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OBJECTIVES: To compare inter and intra-observer agreement of the Manchester Triage System (MTS) and the Emergency Severity Index (ESI). METHODS: 50 representative emergency department (ED) scenarios derived from actual cases were presented to 18 ED nurses from three different hospitals. Eight of them were familiar with MTS, six with ESI and four were not familiar but trained in both systems. They independently assigned triage scores to each scenario according to the triage system(s) they were familiar with. After 4-6 weeks the same nurses again judged the scenarios in a different order. Unanimity in judgement and unweighted and quadratic-weighted kappas were calculated. RESULTS: Unanimity in judgement for MTS was 90% and for ESI 73%. One-level disagreement was found in 8% and 23% of the cases, respectively. Interobserver unweighted kappas were 0.76 (95% CI 0.68 to 0.83) for MTS and 0.46 (95% CI 0.37 to 0.55) for ESI. Quadratic-weighted kappas were 0.82 (95% CI 0.74 to 0.89) and 0.73 (95% CI 0.64 to 0.83), respectively. At 4-6 weeks, one-level intra-observer disagreements were 10% and 22% and 2-level disagreement 1% and 2%, respectively. Intra-observer unweighted kappas were 0.84 (95% CI 0.73 to 0.94) for MTS and 0.65 (95% CI 0.59 to 0.72) for ESI. CONCLUSION: Using paper-based clinical scenarios, MTS was found to have a greater inter and intra-observer agreement than ESI. [ABSTRACT FROM AUTHOR]

AIM OF STUDY: The café fire at Volendam occurred shortly after midnight on the first of January 2001 and resulted in one of the worst mass burn incidents in recent Dutch history. The aim of this study was to provide insight into medical and organisational requirements of a major burns incident. METHODS: Shortly after the fire, two university hospitals and a burn center in the region of the accident developed a plan for evaluation of medical care given during and after this major burn incident. A multidisciplinary research group investigated the management of victims at the scene, in the emergency departments (ED) and during admission in the hospitals. All 245 casualties were included in this study. RESULTS: A brief severe fire occurred in a crowded cafe with around 350 young visitors on a small embankment of a relatively isolated town, resulting in a unusually high number of severely injured burn victims. Four died immediately. The ensuing rescue effort was hampered by poor access and chaotic circumstances. At the scene of the incident, mobile medical teams ensured orderly transport and treatment priority for the injured. There were 245 victims with a median total body surface area burned of 12%. Inhalation injury was present in 96 patients. A total of 182 victims were admitted, with 112 to intensive care. Ten patients died in the hospital. Seventy-eight patients were secondarily transported, many to specialised centers in the Netherlands and abroad. In total, 36 hospitals in three countries participated. CONCLUSION: An incident with high numbers of burn victims poses a challenge to any health care system. The difficult circumstances at the site demonstrated the need for robust organisational structures. The primary and secondary distribution of patients required coordination, general hospitals were able to provide initial medical care to these major burn casualties. [ABSTRACT FROM AUTHOR]

Objectives: Initial trauma care could potentially be improved when conventional imaging and selective CT scanning is omitted and replaced by immediate total-body CT (iTBCT) scanning. Because of the potentially increased radiation exposure by this diagnostic approach, proper selection of the severely injured patients is mandatory., Methods: In the REACT-2 trial, severe trauma patients were randomized to iTBCT or conventional imaging and selective CT based on predefined criteria regarding compromised vital parameters, clinical suspicion of severe injuries, or high-risk trauma mechanisms in five trauma centers. By logistic regression analysis with backward selection on the 15 study inclusion criteria, a revised set of criteria was derived and subsequently tested for prediction of severe injury and shifts in radiation exposure., Results: In total, 1083 patients were enrolled with median ISS of 20 (IQR 9-29) and median GCS of 13 (IQR 3-15). Backward logistic regression resulted in a revised set consisting of nine original and one adjusted criteria. Positive predictive value improved from 76% (95% CI 74-79%) to 82% (95% CI 80-85%). Sensitivity decreased by 9% (95% CI 7-11%). The area under the receiver operating characteristics curve remained equal and was 0.80 (95% CI 0.77-0.83), original set 0.80 (95% CI 0.77-0.83). The revised set retains 8.78 mSv (95% CI 6.01-11.56) for 36% of the non-severely injured patients., Conclusions: Selection criteria for iTBCT can be reduced from 15 to 10 clinically criteria. This improves the positive predictive value for severe injury and reduces radiation exposure for less severely injured patients., Key Points: • Selection criteria for iTBCT can be reduced to 10 clinically useful criteria. • This reduces radiation exposure in 36% of less severely injured patients. • Overall discriminative capacity for selection of severely injured patients remained equal.

Studies on the long-term prevalence of parental posttraumatic stress symptoms (PTSS) following child accidental injury are scarce, and findings on risk factors vary. In this follow-up study (T2, n = 69) we determined the prevalence of parental PTSS 2-4 years after accidental injury of their child, compared with 3 months after the accident (T1, n = 135). Additionally, we examined the association between parental and child factors and PTSS severity. Children were 8-18 years old at the time of the accident. Parent and child PTSS was assessed by self-report. Other data were retrieved from medical records and a telephone interview. Parental PTSS was 9.6% at T1 and 5.8% at T2. Acute parental stress as measured within 2 weeks of the child's accident was significantly associated with parental PTSS severity (T1 and T2), as was the child's hospitalization of more than 1 day at T1 and the child's permanent physical impairment at T2. To prevent adverse long-term psychological consequences we recommend identifying and monitoring parents at risk and offering them timely treatment.

In this study, we determined the long-term prevalence of posttraumatic stress disorder (PTSD) in children and adolescents after accidental injury and gained insight into factors that may be associated with the occurrence of PTSD. In a prospective longitudinal study, we assessed diagnosed PTSD and clinically significant self-reported posttraumatic stress symptoms (PTSS) in 90 children (11-22 years of age, 60% boys), 2-4 years after their accident (mean number of months 32.9, SD 6.6). The outcome was compared to the first assessment 3 months after the accident in 147 children, 8-18 years of age. The prevalence of PTSD was 11.6% at first assessment and 11.4% at follow-up. Children with PTSD or PTSS reported significantly more permanent physical impairment than children without. Children who completed psychotherapy had no symptoms or low levels of symptoms at follow-up. Given the long-term prevalence of PTSD in children following accidents, we recommend systematic monitoring of injured children. The role of possible associated factors in long-term PTSS needs further study.

Background: The optimal surgical approach for displaced intra-articular calcaneal fractures (DIACF) is subject of debate. The primary aim of this systematic review and meta-analysis was to assess wound-healing complications following the sinus tarsi approach (STA) compared to the extended lateral approach (ELA). Secondary aims were to assess time to surgery, operative time, calcaneal anatomy restoration, functional outcome, implant removal and injury to the peroneal tendons and sural nerve., Methods: MEDLINE, EMBASE and Cochrane databases were searched for clinical studies comparing the STA and the ELA (until September 2017)., Results: Nine studies were included (two randomized controlled trials; seven comparative studies). 326 patients (331 fractures) were treated by the STA and 383 patients (390 fractures) by ELA. Ninety-nine per cent were Sanders type II/III fractures. Wound healing complications in the STA and ELA occurred in 11/331 and 82/390 fractures, respectively. Weighted means were 4.9% and 24.9%, respectively. Meta-analysis showed significantly less wound healing complications in the STA compared to ELA (risk ratio 0.20; 95% CI 0.11-0.36; P<0.00001; I 2 =0%). In general, time to surgery and operative time were shorter in the STA. Meta-analysis was not possible due to heterogeneity between studies. No differences were found in remaining secondary outcomes., Conclusions: The STA is associated with significantly less wound healing complications. With similar functional outcome and calcaneal anatomy restoration, the STA may be the preferred approach in the operative treatment of Sanders type II/III DIACF., (Copyright © 2018 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Objectives: The aim of this study was to determine the correlation of the intra-operative fluoroscopic 2D- and 3D-images compared with a postoperative CT-scan, in terms of quality of reduction and fixation of calcaneal fractures., Methods: Patients requiring open reduction and internal fixation (ORIF) of a calcaneal fracture were recruited as part of the EF3X-trial. During surgery, intra-operative images of fluoroscopic 2D- and 3D-imaging were obtained to assess the quality of the reduction and implant position. All patients received a postoperative CT-scan within one week. The operating surgeon evaluated intra-operatively both 2D- and 3D-images according to a 23-item scoring protocol on a 3-point Likert scale. A scoring panel, consisting of three clinical experts, evaluated all images in a blinded and independent fashion. Intraclass correlation coefficients (ICC) with their 95% confidence intervals (CI) were calculated using a two-way-random model with absolute agreement., Results: A total of 102 calcaneal fractures were included. Agreement of 3D-imaging for the quality of reduction was better than 2D-imaging, although still fair, but for fixation moderate to good. Agreement between the 2D-images and the CT-scans was poor to fair. Intra-operative 2D-imaging received the highest ratings for image quality and interpretability, followed by CT-scanning., Conclusion: Implant position can be evaluated satisfactory with the aid of intra-operative 3D imaging. Although intra-operative 3D imaging had a better agreement with postoperative CT-scanning than 2D-imaging, there is a need to improve image quality and suppress scattering from implants to improve the additional value of intra-operative 3D imaging in calcaneal fracture reduction and fixation., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Previous research suggests that acute pain is a risk factor for later posttraumatic stress symptoms (PTSS). In a prospective cohort study, we examined the association between acute pain from accidental injury and PTSS in children and adolescents, taking into account factors potentially related to pain or posttraumatic stress. Participants were 135 children and adolescents, 8-18 years old. We measured the worst experienced pain since the accident took place with a visual analogue scale. Three months after the accident, posttraumatic stress was assessed with a self-report measure. We found a positive association between acute pain and posttraumatic stress. The amount of pain was negatively associated with injury severity in girls and positively associated with the presence of an extremity fracture in boys. In children who reported severe pain, this pain was significantly associated with PTSS and may account for around 10% of the variance in the severity of PTSS. Although the experience of pain is subjective, our study indicates that severe pain is associated with the severity of later PTSS. Timely management of pain according to acute pain protocols in all phases and disciplines after accidental injury is therefore recommended.

The published online version contains a mistake in the author list for the name of the author "J. Carel Goslings" was incorrectly presented in the HTML version.

This study describes how many detainees have been referred to emergency departments for further evaluation or emergency care while in police custody in Amsterdam (years 2012/2013). It provides insights into the diagnoses assigned by forensic doctors and hospital specialists and the appropriateness of the referrals. We made use of the electronic registration system of the Forensic Medicine Department of the Public Health Service Amsterdam. This department is in charge of the medical care for detainees in the Amsterdam region. Hospital diagnoses were obtained through collaboration with several Amsterdam-based hospitals. According to our results, in 1.5% of all consultations performed, the detainee was referred to hospital. The most frequent reasons for referral were injuries (66%), intoxication/withdrawal (11%) and cardiac problems (7%). In 18% of all referrals, hospital admission (defined as at least one night in the hospital) was the consequence. After review of hospital files, the indication for referral as stated by the forensic physician was confirmed in 77% of all cases. A minority of referrals was considered unnecessary (7%). The identified cases allow for a discussion of cases of over-referral. Future research should focus on the problem of under-referral and associated health risks., (Copyright © 2016 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Calcaneal fractures are notoriously difficult to treat and wound complications occur often. However, owing to the rare nature of these fractures, clinical trials on this subject are lacking. Thus, biomechanical studies form a viable source of information on this subject. With our systematic review of biomechanical studies, we aimed to provide an overview of all the techniques available and guide clinicians in their choice of method of fracture fixation. A literature search was conducted using 3 online databases to find biomechanical studies investigating methods of fixation for calcaneal fractures. A total of 14 studies investigating 237 specimens were identified. Large diversity was found in the tested fixation methods and in the test setups used. None of the studies found a significant difference in favor of any of the fixation methods. All tested methods provided a biomechanically stable fixation. All the investigated methods of fixation for calcaneal fractures seem to be biomechanically sufficient. No clear benefit was found for locking plates in the fixation of calcaneal fractures; however, a subtle mechanical superiority might exist compared with nonlocking plates in the case of fractures in osteoporotic bone. Several of the techniques tested would be suitable for a minimal invasive approach. These should be investigated further in clinical trials., (Copyright © 2017 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Calcaneal fractures are uncommon and have a substantial impact on hindfoot function and quality of life. Several surgical treatment options are available; both in surgical approach and type of operation. The aim of this study was to compare functional outcome and quality of life following ORIF and primary arthrodesis. Furthermore, predictors of worse functional outcome were explored., Methods: A retrospective cross-sectional cohort study was performed in patients with surgical fixation of a calcaneal fracture with a minimum follow-up of 18 months. Patients received ORIF through the 1) Extended Lateral Approach (ELA), 2) Sinus Tarsi Approach (STA) or 3) primary arthrodesis via STA. Participants were presented a questionnaire containing demographics, the AOFAS hindfoot scale, Foot Function Index, SF-36, EQ-5D and patient satisfaction., Results: In total 95 patients participated in this study. The three groups were comparable regarding patient characteristics. A median score of 74.5 points on the AOFAS hindfoot scale and 11.9 on the FFI was found for the entire group. There were no statistically significant differences between patients with ORIF of primary arthrodesis. Patients scored a median of 49.0 on the Physical Component Scale of the SF-36 and 55.4 on the Mental Component Scale. On the EQ-5D patients scored a median of 0.8 points. Again no statistically significant differences were observed between the three subgroups. Socio-economic status was the only statistically significant predictor of worse functional outcome (β: 4.06, 95% CI: 0.50-7.62) after multivariable analysis., Interpretation: Good midterm outcomes following in terms of functional outcome and in quality of life are observed. We observed no statistical significant difference in functional outcome between patients with ORIF and patients with primary arthrodesis. The only predictor of worse functional outcome is a lower socio-economic status., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: To determine whether there is a difference in frequency and clinical relevance of incidental findings detected by total-body computed tomography scanning (TBCT) compared to those by the standard work-up (STWU) with selective computed tomography (CT) scanning., Methods: Trauma patients from five trauma centres were randomized between April 2011 and January 2014 to TBCT imaging or STWU consisting of conventional imaging with selective CT scanning. Incidental findings were divided into three categories: 1) major finding, may cause mortality; 2) moderate finding, may cause morbidity; and 3) minor finding, hardly relevant. Generalized estimating equations were applied to assess differences in incidental findings., Results: In total, 1083 patients were enrolled, of which 541 patients (49.9 %) were randomized for TBCT and 542 patients (50.1 %) for STWU. Major findings were detected in 23 patients (4.3 %) in the TBCT group compared to 9 patients (1.7 %) in the STWU group (adjusted rate ratio 2.851; 95%CI 1.337-6.077; p < 0.007). Findings of moderate relevance were detected in 120 patients (22.2 %) in the TBCT group compared to 86 patients (15.9 %) in the STWU group (adjusted rate ratio 1.421; 95%CI 1.088-1.854; p < 0.010)., Conclusions: Compared to selective CT scanning, more patients with clinically relevant incidental findings can be expected by TBCT scanning., Key Points: • Total-body CT scanning in trauma results in 1.5 times more incidental findings. • Evaluation by TBCT in trauma results in more patients with incidental findings. • In every category of clinical relevance, TBCT detects more incidental findings.

Objectives: To investigate whether the sinus tarsi approach (STA) allows for a similar anatomical reduction of the posterior talocalcaneal facet as the extended lateral approach (ELA) and compare the rate of postoperative wound complications., Design: Retrospective., Setting: Level 1 trauma center., Patients: All consecutive patients from 2012 to 2015 with a closed displaced intra-articular calcaneal fracture Sanders type II and III surgically treated with the ELA (N = 60) and the STA (N = 65)., Main Outcome Measurements: Wound complications, timing of surgery, operative time, length of postoperative hospitalization, and reduction of the posterior facet and calcaneal body., Results: Incidence of wound complications, time to surgery, postoperative duration of hospital admission, and number of hospital admissions because of wound complications were significantly different between the ELA group and STA group. There was no significant difference in restoration of calcaneal anatomy with either approach. Importantly, the STA was performed in a median duration of 105 minutes and the ELA in a median of 134 minutes, accounting for nearly half an hour difference in operating time (P < 0.001)., Conclusions: The largest benefit of the STA was found in the significant reduction in wound complications and operative time, where time to closure may have accounted for the latter difference. This difference was without a compromise in reduction. Additional studies comparing functional outcome, especially rates of subtalar arthrosis, will be needed to determine the long-term benefits of STA., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Suicide is currently a topic of high priority for policy-makers, researchers and clinicians. The World Health Organization estimated 804,000 suicide deaths worldwide in 2012. Some studies that focused on patients with self-inflicted injury revealed that mortality in this group is higher than for patients who sustain unintentional injury. However little is known about the impact of psychiatric disorders on health care resources including length of hospital stay., Objectives: To determine whether trauma patients with a psychiatric disorder or after attempting suicide are at higher risk of a complicated course than patients without a psychiatric disorder or accidental cause. The secondary objective was to provide an overview of the current literature on the same group of trauma patients with psychiatric comorbidity in regard to mortality rate, length of stay, hospital costs and quality of life. Our primary outcome measure, complicated course, was found to be most clinically relevant., Methods: We searched PubMed, Embase and PsycInfo electronic databases. All searches were updated to March 2016. The methodological quality was assessed using the QUIPS tool., Results: Our search identified 9284 articles (PubMed 3660, Embase 2590, PsycInfo 3034). Of these, 18 articles were included. Four studies investigated the association between psychiatric disorders and a complicated course after trauma, three found a significant higher risk of complications. Mortality was reviewed in 14 studies, of which seven showed significant higher risk of in-hospital mortality for trauma patients with psychiatric disorder. Eight of nine studies found significant prolonged length of stay for these patients., Conclusion: Patients who have a psychiatric disorder or who have attempted suicide are at higher risk of increased in-hospital mortality and prolonged length of stay after sustaining injuries. These patients also tend to be at higher risk of complications after severe trauma, however future research is needed to confirm these potentially important implications., Level of Evidence: Systematic review, level III.