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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.

Background: Immediate total-body CT (iTBCT) is often used for screening of potential severely injured patients. Patients requiring emergency bleeding control interventions benefit from fast and optimal trauma screening. The aim of this study was to assess whether an initial trauma assessment with iTBCT is associated with lower mortality in patients requiring emergency bleeding control interventions., Methods: In the REACT-2 trial, patients who sustained major trauma were randomized for iTBCT or for conventional imaging and selective CT scanning (standard workup; STWU) in five trauma centers. Patients who underwent emergency bleeding control interventions following their initial trauma assessment with iTBCT were compared for mortality and clinically relevant time intervals to patients that underwent the initial trauma assessment with the STWU., Results: In the REACT-2 trial, 1083 patients were enrolled of which 172 (15.9%) underwent emergency bleeding control interventions following their initial trauma assessment. Within these 172 patients, 85 (49.4%) underwent iTBCT as primary diagnostic modality during the initial trauma assessment. In trauma patients requiring emergency bleeding control interventions, in-hospital mortality was 12.9% (95% CI 7.2-21.9%) in the iTBCT group compared to 24.1% (95% CI 16.3-34.2%) in the STWU group (p = 0.059). Time to bleeding control intervention was not reduced; 82 min (IQR 5-121) versus 98 min (IQR 62-147), p = 0.108., Conclusions: Reduction in mortality in trauma patients requiring emergency bleeding control interventions by iTBCT could not be demonstrated in this study. However, a potentially clinically relevant absolute risk reduction of 11.2% (95% CI - 0.3 to 22.7%) in comparison with STWU was observed., Trial Registration: ClinicalTrials.gov: NCT01523626.

Introduction: Surgery for proximal femoral fractures in the Netherlands is performed by trauma surgeons, general surgeons and orthopaedic surgeons. The aim of this study was to assess whether there is a difference in outcome for patients with proximal femoral fractures operated by trauma surgeons versus general surgeons. Secondly, the relation between hospital and surgeon volume and postoperative complications was explored., Methods: Patients of 18 years and older were included if operated for a proximal femoral fracture by a trauma surgeon or a general surgeon in two academic, eight teaching and two non-teaching hospitals in the Netherlands from January 2010 until December 2013. The combined endpoint was defined as reoperation or surgical site infection. Multivariate analysis was used to adjust for patient and fracture characteristics and hospital and surgeon volume. Categories for hospital volume were>170/year (high volume), 96-170/year (medium volume) and <96/year (low volume)., Results: In 4552 included patients 2382 (52.3%) had surgery by a trauma surgeon. Postoperative complications occurred in 276 (11.6%) patients operated by a trauma surgeon and in 258 (11.9%) operated by a general surgeon (p=0.751). When considering confounders in a multivariate analysis, surgery by trauma surgeons was associated with less postoperative complications (OR 0.746; 95%CI 0.580-0.958; p=0.022). Surgery in high volume hospitals was also associated with less complications (OR 0.997; 95%CI 0.995-0.999; p=0.012). Surgeon volume was not associated with complications (OR 1.008; 95%CI 0.997-1.018; p=0.175)., Conclusion: Surgery by trauma surgeons and high hospital volume are associated with less reoperations and surgical site infections for patients with proximal femoral fractures., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Purpose: The appendix can be a rare cause for chronic right lower quadrant abdominal pain (RLQAP), even though no objective disorder can be determined to the appendix. This condition can be described as chronic appendicitis or (neurogenic) appendicopathy. After careful selection, elective appendectomy is performed in our centre for this group of patients., Methods: All patients that underwent an elective appendectomy between 2006 and 2013 were prospectively analysed. Inclusion criterion was chronic RLQAP without abnormalities seen on imaging. Exclusion criterion was pain after conservative treatment of (complicated) appendicitis or an abnormal appendix on imaging like a mass, mucocoele or faecolith. Primary outcome was the effect on the pain postoperatively., Results: In the period of the study, ten patients met the inclusion criteria and underwent an appendectomy for chronic RLQAP. Average preoperative pain score assessed with visual analogue scale (VAS) was 8.6. Preoperative work-up showed no abnormalities. No macroscopic abnormalities were seen during surgery in any of the patients. Histopathological analysis was obtained and showed limited abnormalities in eight of ten patients, mostly suspicion of previous inflammation. Postoperatively, no complications occurred, and at revision after 3 weeks, average VAS was 1.0. Long-term follow-up showed that patients remained free of symptoms; average VAS after a median of 33 months was 1.0., Conclusions: A significant reduction of pain was achieved after an appendectomy in all patients suffering from chronic RLQAP in this series. Seven out of ten patients were completely free of pain.

Objective: Evaluation of autonomic function responses is increasingly important for risk prediction and hemodynamic evaluation in the ambulant and perioperative setting, but requires a noninvasive arterial blood pressure measurement device. This study describes whether a novel noninvasive beat-to-beat arterial blood pressure measurement device (Nexfin HD) is able to reproducibly reflect autonomic function responses in healthy volunteers., Methods: Noninvasive beat-to-beat arterial blood pressure measurements (Nexfin HD) were performed in 20 healthy men of 22 ± 3 years. Measurements were performed during supine steady state, controlled breathing (0.125 Hz), passive leg raising, a controlled Valsalva maneuver, and a quick stand test. Finally, relative changes in pulse pressure during autonomic function testing and the test-retest reproducibility were determined., Results: Autonomic function tests induced beat-to-beat arterial blood pressure changes that were accurately monitored by the Nexfin device. The intraclass correlation coefficients for systolic and diastolic arterial blood pressure measurements during supine steady state were agreeable [0.91 (0.82-0.96) and 0.84 (0.69-0.93), respectively]. The reproducibility of blood pressure changes during controlled breathing, passive leg raising, and Valsalva maneuver averaged 0.92 (0.82-0.96), 0.76 (0.50-0.90), and 0.94 (0.89-0.97), respectively. The reproducibility of the pulse pressure variation (PPV) as calculated from controlled breathing-induced changes in the arterial blood pressure (13 ± 5%) was high [0.96 (0.93-0.98)]., Conclusion: This study shows that noninvasive beat-to-beat Nexfin HD arterial blood pressure measurements reproducibly reflect autonomic function responses in healthy volunteers.