiratory distress (RR < 10/min, or > 29/min; p < 0.0001), and had deranged neurology on admission (Glasgow Coma Score [GCS] ≤ 8; p < 0.0001), compared to those ≥ 55 years. Causes of death were central nervous system (CNS) injuries (67%), exsanguination (25%), and multiorgan failure (8%). The temporal death distribution is model-dependent and can be visualized in unimodal, bimodal, or trimodal patterns. Age increased (r = 0.43) and ISS decreased (r = –0.52) with longer time from injury to death (p < 0.001). Mean age of the trauma patients who died increased by almost a decade during the study period (from mean 41.7 ± 24.2 years to mean 50.5 ± 25.4 years; p = 0.04). The pre-hospital:in-hospital death ratio shifted from 1.5 to 0.75 (p < 0.007).ConclusionsWhile pre-hospital and early deaths still predominate, an increasing proportion succumb after arrival in hospital. Focus on injury prevention is imperative, particularly for brain injuries. Although hemorrhage and multiorgan failure deaths have decreased, they do still occur. Redirected attention and focus on the geriatric trauma population is mandated.

Epidemiology of ruptured abdominal aortic aneurysms in a well-defined Norwegian population with trends in incidence, intervention rate, and mortality

OBJECTIVE Ruptured infrarenal abdominal aortic aneurysms (rAAAs) represent both a life-threatening emergency for the affected patient and a considerable health burden globally. The aim of this study was to investigate the contemporary epidemiology of rAAA in a defined Norwegian population for which both hospital and autopsy data were available. METHODS This was a retrospective, single-center population-based study of rAAA. The study includes all consecutively diagnosed prehospital and in-hospital cases of rAAA in the catchment area of Stavanger University Hospital between January 2000 and December 2012. Incidence and mortality rates (crude and adjusted) were calculated using national demographic data. RESULTS A total of 216 patients with primary rAAA were identified. The adjusted incidence rate for the study period was 11.0 per 100,000 per year (95% confidence interval [CI], 9.6-12.5). Twenty patients died out of the hospital, and 144 of the 196 patients (73%) admitted to the hospital underwent surgery. The intervention rate varied from 48% to 81% during the study period. The adjusted mortality rate was 7.5 per 100,000 per year (95% CI, 6.3-8.8). No differences in the incidence and mortality rates were found in comparing early and late periods. The 90-day standardized mortality ratio for the study period was 37.2 (95% CI, 31.6-43.7). The overall 90-day mortality was 68% (146 of 216 persons) and 51% (74 of 144 persons) for the patients treated for rAAA. CONCLUSIONS We found a stable incidence and mortality rate during a decade. The prehospital death rate was lower (9%), the intervention rate (73%) higher, and the total mortality (68%) lower than in most other studies. Geographic and regional differences may influence the epidemiologic description of rAAA and hence should be taken into consideration in comparing outcomes for in-hospital mortality and intervention rates.

Routine Use of Color Doppler in Fetal Heart Scanning in a Low-Risk Population

Objectives. To investigate the detection rate of major fetal heart defects in a low-risk population implementing routine use of color Doppler. Material and Methods. In a prospective observational study, all women undergoing fetal heart scanning (including 6781 routine examinations in the second trimester) during a three-year period were included. First a gray-scale scanning was performed including assessment of the four-chamber view and the great vessels. Thereafter three cross-sectional planes through the fetal thorax were assessed with color Doppler. Results. Thirty-nine fetuses had major heart defects, and 26 (67%) were prenatally detected. In 9/26 (35%) of cases the main ultrasound finding was related to the use of color Doppler. The survival rate of live born children was 91%. Conclusions. Routine use of color Doppler in fetal heart scanning in a low-risk population may be helpful in the detection of major heart defects; however, still severe malformations were missed prenatally.

High Norwegian prostate cancer mortality: evidence of over-reporting

Abstract Objective: This study aimed to determine the level of misattribution of prostate cancer deaths in Norway based on the county of Vestfold in the years 2009–2014. Materials and methods: The study included 328 patients registered as dead from prostate cancer (PCD; part I of death certificate), 126 patients with prostate cancer as other significant condition at death (OCD; part II of death certificate) and 310 patients who died with a diagnosis of prostate cancer not registered on the death certificate (PC-DCneg) in Vestfold County in 2009–2014. The complete cohort with patients’ names and dates of birth was provided by the Norwegian Institute of Public Health and the Norwegian Cancer Registry. The true cause of death of all patients was evaluated based on patient journals. Results: Over-reporting of prostate cancer deaths in the PCD group was 33% while under-reporting in the OCD and PC-DCneg groups was 19% and 5%, respectively. The correlation between registered and observed causes of death was 0.81 (95% confidence interval 0.78–0.83). Misattribution of prostate cancer deaths increased significantly with patient age and decreasing Gleason score. Conclusions: Prostate cancer mortality statistics in Norway are relatively accurate for patients aged <75 years at death. However, overall accuracy of cause of death assignment is significantly reduced by misattribution among older patients (> 75 years), who represent the large majority of prostate cancer deaths. Over-reporting of prostate cancer deaths among elderly people may not be an exclusively Norwegian phenomenon and may affect prostate cancer mortality statistics in other countries.

A missionary with a swelling on her hip

A 58-year-old Norwegian woman was referred from her general practitioner because of a non-tender swelling on her left hip. She used to work as a midwife in the Democratic Republic of the Congo until 5 years ago. Previously she had recovered well from hepatitis A, hepatitis B, and several times from malaria. She had earlier been treated for fi lariasis with diethyl carbamazine. She was in generally good condition, body weight slightly above average, with no other complaints. Just above the left iliac crest there was a palpable non-adherent subcutaneous tumour about 3 × 2 cm with a central more dense area. Ultrasound scan showed a cystic tumour 2 × 1 cm with a surrounding capsule in the muscle layer. The tumour was removed under local anaesthesia (fi gure, A). Histological examination showed a fi brous nodule with worms embedded in granulation tissue with mixed infl ammatory cells including foreign-body giant cells (fi gure, B). The diameter of the worms was about 0·3 mm. Microfi lariae could be seen both inside the uteri of the female worms (fi gure, B, arrows) and in the surrounding fi brous tissue. The appearance was consistent with an onchocercoma. 4 years earlier a skin biopsy had shown unspecifi c lichenoid dermatitis. In retrospect, this possibly could have been secondary to onchocerciasis, but microfi lariae were not be detected in the biopsy. She was given ivermectin 150 µg/kg orally immediately and the same dose was repeated after 1 year. This treatment aff ects only the microfi laria, but not the adult worms. The expected lifetime of an adult worm is 10–15 years and the treatment must be repeated yearly until then. When the nodules are situated in the head and neck area, nodulectomy is recommended to avoid eye involvement, which may result in blindness (“river blindness”). However, there is debate in the medical literature whether nodulectomy from the rest of the body is to be recommended. The patient has returned to the Democratic Republic of the Congo, is in good health, and is continuing on the recommended treatment regimen.