Joanne C. Sierink

Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients.

The aim of this review was to assess the value of immediate total‐body computed tomography (CT) during the primary survey of injured patients compared with conventional radiographic imaging supplemented with selective CT.

A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2)

BackgroundComputed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients.Methods/designThe REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness.DiscussionThe REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group.Trial RegistrationClinicalTrials.gov: (NCT01523626).

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial

BACKGROUND Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma. METHODS We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with traumatic brain injury. The χ(2) test was used to assess differences in mortality. This trial is registered with ClinicalTrials.gov, number NCT01523626. FINDINGS Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body CT scanning and 701 to the standard work-up. 541 patients in the immediate total-body CT scanning group and 542 in the standard work-up group were included in the primary analysis. In-hospital mortality did not differ between groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542; p=0.92). In-hospital mortality also did not differ between groups in subgroup analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard work-up 82 [25%] of 331; p=0.46) and traumatic brain injury (68 [38%] of 178 vs 66 [44%] of 151; p=0.31). Three serious adverse events were reported in patients in the total-body CT group (1%), one in the standard work-up group (<1%), and one in a patient who was excluded after random allocation. All five patients died. INTERPRETATION Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT. FUNDING ZonMw, the Netherlands Organisation for Health Research and Development.

Split bolus technique in polytrauma: a prospective study on scan protocols for trauma analysis

Background For the evaluation of severely injured trauma patients a variety of total body computed tomography (CT) scanning protocols exist. Frequently multiple pass protocols are used. A split bolus contrast protocol can reduce the number of passes through the body, and thereby radiation exposure, in this relatively young and vitally threatened population. Purpose To evaluate three protocols for single pass total body scanning in 64-slice multidetector CT (MDCT) on optimal image quality. Material and Methods Three total body CT protocols were prospectively evaluated in three series of 10 consecutive trauma patients. In Group A unenhanced brain and cervical spine CT was followed by chest–abdomen–pelvis CT in portovenous phase after repositioning of the arms. Group B underwent brain CT followed without arm repositioning by a one-volume contrast CT from skull base to the pubic symphysis. Group C was identical to Group A, but the torso was scanned with a split bolus technique. Three radiologists independently evaluated protocol quality scores (5-point Likert scale), parenchymal and vascular enhancement and artifacts. Results Overall image quality was good (4.10) in Group A, more than satisfactory (3.38) in Group B, and nearly excellent (4.75) in Group C (P < 0.001). Interfering artifacts were mostly reported in Group B in the liver and spleen. Conclusion In single pass total body CT scanning a split bolus technique reached the highest overall image quality compared to conventional total body CT and one-volume contrast CT.

Time to intervention in patients with splenic injury in a Dutch level 1 trauma centre

BACKGROUND Timely intervention in patients with splenic injury is essential, since delay to treatment is associated with an increased risk of mortality. Transcatheter Arterial Embolisation (TAE) is increasingly used as an adjunct to non-operative management. The aim of this study was to report time intervals between admission to the trauma room and start of intervention (TAE or splenic surgery) in patients with splenic injury. METHODS Consecutive patients with splenic injury aged ≥ 16 years admitted between January 2006 and January 2012 were included. Data were reported according to haemodynamic status (stable versus unstable). In haemodynamically (HD) unstable patients, transfusion requirement, intervention-related complications and the need for a re-intervention were compared between the TAE and splenic surgery group. RESULTS The cohort consisted of 96 adults of whom 16 were HD unstable on admission. In HD stable patients, median time to intervention was 105 (IQR 77-188) min: 117 (IQR 78-233) min for TAE compared to 95 (IQR 69-188) for splenic surgery (p=0.58). In HD unstable patients, median time to intervention was 58 (IQR 41-99) min: 46 (IQR 27-107) min for TAE compared to 64 (IQR 45-80) min for splenic surgery (p=0.76). The median number of transfused packed red blood cells was 8 (3-22) in HD unstable patients treated with TAE versus 24 (9-55) in the surgery group (p=0.09). No intervention-related complications occurred in the TAE group and one in the splenic surgery group (p=0.88). Two spleen related re-interventions were performed in the TAE group versus 3 in the splenic surgery group (p=0.73). CONCLUSIONS Time to intervention did not differ significantly between HD unstable patients treated with TAE and patients treated with splenic surgery. Although no difference was observed with regard to intervention-related complications and the need for a re-intervention, a trend towards lower transfusion requirement was observed in patients treated with TAE compared to patients treated with splenic surgery. We conclude that if 24/7 interventional radiology facilities are available, TAE is not associated with time loss compared to splenic surgery, even in HD unstable patients.

Treatment strategies in elderly breast cancer patients: Is there a need for surgery? *

BACKGROUND The aim of this study was to determine the role of surgery in elderly patients with breast cancer. METHODS Between 1999 and 2009, 153 consecutive women, ≥80 years old with breast cancer were treated at our hospital. Surgically and non-surgically treated patients were compared with respect to characteristics and survival. RESULTS Treatment was surgical in 102 patients (67%). The non-surgically treated patients were older than surgically treated patients, had more co-morbidity and were more often diagnosed with a clinically T3/T4 tumour and distant metastasis. Patients not receiving surgery, had an 11% overall survival rate at 5-year versus 48% in surgically treated patients (P < 0.001). Independent factors for survival were clinical N0 status, M0 status at presentation and surgery. CONCLUSION One in three patients of 80 years and older did not have surgical treatment for breast cancer. Patient not treated surgically are older, have more severe co-morbidity and are diagnosed with more advanced disease than patients who underwent surgery.The selection of patients, who have a poor prognosis, is made on clinical grounds not measurable with a common co-morbidity survey. Better and evidence-based selection criteria for surgical and non-surgical treatment in these patients are needed.

Response to Letter to the Editor regarding “Systematic review of flexion/extension radiography of the cervical spine in trauma patients”

We would like to thank Dr. Wu and colleagues for their Letter o the Editor regarding our systematic review published in Euroean Journal of Radiology in 2013 [1]. We appreciate their critical ppraisal of our article and read their letter with great interest. Their first comment comprises one of the included studies from uane et al. [2] in which flexion–extension films were compared ith MRI as the gold standard. In Table 4 detailed MRI and flexon/extension findings are listed for each specific patient. Wu and olleagues argue that patients #2,5,7 and 8 did not sustain unstable njuries, which could therefore not be expected to be seen on flexon/extension radiography. Whether this is a correct assumption n these specific patients cannot be answered by the undersigned, ut should be debated with Duane at al. who performed the study. evertheless, patients #2 and 5 did have ligamentous injury (C5–C5 igament injury with hemorrhage and C3-4 interspinous ligament njury with anterior and posterior columns intact respectively) and ight therefore have possibly sustained cervical spine injury. We herefore think that it is defendable that Duane et al. identified hese patients as false-negatives. We do agree with Wu and coleagues that patients #7 and 8 (mild C6-7 interspinous ligament dema and C3-4 small disc herniation respectively) should probbly not be classified as unstable. Whether patient #3 (perched acets) is a missed diagnosis on flexion/extension radiography nstead of a false-negative, as suggested by Wu and colleagues, canot be answered by us Perched facets indicate serious injury, but oes not necessarily lead to instability, thus explaining a negative /E exam. Their second comment is about the study of Padayachee et al., 3] in which flexion/extension radiographs were compared with CT. u et al. criticize the study design (i.e. not all patients who had a egative F/E received a MRI). We encountered exactly this same roblem when collecting the data for our systematic review. In ur discussion section we explain carefully why we still decided to nclude those studies. Specifically, Wu et al. mention four patients ith negative CT but positive F/E findings saying that this contraicts our claim of a 100% NPV of CT in reference to F/E. However, ased on the study of Padayachee et al., these were regarded as alse-positive findings of F/E rather than false-negative findings of T. Hence, again a difference of wording and insights, which seems o dominate the debate about F/E radiographs.

A case-matched series of total body CT scanning in trauma patients: reply.

Dear colleagues Thank you for your interesting Letter to the Editor regarding our study entitled A Case-Matched Series of Immediate Total-Body CT Scanning versus the Standard Radiological Work-Up in Trauma Patients [1], published in World Journal of Surgery. We fully agree with the authors that radiation dose is a point of interest. However, another recent study of our group showed that radiation dose during total index admission was comparable between severely injured patients who received a total-body computed tomography (CT) scan and patients who underwent the conventional work-up supplemented by selective CT scanning [2]. This is probably due to the more complete overview of all possible injuries that is obtained with total-body CT scanning at the trauma room. Furthermore, we acknowledge that not all trauma centers have a CT scanner available in their emergency department or in the trauma resuscitation room itself like we do [3]. Nevertheless, several studies show a time benefit of total-body CT scanning compared with conventional imaging and selective CT scanning [4, 5]. Furthermore, an increasing number of level-one trauma centers do have a CT scanner in the emergency department, and, particularly in those centers, the severely injured patients involved are admitted. Currently, we are analyzing the results of the REACT-2 trial [6], where patients were randomized between the conventional work-up supplemented by selective CT scanning and immediate total-body CT scanning. The results of this randomized controlled trial are expected at the end of 2014.