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Pitak-Arnnop P, Hirsch J, Stengel D. [Are certain facial fractures indicators for cerebrovascular injuries or intracranial hemorrhage?]. Unfallchirurgie (Heidelb) 2024; 127:407-409. [PMID: 38498156 DOI: 10.1007/s00113-024-01421-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/20/2024]
Affiliation(s)
- Poramate Pitak-Arnnop
- Klinik und Poliklinik für Mund‑, Kiefer- und Plastische Gesichtschirurgie, Medizinische Fakultät, UKGM, Universitätsklinikum Marburg, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg (Lahn), Deutschland.
- Klinik für Mund-Kiefer-Gesichtschirurgie und Plastische Operationen, Universitätsklinikum Ruppin-Brandenburg, Medizinische Fakultät, Medizinische Hochschule Brandenburg, Fehrbelliner Str. 38, 16816, Neuruppin, Deutschland.
| | - Julius Hirsch
- Medizinische Fakultät, Philipps-Universität Marburg, Baldingerstraße, 35043, Marburg (Lahn), Deutschland
| | - Dirk Stengel
- Ressort Medizin, BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Leipziger Pl. 1, 10117, Berlin, Deutschland
- , Berlin, Deutschland
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Weigeldt M, Schulz-Drost S, Stengel D, Lefering R, Treskatsch S, Berger C. In-hospital mortality after prehospital endotracheal intubation versus alternative methods of airway management in trauma patients. A cohort study from the TraumaRegister DGU®. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02498-8. [PMID: 38509186 DOI: 10.1007/s00068-024-02498-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/10/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE Prehospital airway management in trauma is a key component of care and is associated with particular risks. Endotracheal intubation (ETI) is the gold standard, while extraglottic airway devices (EGAs) are recommended alternatives. There is limited evidence comparing their effectiveness. In this retrospective analysis from the TraumaRegister DGU®, we compared ETI with EGA in prehospital airway management regarding in-hospital mortality in patients with trauma. METHODS We included cases only from German hospitals with a minimum Abbreviated Injury Scale score ≥ 2 and age ≥ 16 years. All patients without prehospital airway protection were excluded. We performed a multivariate logistic regression to adjust with the outcome measure of hospital mortality. RESULTS We included n = 10,408 cases of whom 92.5% received ETI and 7.5% EGA. The mean injury severity score was higher in the ETI group (28.8 ± 14.2) than in the EGA group (26.3 ± 14.2), and in-hospital mortality was comparable: ETI 33.0%; EGA 30.7% (27.5 to 33.9). After conducting logistic regression, the odds ratio for mortality in the ETI group was 1.091 (0.87 to 1.37). The standardized mortality ratio was 1.04 (1.01 to 1.07) in the ETI group and 1.1 (1.02 to 1.26) in the EGA group. CONCLUSIONS There was no significant difference in mortality rates between the use of ETI or EGA, or the ratio of expected versus observed mortality when using ETI.
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Affiliation(s)
- Moritz Weigeldt
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany.
| | | | - Dirk Stengel
- BG Kliniken - Hospital Group of the German Federal Statutory Accident Insurance, Leipziger Platz 1, 10117, Berlin, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Faculty of Health, Witten/Herdecke University, 51109, Cologne, Germany
- Committee On Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Berlin, Germany
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
| | - Christian Berger
- Department of Anesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Germany
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Schemitsch EH, Nowak LL, Schulz AP, Brink O, Poolman RW, Mehta S, Stengel D, Zhang CQ, Martinez S, Kinner B, Chesser TJS, Bhandari M. Intramedullary Nailing vs Sliding Hip Screw in Trochanteric Fracture Management: The INSITE Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2317164. [PMID: 37278998 DOI: 10.1001/jamanetworkopen.2023.17164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
Importance Fractures of the hip have devastating effects on function and quality of life. Intramedullary nails (IMN) are the dominant implant choice for the treatment of trochanteric fractures of the hip. Higher costs of IMNs and inconclusive benefit in comparison with sliding hip screws (SHSs) convey the need for definitive evidence. Objective To compare 1-year outcomes of patients with trochanteric fractures treated with the IMN vs an SHS. Design, Setting, and Participants This randomized clinical trial was conducted at 25 international sites across 12 countries. Participants included ambulatory patients aged 18 years and older with low-energy trochanteric (AO Foundation and Orthopaedic Trauma Association [AO/OTA] type 31-A1 or 31-A2) fractures. Patient recruitment occurred between January 2012 and January 2016, and patients were followed up for 52 weeks (primary end point). Follow-up was completed in January 2017. The analysis was performed in July 2018 and confirmed in January 2022. Interventions Surgical fixation with a Gamma3 IMN or an SHS. Main Outcomes and Measures The primary outcome was health-related quality of life (HRQOL), measured by the EuroQol-5 Dimension (EQ5D) at 1-year postsurgery. Secondary outcomes included revision surgical procedure, fracture healing, adverse events, patient mobility (measured by the Parker mobility score), and hip function (measured by the Harris hip score). Results In this randomized clinical trial, 850 patients were randomized (mean [range] age, 78.5 [18-102] years; 549 [64.6% female) with trochanteric fractures to undergo fixation with either the IMN (n = 423) or an SHS (n = 427). A total of 621 patients completed follow-up at 1 year postsurgery (304 treated with the IMN [71.9%], 317 treated with an SHS [74.2%]). There were no significant differences between groups in EQ5D scores (mean difference, 0.02 points; 95% CI, -0.03 to 0.07 points; P = .42). Furthermore, after adjusting for relevant covariables, there were no between-group differences in EQ5D scores (regression coefficient, 0.00; 95% CI, -0.04 to 0.05; P = .81). There were no between-group differences for any secondary outcomes. There were also no significant interactions for fracture stability (β [SE] , 0.01 [0.05]; P = .82) or previous fracture (β [SE], 0.01 [0.10]; P = .88) and treatment group. Conclusions and Relevance This randomized clinical trial found that IMNs for the treatment of trochanteric fractures had similar 1-year outcomes compared with SHSs. These results suggest that the SHS is an acceptable lower-cost alternative for trochanteric fractures of the hip. Trial Registration ClinicalTrials.gov Identifier: NCT01380444.
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Affiliation(s)
- Emil H Schemitsch
- London Health Sciences Centre, London, Ontario, Canada
- Western University, London, Ontario, Canada
| | - Lauren L Nowak
- London Health Sciences Centre, London, Ontario, Canada
- Western University, London, Ontario, Canada
| | | | | | | | | | - Dirk Stengel
- BG Kliniken: Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
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Stengel D, Wünscher J, Dubs L, Ekkernkamp A, Renkawitz T. [Evidence-based versus expertise-based medicine in orthopedic and trauma surgery : There is nothing more practical than a good theory]. Orthopadie (Heidelb) 2023:10.1007/s00132-023-04382-6. [PMID: 37222750 DOI: 10.1007/s00132-023-04382-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/25/2023]
Abstract
About a quarter of a century after the introduction of the concept and principles of evidence-based medicine (EbM), some healthcare providers are still adamant that these are incompatible with knowledge gained through experience. Across the surgical disciplines, it is often argued EbM underestimates or neglects the importance of intuition and surgical skills. To put it bluntly, these assumptions are wrong and often characterized by a misunderstanding of the methodology of EbM. Even the best controlled trial cannot be properly interpreted or implemented without clinical reasoning; furthermore, clinicians of all disciplines are obligated to provide care according to the current state of scientific knowledge. In an era of revolutionary biomedical developments, exponential increase of research but incremental innovations, they must become familiar with pragmatic tools to appraise the validity and relevance of clinical study results, and to decide whether there is a need to adapt current beliefs and practices based on the new information. We herein use the recent example of a new medical device for the surgical treatment of rotator cuff tears and subacromial impingement syndrome to illustrate how important it is to interpret data in the context of a precise, answerable question and to combine clinical expertise with methodological principles offered by EbM.
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Affiliation(s)
- Dirk Stengel
- BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Leipziger Platz 1, 10117, Berlin, Deutschland.
| | - Johannes Wünscher
- BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Leipziger Platz 1, 10117, Berlin, Deutschland
| | | | - Axel Ekkernkamp
- BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Leipziger Platz 1, 10117, Berlin, Deutschland
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Deutschland
- Klinik und Poliklinik für Unfall‑, Wiederherstellungschirurgie und Rehabilitative Medizin, Universitätsmedizin Greifswald, Greifswald, Deutschland
| | - Tobias Renkawitz
- Orthopädische Universitätsklinik Heidelberg, Ruprecht-Karls-Universität, Heidelberg, Deutschland
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Liebs TR, Dubs L, Stengel D, Renkawitz T. [Rehabilitation versus autologous repair for anterior cruciate ligament injury in the postacute phase : An evidence-based critical appraisal of the multicenter randomized ACL SNNAP trial]. Orthopadie (Heidelb) 2023:10.1007/s00132-023-04366-6. [PMID: 37219564 DOI: 10.1007/s00132-023-04366-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 05/24/2023]
Affiliation(s)
- Thoralf Randolph Liebs
- Klinik für Orthopädie und Traumatologie, Zentrum für muskuloskelettale Infektionen, Universitätsspital Basel, Spitalstrasse 21, Basel, Schweiz.
- Klinik für Orthopädie und Traumatologie, Kantonsspital Aarau, Aarau, Schweiz.
| | | | - Dirk Stengel
- BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Berlin, Deutschland
| | - Tobias Renkawitz
- Orthopädische Universitätsklinik Heidelberg, Ruprecht-Karls-Universität, Heidelberg, Deutschland
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Stengel D, Renkawitz T. Erratum zu: Niedrig-dosierte orale Acetylsalicylsäure vs. niedermolekularem subkutanem Heparin zur Thromboembolieprophylaxe nach Frakturen. Unfallchirurgie (Heidelb) 2023; 126:404. [PMID: 36988662 DOI: 10.1007/s00113-023-01314-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Dirk Stengel
- Forschung - Ressort Medizin, BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Leipziger Pl. 1, 10117, Berlin, Deutschland.
| | - Tobias Renkawitz
- Orthopädische Universitätsklinik Heidelberg, Heidelberg, Deutschland
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Stengel D, Spranger N, Bhandari M, Giannoudis PV. Clinical research- turning an oxymoron into symbiosis. Injury 2023; 54 Suppl 3:S1. [PMID: 37419551 DOI: 10.1016/j.injury.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Affiliation(s)
- Dirk Stengel
- BG Kliniken - Hospital Group of the German Federal Statutory Accident Insurance, Leipziger Platz 1, 10117 Berlin, Germany.
| | - Nikolai Spranger
- Unfallchirurgie und Orthopädie BG Klinikum Unfallkrankenhaus Berlin, Germany
| | - Mohit Bhandari
- Department of Surgery, McMaster University, Hamilton General Hospital, 237 Barton Street East, Hamilton, ON, L8L 2 × 2, Canada
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom
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Stengel D, Renkawitz T. [Low-dose aspirin vs. low molecular weight heparin for thromboprophylaxis after fractures : Critical appraisal of the multicenter PREVENT CLOT trial conducted by the Major Extremity Trauma Research Consortium (METRC)]. Unfallchirurgie (Heidelb) 2023; 126:326-331. [PMID: 36806888 DOI: 10.1007/s00113-023-01301-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Dirk Stengel
- Forschung - Ressort Medizin, BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Leipziger Pl. 1, 10117, Berlin, Deutschland.
| | - Tobias Renkawitz
- Orthopädische Universitätsklinik Heidelberg, Heidelberg, Deutschland
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Stengel D, Augat P, Giannoudis PV. Large-scale, pragmatic randomized trials in the era of big data, precision medicine and machine learning. Valid and necessary, or outdated and a waste of resources? Injury 2022:S0020-1383(22)00921-4. [PMID: 36549979 DOI: 10.1016/j.injury.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
During the past decade, more and more large-scale pragmatic clinical trials have been carried out in orthopedic trauma surgery. This trend is fueled by the common belief that the larger the numbers in a trial, the broader the eligibility criteria, and the less strict the regimentation of local treatment standards by protocol, the more trustworthy the findings would be. However, it must also be taken into account that the precision of an outcome measurement does not depend on the sample size alone, but the homogeneity of the studied population. Consequently, a small trial with stringent entry and assessment criteria may offer similarly precise answers as a large trial with less strict entry and assessment criteria because of the basic mathematical correlation between standard deviation and standard error of the mean. There is now a lively and controversial debate about the role of randomized controlled trials (RCT) in an era of stratified medicine driven by the ever increasing understanding and clinical measurability of molecular pathways, making a certain intervention more effective in patients who show a distinct genetic variant. Cluster and pattern recognition by artificial intelligence (AI) and its methodological variety applied to huge datasets and population-based cohorts further propel the spiral of knowledge. Advanced adaptive RCT concepts like enrichment designs, basket and bucket trials, master protocols etc. were developed to combine classic principles of the scientific method with big data, the latter of which have not arrived yet in trauma care. In spite of all biomedical and methodological achievements made, surprisingly such key questions remain unanswered as a) is a certain treatment causally responsible for making a difference in patient-centered outcomes compared to placebo, a control treatment, or the standard of care, b) do the results of a controlled experiment are relevant enough to change clinical practice, and c) under which conditions and assumptions shall we conduct large-scale pragmatic RCTs, focused confirmatory RCTs, or personalized analyses with or without AI support.
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Affiliation(s)
- Dirk Stengel
- BG Kliniken - Hospital Group of the German Federal Statutory Accident Insurance, Leipziger Platz 1, 10117 Berlin, Germany.
| | - Peter Augat
- Institute for Biomechanics, BG Unfallklinik Murnau, Prof.-Kuentscher-Str. 8, 82418, Murnau am Staffelsee, Germany; Institute for Biomechanics, Paracelsus Medical University Salzburg, Strubergasse 21, 5020 Salzburg, Austria
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, United Kingdom; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, United Kingdom
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Stengel D, Mutschler W, Dubs L, Kirschner S, Renkawitz T. [Interpretation of systematic review articles and meta-analyses : Clinical trials in trauma surgery and orthopedics]. Unfallchirurgie (Heidelb) 2022; 125:897-908. [PMID: 36166082 DOI: 10.1007/s00113-022-01244-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 06/16/2023]
Abstract
Clinical trials must be planned and interpreted in the context of current best clinical and scientific evidence, undoubtedly provided by systematic reviews and meta-analyses, especially Cochrane Reviews. While many clinicians feel overwhelmed by this complex data source, few visualElements (e.g., the traffic light system of the Cochrane risk of bias [RoB‑2] tool, forest plots, etc.), together with indices such as the I2 heterogeneity statistic, allow for a quick appraisal of all critical and necessary qualitative and quantitative information. The effectiveness of different treatment options can indirectly be assessed by methodological advancements like network meta-analyses.Point estimates of percentages are insufficient to describe the utility and value of a proposed novel intervention, which, in orthopedic and trauma surgery, often represents a step innovation. 95% confidence intervals and the so-called fragility index are helpful in determining the ultimate patient benefit.
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Affiliation(s)
- Dirk Stengel
- Forschung - Ressort Medizin, BG Kliniken - Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Leipziger Pl. 1, 10117, Berlin, Deutschland.
| | - Wolf Mutschler
- Klinik für Allgemeine, Unfall- und Wiederherstellungschirurgie, LMU Klinikum der Universität München, Nußbaumstr. 20, 80336, München, Deutschland
| | - Luzi Dubs
- FMH für Orthopädische Chirurgie, Rychenbergstr. 155, 8400, Winterthur, Schweiz
| | - Stephan Kirschner
- Klinik für Orthopädie, St. Vincentius-Kliniken gAG, Steinhäuserstr. 18, 76135, Karlsruhe, Deutschland
| | - Tobias Renkawitz
- Orthopädie, Unfallchirurgie und Paraplegiologie, Orthopädische Universitätsklinik Heidelberg, Im Neuenheimer Feld 672, 69120, Heidelberg, Deutschland
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Hoenning A, Lemcke J, Rot S, Stengel D, Hoppe B, Zappel K, Schuss P, Mutze S, Goelz L. Middle Meningeal Artery Embolization Minimizes Burdensome Recurrence Rates After Newly Diagnosed Chronic Subdural Hematoma Evacuation (MEMBRANE): study protocol for a randomized controlled trial. Trials 2022; 23:703. [PMID: 35996195 PMCID: PMC9396835 DOI: 10.1186/s13063-022-06506-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
Background Chronic subdural hematoma (cSDH) is the most common complication of mild traumatic brain injury demanding neurosurgery in high-income countries. If undetected and untreated, cSDH may increase intracranial pressure and cause neurological deficiencies. The first-line intervention of choice is burr hole trepanation and hematoma evacuation. However, any third patient may experience rebleeding, demanding craniotomy with excess morbidity. Adjunct endovascular embolization of the frontal and parietal branches of the middle meningeal artery (MMA) is a promising approach to avoid relapse and revision but was hitherto not studied in a randomized trial. Methods MEMBRANE is an investigator-initiated, single-center, randomized controlled trial. Male, female, and diverse patients older than 18 years scheduled for surgical evacuation of a first cSDH will be assigned in a 1:1 fashion by block randomization to the intervention (surgery plus endovascular MMA embolization) or the control group (surgery alone). The primary trial endpoint is cSDH recurrence within 3 months of follow-up after surgery. Secondary endpoints comprise neurological deficits assessed by the modified Rankin Scale (mRS) and recurrence- or intervention-associated complications during 3 months of follow-up. Assuming a risk difference of 20% of rebleeding and surgical revision, a power of 80%, and a drop-out rate of 10%, 154 patients will be enrolled onto this trial, employing an adaptive O’Brien-Fleming approach with a planned interim analysis halfway. Discussion The MEMBRANE trial will provide first clinical experimental evidence on the effectiveness of endovascular embolization of the MMA as an adjunct to surgery to reduce the risk of recurrence after the evacuation of cSDH. Trial registration German Clinical Trials Registry (Deutsches Register Klinischer Studien [DRKS]) DRKS00020465. Registered on 18 Nov 2021. ClinicalTrials.gov NCT05327933. Registered on 13 Apr 2022.
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Affiliation(s)
- Alexander Hoenning
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.
| | - Johannes Lemcke
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Sergej Rot
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Dirk Stengel
- BG Kliniken - Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Leipziger Pl. 1, 10117, Berlin, Germany
| | - Berthold Hoppe
- Institute of Laboratory Medicine, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Kristina Zappel
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Patrick Schuss
- Department of Neurosurgery, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Sven Mutze
- Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
| | - Leonie Goelz
- Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
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Firle C, Steinmetz A, Stier O, Stengel D, Ekkernkamp A. Aerosol emission from playing wind instruments and related COVID-19 infection risk during music performance. Sci Rep 2022; 12:8598. [PMID: 35597808 PMCID: PMC9124212 DOI: 10.1038/s41598-022-12529-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/29/2022] [Indexed: 12/29/2022] Open
Abstract
The pandemic of COVID-19 led to restrictions in all kinds of music activities. Airborne transmission of SARS-CoV-2 requires risk assessment of wind instrument playing in various situations. Previous studies focused on short-range transmission, whereas long-range transmission risk has not been assessed. The latter requires knowledge of aerosol emission rates from wind instrument playing. We measured aerosol concentrations in a hermetically closed chamber of 20 m3 in an operating theatre as resulting from 20 min standardized wind instrument playing (19 flute, 11 oboe, 1 clarinet, 1 trumpet players). We calculated aerosol emission rates showing uniform distribution for both instrument groups. Aerosol emission from wind instrument playing ranged from 11 ± 288 particles/second (P/s) up to 2535 ± 195 P/s, expectation value ± uncertainty standard deviation. The analysis of aerosol particle size distributions shows that 70–80% of emitted particles had a size of 0.25–0.8 µm and thus are alveolar. Masking the bell with a surgical mask did not reduce aerosol emission. Aerosol emission rates were higher from wind instrument playing than from speaking or breathing. Differences between instrumental groups could not be found but high interindividual variance, as expressed by uniform distribution of aerosol emission rates. Our findings indicate that aerosol emission depends on physiological factors and playing techniques rather than on the type of instrument, in contrast to some previous studies. Based on our results, we present transmission risk calculations for long-range transmission of COVID-19 for three typical woodwind playing situations.
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Affiliation(s)
- Carl Firle
- GP Practice, Dr. Claudia-Isabella Wildfeuer, 10715, Berlin, Germany.
| | - Anke Steinmetz
- Physical and Rehabilitation Medicine, Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany
| | | | - Dirk Stengel
- BG Kliniken-Klinikverbund Der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany.,BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Axel Ekkernkamp
- Physical and Rehabilitation Medicine, Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany.,Department of Trauma, Reconstructive Surgery, and Rehabilitation Medicine, University Medicine Greifswald, Greifswald, Germany.,BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
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Stengel D, Spranger N, Wirth S, Schmittner M. Spinalanästhesie vs. Allgemeinnarkose bei operativer Stabilisierung hüftgelenknaher Femurfrakturen. Unfallchirurg 2022; 125:336-338. [DOI: 10.1007/s00113-022-01146-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2022] [Indexed: 10/19/2022]
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Stengel D, Hönning A, Just S, Mutze S, Ekkernkamp A, Ohmann T, Haase H, Kröpil P, Gölz L. The CRECHE study: testing the urban myth that chocolate Santa Clauses are re-wrapped Easter Bunnies. Med J Aust 2021; 215:531-535. [PMID: 34897722 DOI: 10.5694/mja2.51346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 10/18/2021] [Accepted: 10/20/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To test the urban myth that surplus chocolate Easter Bunnies are re-packaged as Santa Clauses for the following Christmas holiday season. DESIGN Prospective radiographic cohort study of seasonal chocolate figurines, supplemented by anonymous 5-item questionnaire survey of belief in the re-wrapping myth (Generic Risk Items Noted by Chocolate consumers in Health care settings; GRINCH). SETTING Two tertiary referral trauma centres in Germany (Berlin and Duisburg). PARTICIPANTS Eighteen chocolate Easter Bunnies and 15 chocolate Santa Clauses from different manufacturers purchased during 2020; 502 randomly selected people passing through the entrance halls of the two hospitals during 16 September - 12 October 2020. MAIN OUTCOME MEASURES Whole body computed tomography (WBCT) images of chocolate Easter Bunnies and Santa Clauses assessed by four independent, board-certified radiologists using a visual contour resemblance scale (CRS); survey participants' views on statements related to the re-wrapping myth. RESULTS Expert examiners clearly distinguished the WBCT images of chocolate Easter Bunnies and Santa Clauses; the mean difference in CRS was 84.2 points (95% CI, 78.5-90.0 points), with excellent inter-observer agreement (mean intra-class correlation coefficient, 0.99; 95% CI, 0.99-1.00). A total of 214 survey participants (43%) disagreed and 145 (29%) agreed with the proposition that seasonal chocolate figurines are re-packaged and re-sold the following season. CONCLUSION Although about one-third of our survey respondents did not rule out the possibility of seasonal sweets being re-used, WBCT imaging found no similarity between chocolate foil-wrapped Easter and Christmas figurines, providing solid evidence against this urban myth. Chocolate Santa Clauses are unlikely to pose a significant threat to hospital food hygiene requirements. TRIAL REGISTRATION Current Controlled Trials, ISRCTN16847363 (prospective).
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Affiliation(s)
- Dirk Stengel
- BG Kliniken: Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
| | - Alexander Hönning
- Centre for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | - Stephan Just
- BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Sven Mutze
- Institute of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
| | | | | | - Hajo Haase
- Institute of Food Chemistry, Technical University of Berlin, Berlin, Germany
| | | | - Leonie Gölz
- Institute of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
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Stengel D, Leisterer J, Ferrada P, Ekkernkamp A, Mutze S, Hoenning A. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. Emergencias 2021; 32:280-281. [PMID: 32692006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Dirk Stengel
- Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin, Berlín, Alemania
| | | | - Paula Ferrada
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, Estados Unidos
| | - Axel Ekkernkamp
- Klinikum Department of Trauma and Reconstructive Surgery, University Hospital, Greifswald, Alemania
| | - Sven Mutze
- Department of Diagnostic and Interventional Radiology, Unfallkrankenhaus Berlin, Berlín, Alemania
| | - Alexander Hoenning
- Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin, Berlín, Alemania
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Dornberger JE, Rademacher G, Stengel D, Hönning A, Dipl-Phys GS, Eisenschenk A, Mutze S, Goelz L. What Is the Diagnostic Accuracy of Flat-panel Cone-beam CT Arthrography for Diagnosis of Scapholunate Ligament Tears? Clin Orthop Relat Res 2021; 479:151-160. [PMID: 32701771 PMCID: PMC7899599 DOI: 10.1097/corr.0000000000001425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/01/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cone beam CT (CBCT) is a widely available technique with possible indications in carpal ligament injuries. The accuracy of CBCT arthrography in diagnosing traumatic tears of the scapholunate ligament has not been reported. QUESTIONS/PURPOSES (1) What is the diagnostic accuracy of CBCT and how does it relate to the accuracy of multislice CT arthrography and conventional arthrography in diagnosing scapholunate ligament tears? (2) What is the estimated magnitude of skin radiation doses of each method? METHODS This secondary analysis of a previous prospective study included 71 men and women with suspected scapholunate ligament tears and indications for arthroscopy. Preoperative imaging was conventional arthrography and either MSCT arthrography for the first half of patients to be included (n = 36) or flat-panel CBCT arthrography for the remaining patients (n = 35). Index tests identified therapy-relevant SLL tears with dorsal or complete SLL ruptures, and these tears were compared with relevant SLL tears which were determined through arthroscopy as Geissler Stadium III and IV by probing the instable SL joint with a microhook or arthroscope. These injuries were treated by open ligament repair and Kirschner wire fixation. Accuracy values and 95% confidence intervals were calculated. Additional estimates of the radiation skin doses of each CBCT exam and two MSCT protocols were subsequently calculated using dose area products, dose length products, and CT dose indices. RESULTS The diagnostic accuracy was high for all imaging methods. 95% CIs were broadly overlapping and therefore did not indicate differences between the diagnostic groups: Sensitivity of CBCT arthrography was 100% (95% CI 77 to 100), specificity was 95% (95% CI 76 to 99.9), positive predictive value was 93% (95% CI 68 to 99.8), and negative predictive value was 100% (95% CI 83 to 100). For MSCT arthrography, the sensitivity was 92% (95% CI 64 to 99.8), specificity was 96% (95% CI 78 to 99.9), positive predictive value was 92% (95% CI 64 to 99.8), and negative predictive value was 96% (95% CI 78 to 99.9). For conventional arthrography, the sensitivity was comparably high: 96% (95% CI 81 to 99.9). Specificity was (81% [95% CI 67 to 92]); the positive predictive value was 77% (95% CI 59 to 89) and negative predictive value was 97% (95% CI 86 to 99.9). Estimated mean (range) radiation skin doses were reported in a descriptive fashion and were 12.9 mSv (4.5 to 24.9) for conventional arthrography, and 3.2 mSv (2.0 to 4.8) for CBCT arthrography. Estimated radiation skin doses were 0.2 mSv and 12 mSv for MSCT arthrography, depending on the protocol. CONCLUSION Flat-panel CBCT arthrography can be recommended as an accurate technique to diagnose scapholunate ligament injuries after wrist trauma. Estimated skin doses are low for CBCT arthrography and adapted MSCT arthrography protocols. LEVEL OF EVIDENCE Level III, diagnostic study.
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Affiliation(s)
- Jenny E Dornberger
- J. E. Dornberger, Burn Centre with Plastic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- J. E. Dornberger, A. Eisenschenk, Department of Hand, Replantation and Microsurgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- G. Rademacher, G. Schüler, S. Mutze, L. Goelz, Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
- D. Stengel, A. Hönning, Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- A. Eisenschenk, Department of Hand Surgery and Microsurgery, University Medicine Greifswald, Greifswald, Germany
- S. Mutze, L. Goelz, Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Grit Rademacher
- J. E. Dornberger, Burn Centre with Plastic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- J. E. Dornberger, A. Eisenschenk, Department of Hand, Replantation and Microsurgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- G. Rademacher, G. Schüler, S. Mutze, L. Goelz, Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
- D. Stengel, A. Hönning, Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- A. Eisenschenk, Department of Hand Surgery and Microsurgery, University Medicine Greifswald, Greifswald, Germany
- S. Mutze, L. Goelz, Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Dirk Stengel
- J. E. Dornberger, Burn Centre with Plastic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- J. E. Dornberger, A. Eisenschenk, Department of Hand, Replantation and Microsurgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- G. Rademacher, G. Schüler, S. Mutze, L. Goelz, Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
- D. Stengel, A. Hönning, Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- A. Eisenschenk, Department of Hand Surgery and Microsurgery, University Medicine Greifswald, Greifswald, Germany
- S. Mutze, L. Goelz, Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Alexander Hönning
- J. E. Dornberger, Burn Centre with Plastic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- J. E. Dornberger, A. Eisenschenk, Department of Hand, Replantation and Microsurgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- G. Rademacher, G. Schüler, S. Mutze, L. Goelz, Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
- D. Stengel, A. Hönning, Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- A. Eisenschenk, Department of Hand Surgery and Microsurgery, University Medicine Greifswald, Greifswald, Germany
- S. Mutze, L. Goelz, Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Gabriele Schüler Dipl-Phys
- J. E. Dornberger, Burn Centre with Plastic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- J. E. Dornberger, A. Eisenschenk, Department of Hand, Replantation and Microsurgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- G. Rademacher, G. Schüler, S. Mutze, L. Goelz, Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
- D. Stengel, A. Hönning, Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- A. Eisenschenk, Department of Hand Surgery and Microsurgery, University Medicine Greifswald, Greifswald, Germany
- S. Mutze, L. Goelz, Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Andreas Eisenschenk
- J. E. Dornberger, Burn Centre with Plastic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- J. E. Dornberger, A. Eisenschenk, Department of Hand, Replantation and Microsurgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- G. Rademacher, G. Schüler, S. Mutze, L. Goelz, Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
- D. Stengel, A. Hönning, Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- A. Eisenschenk, Department of Hand Surgery and Microsurgery, University Medicine Greifswald, Greifswald, Germany
- S. Mutze, L. Goelz, Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Sven Mutze
- J. E. Dornberger, Burn Centre with Plastic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- J. E. Dornberger, A. Eisenschenk, Department of Hand, Replantation and Microsurgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- G. Rademacher, G. Schüler, S. Mutze, L. Goelz, Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
- D. Stengel, A. Hönning, Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- A. Eisenschenk, Department of Hand Surgery and Microsurgery, University Medicine Greifswald, Greifswald, Germany
- S. Mutze, L. Goelz, Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Leonie Goelz
- J. E. Dornberger, Burn Centre with Plastic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- J. E. Dornberger, A. Eisenschenk, Department of Hand, Replantation and Microsurgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- G. Rademacher, G. Schüler, S. Mutze, L. Goelz, Department of Radiology and Neuroradiology, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
- D. Stengel, A. Hönning, Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin, Germany
- D. Stengel, Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Germany
- A. Eisenschenk, Department of Hand Surgery and Microsurgery, University Medicine Greifswald, Greifswald, Germany
- S. Mutze, L. Goelz, Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
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Stengel D, Mutze S, Güthoff C, Weigeldt M, von Kottwitz K, Runge D, Razny F, Lücke A, Müller D, Ekkernkamp A, Kahl T. Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma. JAMA Surg 2020; 155:224-232. [PMID: 31940019 PMCID: PMC6990738 DOI: 10.1001/jamasurg.2019.5468] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Question Is low-dose whole-body computed tomography with statistical image reconstruction associated with similar rates of missed injuries and accuracy but reduced radiation exposure compared with standard-dose whole-body computed tomography in the primary diagnostic workup of blunt multiple trauma? Findings In this quasi-experimental cohort study of 971 patients with suspected blunt multiple trauma, participants in the standard-dose and low-dose whole-body computed tomography groups had the same risk of missed injury diagnoses. Low-dose scanning markedly reduced exposure to radiation, improved the contrast-to-noise ratio, and showed similar diagnostic accuracy among the investigated anatomical areas and organs when compared with standard-dose scanning. Meaning These findings suggest that low-dose whole-body computed tomography may safely replace standard-dose scanning in the primary diagnostic workup of blunt multiple trauma. Importance Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure. Objective To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure. Design, Setting, and Participants This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019. Interventions Standard- or low-dose WBCT. Main Outcomes and Measures The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy. Results Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, −2.0% [95% CI, −7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001). Conclusions and Relevance Low-dose WBCT using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.
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Affiliation(s)
- Dirk Stengel
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany.,Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany.,BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
| | - Sven Mutze
- Institute of Radiology, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany.,Institute for Diagnostic Radiology and Neuroradiology, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Claas Güthoff
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Moritz Weigeldt
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Konrad von Kottwitz
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Domenique Runge
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Filip Razny
- Institute of Radiology, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Anna Lücke
- Institute of Radiology, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Dirk Müller
- Consultant in radiation physics, Hamburg, Germany
| | - Axel Ekkernkamp
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany.,BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany.,Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Thomas Kahl
- Institute of Radiology, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
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Stengel D, Mutschler W, Renkawitz T. [Surgical treatment of displaced hip fractures by total hip arthroplasty or hemiarthroplasty : Results of the multicentric international HEALTH trial]. Unfallchirurg 2020; 123:665-668. [PMID: 32519089 DOI: 10.1007/s00113-020-00831-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Dirk Stengel
- Forschung, BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Leipziger Platz 1, 10117, Berlin, Deutschland.
| | - Wolf Mutschler
- Klinik für Unfallchirurgie, Klinikum der Universität München, München, Deutschland
| | - Tobias Renkawitz
- Orthopädische Universitätsklinik Regensburg, Bad Abbach, Deutschland
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Renkawitz T, Stengel D. [Reduced postoperative knee pain after operative stabilization of tibial shaft fractures using a suprapatellar approach for tibial nailing : Results of a prospective randomized multicenter trial]. Unfallchirurg 2020; 123:339-340. [PMID: 32052082 DOI: 10.1007/s00113-020-00785-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- T Renkawitz
- Orthopädische Universitätsklinik Regensburg, Kaiser-Karl V. Allee 3, 93077, Bad Abbach, Deutschland.
| | - D Stengel
- Forschung, BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Berlin, Deutschland
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Eisenschenk A, Spitzmüller R, Güthoff C, Obladen A, Kim S, Henning E, Dornberger JE, Stengel D. Single versus dual Kirschner wires for closed reduction and intramedullary nailing of displaced fractures of the fifth metacarpal neck (1-2 KiWi): a randomized controlled trial. Bone Joint J 2019; 101-B:1263-1271. [PMID: 31564142 DOI: 10.1302/0301-620x.101b10.bjj-2019-0410.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIMS The aim of this study was to investigate whether clinical and radiological outcomes after intramedullary nailing of displaced fractures of the fifth metacarpal neck using a single thick Kirschner wire (K-wire) are noninferior to those of technically more demanding fixation with two thinner dual wires. PATIENTS AND METHODS This was a multicentre, parallel group, randomized controlled noninferiority trial conducted at 12 tertiary trauma centres in Germany. A total of 290 patients with acute displaced fractures of the fifth metacarpal neck were randomized to either intramedullary single-wire (n = 146) or dual-wire fixation (n = 144). The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire six months after surgery, with a third of the minimal clinically important difference (MCID) used as the noninferiority threshold. Secondary outcomes were pain, health-related quality of life (EuroQol five-dimensional questionnaire (EQ-5D)), radiological measures, functional deficits, and complications. RESULTS Overall, 151/290 of patients (52%) completed the six months of follow-up, leaving 83 patients in the single-wire group and 68 patients in the dual-wire group. In the modified intention-to-treat analysis set, mean DASH scores six months after surgery were 3.8 (sd 7.0) and 4.4 (sd 9.4), respectively. With multiple imputation (n = 288), mean DASH scores were estimated at 6.3 (sd 8.7) and 7.0 (sd 10.0). Upper (1 - 2α)) confidence limits consistently remained below the noninferiority margin of 3.0 points in the DASH instrument. While there was a statistically nonsignificant trend towards a higher rate of shortening and rotational malalignment in the single wire group, no statistically significant differences were observed across groups in any secondary outcome measure. CONCLUSION A single thick K-wire is sufficient for intramedullary fixation of acute displaced subcapital fractures of the fifth metacarpal neck. The less technically demanding single-wire technique produces noninferior clinical and radiological outcomes compared with the dual-wire approach. Cite this article: Bone Joint J 2019;101-B:1263-1271.
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Affiliation(s)
- Andreas Eisenschenk
- Department of Hand, Replantation and Microsurgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany.,Department of Trauma, Reconstructive Surgery and Rehabilitative Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Romy Spitzmüller
- Department of Trauma, Reconstructive Surgery and Rehabilitative Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Claas Güthoff
- Centre for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Adrian Obladen
- Department of Hand, Replantation and Microsurgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Simon Kim
- Department of Trauma, Reconstructive Surgery and Rehabilitative Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Esther Henning
- Department of Trauma, Reconstructive Surgery and Rehabilitative Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Jenny E Dornberger
- Burn Centre and Department of Plastic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Dirk Stengel
- Department of Research, Business Division Medicine, BG Kliniken - Klinikverbund der gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
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Parsons N, Carey-Smith R, Dritsaki M, Griffin X, Metcalfe D, Perry D, Stengel D, Costa M. Statistical significance and p-values: guidelines for use and reporting. Bone Joint J 2019; 101-B:1179-1183. [PMID: 31564151 DOI: 10.1302/0301-620x.101b10.bjj-2019-0890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Nick Parsons
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Richard Carey-Smith
- Sir Charles Gairdner Hospital and The University of Western Australia, Nedlands, Perth, Australia
| | - Melina Dritsaki
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Xavier Griffin
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David Metcalfe
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Daniel Perry
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Dirk Stengel
- Department of Trauma and Orthopaedic Surgery, Centre for Clinical Research, Unfallkrankenhaus Berlin, Berlin, Germany
| | - Matthew Costa
- Oxford Trauma, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Schulz-Drost S, Ekkernkamp A, Stengel D. [Epidemiology, injury entities and treatment practice for chest wall injuries : Current scientific knowledge and treatment recommendations]. Unfallchirurg 2019; 121:605-614. [PMID: 30073550 DOI: 10.1007/s00113-018-0532-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fractures of the bony chest wall are common injuries. They affect almost every second severely injured person and are gaining more and more importance even after low-energy accidents, especially among older people. Complications mainly occur due to respiratory insufficiency, secondary pulmonary complications and remaining deformities with a functional disorder of the chest wall. In addition to the important conservative therapeutic measures, such as a differentiated pain therapy and pneumonia prophylaxis, operative stabilization of fractures can be an option; however, this is still controversially discussed. OBJECTIVE A thematically structured overview provides basic knowledge on rib and sternal fractures as well as the treatment options. MATERIAL AND METHODS Epidemiological facts are presented based on the relevant literature and clinical experience. Anatomical principles are intended to improve understanding of the various entities of rib and sternal fractures. For this purpose, the new AO‑/OTA classification system is presented and finally therapeutic options including different osteosynthesis procedures are presented and their importance discussed. RESULTS AND DISCUSSION Multimodal therapy concepts and closely controlled follow-up examinations of fractures avoid complications or can detect them early. Bony chest wall injuries should still be evaluated for complications and typical fracture patterns identified and classified. Modern osteosynthesis procedures with high patient safety and soft tissue-preserving tissue preparation for the surgical access route to the ribs and sternum provide an excellent opportunity for successful restoration of the anatomical and physiological integrity of the bony thorax.
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Affiliation(s)
- S Schulz-Drost
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland.
| | - A Ekkernkamp
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
| | - D Stengel
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
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Spitzmüller R, Gümbel D, Güthoff C, Zaatreh S, Klinder A, Napp M, Bader R, Mittelmeier W, Ekkernkamp A, Kramer A, Stengel D. Duration of antibiotic treatment and risk of recurrence after surgical management of orthopaedic device infections: a multicenter case-control study. BMC Musculoskelet Disord 2019; 20:184. [PMID: 31043177 PMCID: PMC6495646 DOI: 10.1186/s12891-019-2574-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 04/15/2019] [Indexed: 11/10/2022] Open
Abstract
Background Device-related infections in orthopaedic and trauma surgery are a devastating complication with substantial impact on morbidity and mortality. Systemic suppressive antibiotic treatment is regarded an integral part of any surgical protocol intended to eradicate the infection. The optimal duration of antimicrobial treatment, however, remains unclear. In a multicenter case-control study, we aimed at analyzing the influence of the duration of antibiotic exposure on reinfection rates 1 year after curative surgery. Methods This investigation was part of a federally funded multidisciplinary network project aiming at reducing the spread of multi-resistant bacteria in the German Baltic region of Pomerania. We herein used hospital chart data from patients treated for infections of total joint arthroplasties or internal fracture fixation devices at three academic referral institutions. Subjects with recurrence of an implant-related infection within 1 year after the last surgical procedure were defined as case group, and patients without recurrence of an implant-related infection as control group. We placed a distinct focus on infection of open reduction and internal fixation (ORIF) constructs. Uni- and multivariate logistic regression analyses were employed for data modelling. Results Of 1279 potentially eligible patients, 269 were included in the overall analysis group, and 84 contributed to an extramedullary fracture-fixation-device sample. By multivariate analysis, male sex (odds ratio [OR] 2.06, 95% confidence interval [CI] 1.08 to 3.94, p = 0.029) and facture fixation device infections (OR 2.05, 95% CI 1.05 to 4.02, p = 0.036) remained independent predictors of reinfection. In the subgroup of infected ORIF constructs, univariate point estimates suggested a nearly 60% reduced odds of reinfection with systemic fluoroquinolones (OR 0.42, 95% CI 0.04 to 2.46) or rifampicin treatment (OR 0.41, 95% CI 0.08 to 2.12) for up to 31 days, although the width of confidence intervals prohibited robust statistical and clinical inferences. Conclusion The optimal duration of systemic antibiotic treatment with surgical concepts of curing wound and device-related orthopaedic infections is still unclear. The risk of reinfection in case of infected extramedullary fracture-fxation devices may be reduced with up to 31 days of systemic fluoroquinolones and rifampicin, although scientific proof needs a randomized trial with about 1400 subjects per group. Concerted efforts are needed to determine which antibiotics must be applied for how long after radical surgical sanitation to guarantee sustainable treatment success.
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Affiliation(s)
- Romy Spitzmüller
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Str, 17475, Greifswald, Germany.
| | - Denis Gümbel
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Str, 17475, Greifswald, Germany.,Department of Trauma and Orthopaedic Surgery, BG Hospital Unfallkrankenhaus Berlin gGmbH, Warener Str 7, 12683, Berlin, Germany
| | - Claas Güthoff
- Center for Clinical Research, BG Hospital Unfallkrankenhaus Berlin gGmbH, Warener Str 7, 12683, Berlin, Germany
| | - Sarah Zaatreh
- Department of Orthopaedics, University Medicine Rostock, Doberaner Str 142, 18057, Rostock, Germany
| | - Annett Klinder
- Department of Orthopaedics, University Medicine Rostock, Doberaner Str 142, 18057, Rostock, Germany
| | - Matthias Napp
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Str, 17475, Greifswald, Germany
| | - Rainer Bader
- Department of Orthopaedics, University Medicine Rostock, Doberaner Str 142, 18057, Rostock, Germany
| | - Wolfram Mittelmeier
- Department of Orthopaedics, University Medicine Rostock, Doberaner Str 142, 18057, Rostock, Germany
| | - Axel Ekkernkamp
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Str, 17475, Greifswald, Germany
| | - Axel Kramer
- Department of Hygiene and Environmental Medicine, University Medicine Greifswald, Walther-Rathenau-Str 49A, 17489, Greifswald, Germany
| | - Dirk Stengel
- BG Kliniken Group of Hospitals, Leipziger Pl 1, 10117, Berlin, Germany
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Scholz R, Hönning A, Seifert J, Spranger N, Stengel D. Effectiveness of architectural separation of septic and aseptic operating theatres for improving process quality and patient outcomes: a systematic review. Syst Rev 2019; 8:16. [PMID: 30626433 PMCID: PMC6325836 DOI: 10.1186/s13643-018-0937-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 12/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Architectural division of aseptic and septic operating theatres is a distinct structural feature of surgical departments in Germany. Internationally, hygienists and microbiologists mainly recommend functional separation (i.e. aseptic procedures first) without calling for separate operating floors and rooms. However, patients with severe musculoskeletal infections (e.g. joint empyema, spondylodiscitis, deep implant-associated infections) may benefit from the permanent availability of septic operating capacities without delay caused by an ongoing aseptic surgical program. A systematic literature review on the influence of a structural separation of septic and aseptic operating theatres on process and/or outcome quality has not yet been conducted. METHODS Systematic literature search in PubMed MEDLINE, Ovid Embase, CINAHL and the Cochrane Library, screening of referenced citations, and assessment of grey literature. RESULTS A total of 572 articles were found through the systematic literature search. No head-to-head studies (neither randomised, quasi-randomised nor observational) were identified which examined the impact of structural separation of septic and aseptic operating theatres on process and/or outcome quality. CONCLUSIONS This review did not identify evidence in favour nor against architectural separation of septic or aseptic operating theatre. Specifically, there is no evidence of a harmful effect of architectural separation. Unless prospective studies, ideally randomised trials, will be available, it is unjustified to call for abolishing established hospital structures. Future investigations must address patient-centered endpoints, surgical site infections, process quality and hospital economy. SYSTEMATIC REVIEW REGISTRATION PROSPERO (International prospective register of systematic reviews): CRD42018086568.
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Affiliation(s)
- Romy Scholz
- Centre for Clinical Research, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Alexander Hönning
- Centre for Clinical Research, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Julia Seifert
- Department of Trauma and Orthopaedic Surgery, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Nikolai Spranger
- Department of Trauma and Orthopaedic Surgery, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
| | - Dirk Stengel
- Centre for Clinical Research, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
- Department of Trauma and Orthopaedic Surgery, BG Hospital Unfallkrankenhaus Berlin, Berlin, Germany
- Hospital Group of the Statutory Accident Insurance, Berlin, Germany
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25
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Wippert PM, Arampatzis A, Banzer W, Beck H, Hasenbring MI, Schiltenwolf M, Schneider C, Stengel D, Platen P, Mayer F. Psychosoziale Risikofaktoren in der Entstehung von chronisch unspezifischen Rückenschmerzen. Zeitschrift für Sportpsychologie 2019. [DOI: 10.1026/1612-5010/a000245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Zusammenfassung. Chronisch unspezifische Rückenschmerzen (CURS) gehören international zu den häufigsten Schmerzphänomenen und können für Athletinnen und Athleten karrierelimitierend sein. Knapp ein Drittel der jährlichen Trainingsausfallzeiten werden auf CURS zurückgeführt. In der Entstehung von chronischen Schmerzen ist ein multifaktorielles Ätiologiemodell mit einem signifikanten Einfluss psychosozialer Risikofaktoren evident. Obwohl dies in der Allgemeinbevölkerung bereits gut erforscht ist, gibt es in der Sportwissenschaft vergleichsweise wenige Arbeiten darüber. Dieses Thema wird daher in drei Multicenterstudien und zahlreichen Teilstudien des MiSpEx-Netzwerks ( Medicine in Spine-Exercise-Network, Förderzeitraum 2011 – 2018) aufgegriffen. Entsprechend der Empfehlung einer frühzeitigen Diagnostik von Chronifizierungsfaktoren in der „Nationalen Versorgungsleitlinie Kreuzschmerz“, beschäftigt sich das Netzwerk u. a. mit der Überprüfung, Entwicklung und Evaluation diagnostischer Möglichkeiten. Der vorliegende Beitrag beschreibt die Entwicklung einer Diagnostik von psychosozialen Risikofaktoren, die einerseits eine Einschätzung des Risikos der Entwicklung von CURS und andererseits eine individuelle Zuweisung zu (Trainings)Interventionen erlaubt. Es wird die Entwicklungsrationale beschrieben und dabei verschiedene methodische Herangehensweisen und Entscheidungssequenzen reflektiert.
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Affiliation(s)
| | - Adamantios Arampatzis
- Department für Trainings- und Bewegungswissenschaften, Humboldt-Universität zu Berlin
| | - Winfried Banzer
- Abteilung für Trainings- und Sportmedizin, Goethe-Universität Frankfurt am Main
| | - Heidrun Beck
- Centrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, Dresden
| | | | | | - Christian Schneider
- Sportorthopädisches Institut der Schön Klinik München Harlaching
- Orthopädiezentrum Theresie, München
| | - Dirk Stengel
- Zentrum für Klinische Forschung, Unfallkrankenhaus Berlin
| | - Petra Platen
- Fakultät für Sportwissenschaft, Sportmedizin und Sporternährung, Ruhr-Universität Bochum
| | - Frank Mayer
- Zentrum für Sportmedizin, Universität Potsdam, Hochschulambulanz
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Stengel D, Leisterer J, Ferrada P, Ekkernkamp A, Mutze S, Hoenning A. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. Cochrane Database Syst Rev 2018; 12:CD012669. [PMID: 30548249 PMCID: PMC6517180 DOI: 10.1002/14651858.cd012669.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Point-of-care sonography (POCS) has emerged as the screening modality of choice for suspected body trauma in many emergency departments worldwide. Its best known application is FAST (focused abdominal sonography for trauma). The technology is almost ubiquitously available, can be performed during resuscitation, and does not expose patients or staff to radiation. While many authors have stressed the high specificity of POCS, its sensitivity varied markedly across studies. This review aimed to compile the current best evidence about the diagnostic accuracy of POCS imaging protocols in the setting of blunt thoracoabdominal trauma. OBJECTIVES To determine the diagnostic accuracy of POCS for detecting and excluding free fluid, organ injuries, vascular lesions, and other injuries (e.g. pneumothorax) compared to a diagnostic reference standard (i.e. computed tomography (CT), magnetic resonance imaging (MRI), thoracoscopy or thoracotomy, laparoscopy or laparotomy, autopsy, or any combination of these) in patients with blunt trauma. SEARCH METHODS We searched Ovid MEDLINE (1946 to July 2017) and Ovid Embase (1974 to July 2017), as well as PubMed (1947 to July 2017), employing a prospectively defined literature and data retrieval strategy. We also screened the Cochrane Library, Google Scholar, and BIOSIS for potentially relevant citations, and scanned the reference lists of full-text papers for articles missed by the electronic search. We performed a top-up search on 6 December 2018, and identified eight new studies which may be incorporated into the first update of this review. SELECTION CRITERIA We assessed studies for eligibility using predefined inclusion and exclusion criteria. We included either prospective or retrospective diagnostic cohort studies that enrolled patients of any age and gender who sustained any type of blunt injury in a civilian scenario. Eligible studies had to provide sufficient information to construct a 2 x 2 table of diagnostic accuracy to allow for calculating sensitivity, specificity, and other indices of diagnostic test accuracy. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles, abstracts, and full texts of reports using a prespecified data extraction form. Methodological quality of individual studies was rated by the QUADAS-2 instrument (the revised and updated version of the original Quality Assessment of Diagnostic Accuracy Studies list of items). We calculated sensitivity and specificity with 95% confidence intervals (CI), tabulated the pairs of sensitivity and specificity with CI, and depicted these estimates by coupled forest plots using Review Manager 5 (RevMan 5). For pooling summary estimates of sensitivity and specificity, and investigating heterogeneity across studies, we fitted a bivariate model using Stata 14.0. MAIN RESULTS We included 34 studies with 8635 participants in this review. Summary estimates of sensitivity and specificity were 0.74 (95% CI 0.65 to 0.81) and 0.96 (95% CI 0.94 to 0.98). Pooled positive and negative likelihood ratios were estimated at 18.5 (95% CI 10.8 to 40.5) and 0.27 (95% CI 0.19 to 0.37), respectively. There was substantial heterogeneity across studies, and the reported accuracy of POCS strongly depended on the population and affected body area. In children, pooled sensitivity of POCS was 0.63 (95% CI 0.46 to 0.77), as compared to 0.78 (95% CI 0.69 to 0.84) in an adult or mixed population. Associated specificity in children was 0.91 (95% CI 0.81 to 0.96) and in an adult or mixed population 0.97 (95% CI 0.96 to 0.99). For abdominal trauma, POCS had a sensitivity of 0.68 (95% CI 0.59 to 0.75) and a specificity of 0.95 (95% CI 0.92 to 0.97). For chest injuries, sensitivity and specificity were calculated at 0.96 (95% CI 0.88 to 0.99) and 0.99 (95% CI 0.97 to 1.00). If we consider the results of all 34 included studies in a virtual population of 1000 patients, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 28%, POCS would miss 73 patients with injuries and falsely suggest the presence of injuries in another 29 patients. Furthermore, in a virtual population of 1000 children, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 31%, POCS would miss 118 children with injuries and falsely suggest the presence of injuries in another 62 children. AUTHORS' CONCLUSIONS In patients with suspected blunt thoracoabdominal trauma, positive POCS findings are helpful for guiding treatment decisions. However, with regard to abdominal trauma, a negative POCS exam does not rule out injuries and must be verified by a reference test such as CT. This is of particular importance in paediatric trauma, where the sensitivity of POCS is poor. Based on a small number of studies in a mixed population, POCS may have a higher sensitivity in chest injuries. This warrants larger, confirmatory trials to affirm the accuracy of POCS for diagnosing thoracic trauma.
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Affiliation(s)
- Dirk Stengel
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryBerlinGermany12683
| | | | - Paula Ferrada
- Virginia Commonwealth UniversityDepartment of SurgeryRichmondVAUSA
| | - Axel Ekkernkamp
- University HospitalDepartment of Trauma and Reconstructive SurgeryGreifswaldGermany17475
| | - Sven Mutze
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
| | - Alexander Hoenning
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryBerlinGermany12683
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Scholz R, Lemcke J, Meier U, Stengel D. Efficacy and safety of programmable compared with fixed anti-siphon devices for treating idiopathic normal-pressure hydrocephalus (iNPH) in adults - SYGRAVA: study protocol for a randomized trial. Trials 2018; 19:566. [PMID: 30333067 PMCID: PMC6192316 DOI: 10.1186/s13063-018-2951-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 09/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Idiopathic normal-pressure hydrocephalus (iNPH) is a distinct form of dementia, characterized by gait ataxia, cognitive impairment and urinary incontinence. In contrast to all other causes of dementia (e.g., Alzheimer-type and others), ventriculoperitoneal (VP) shunt surgery may offer a curative treatment option to patients. While being a rather low-risk type of surgery, it may cause significant over- or underdrainage complications (e.g., headaches, dizziness, vomiting, intracerebral bleeding, etc.) during posture change. Anti-siphon devices (ASDs) are a group of technically different additional valves used in shunt surgery. They are designed to maintain intraventricular pressure within a normal physiological range regardless of patient position. Fixed ASDs proved to substantially lower the rate of overdrainage complications. No significant differences, however, were noted regarding underdrainage complications. Technical successors of fixed ASDs are programmable ASDs. The aim of this study is to evaluate whether programmable ASDs compared to fixed ASDs are able to avoid both over- and underdrainage complications. METHODS/DESIGN In this investigator-initiated, multicenter randomized trial, 306 patients are planned to be recruited. Male and female patients aged ≥18 years with iNPH who are eligible for VP shunt surgery and meet all other entry criteria can participate. Patients will be randomized in a balanced 1: 1 fashion to a VP shunt with a programmable valve either supplemented with a fixed ASD, or a programmable ASD. Patients will be followed-up 3, 6 and, on an optional basis, 12 months after surgery. The primary outcome measure is the cumulative incidence of over- or underdrainage 6 months post surgery, as defined by clinical and imaging parameters. DISCUSSION SYGRAVA is the first randomized trial to determine whether programmable ASDs reduce complications of drainage compared to fixed ASDs in patients with iNPH. The results of this study may contribute to health-technology assessment of different valve systems used for VP-shunt surgery, and determination of the future standard of care. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number: ISRCTN13838310 . Registered on 10 November 2016.
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Affiliation(s)
- Romy Scholz
- Centre for Clinical Research, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.
| | - Ullrich Meier
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Dirk Stengel
- Centre for Clinical Research, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Department of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Julius Wolff Institute, Charité Medical University Centre, Augustenburger Platz 1, 13353, Berlin, Germany
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Addison B, Onofrei D, Stengel D, Blass B, Brenneman B, Ayon J, Holland GP. Spider prey-wrapping silk is an α-helical coiled-coil/β-sheet hybrid nanofiber. Chem Commun (Camb) 2018; 54:10746-10749. [PMID: 30191228 DOI: 10.1039/c8cc05246h] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Solid-State NMR results on 13C-Ala/Ser and 13C-Val enriched Argiope argentata prey-wrapping silk show that native, freshly spun aciniform silk nanofibers are dominated by α-helical (∼50% total) and random-coil (∼35% total) secondary structures, with minor β-sheet nanocrystalline domains (∼15% total). This is the most in-depth study to date characterizing the protein structural conformation of the toughest natural biopolymer: aciniform prey-wrapping silks.
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Affiliation(s)
- B Addison
- Department of Chemistry and Biochemistry, San Diego State University, San Diego, CA 92182-1030, USA.
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Mayer F, Arampatzis A, Banzer W, Beck H, Brüggemann GP, Hasenbring M, Kellmann M, Kleinert J, Schiltenwolf M, Schmidt H, Schneider C, Stengel D, Wippert PM, Platen P. Medicine in Spine Exercise [MiSpEx] – a national research network to evaluate back
pain. Dtsch Z Sportmed 2018. [DOI: 10.5960/dzsm.2018.340] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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30
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Stengel D, Mauffrey C, Civil I, Gray AC, Roberts C, Pape HC, Evans C, Kool B, Mauffrey OJ, Giannoudis P. Recruitment rates in orthopaedic trauma trials: Zen or the art of riding dead horses. Injury 2017; 48:1719-1721. [PMID: 28807412 DOI: 10.1016/j.injury.2017.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Dirk Stengel
- BG Kliniken Group of Hospitals, BG Klinikum Unfallkrankenhaus Berlin gGmH, Warener Str. 7, 12683 Berlin, Germany.
| | - Cyril Mauffrey
- BG Kliniken Group of Hospitals, BG Klinikum Unfallkrankenhaus Berlin gGmH, Warener Str. 7, 12683 Berlin, Germany
| | - Ian Civil
- BG Kliniken Group of Hospitals, BG Klinikum Unfallkrankenhaus Berlin gGmH, Warener Str. 7, 12683 Berlin, Germany
| | - A C Gray
- BG Kliniken Group of Hospitals, BG Klinikum Unfallkrankenhaus Berlin gGmH, Warener Str. 7, 12683 Berlin, Germany
| | - C Roberts
- BG Kliniken Group of Hospitals, BG Klinikum Unfallkrankenhaus Berlin gGmH, Warener Str. 7, 12683 Berlin, Germany
| | - Hans-Christoph Pape
- BG Kliniken Group of Hospitals, BG Klinikum Unfallkrankenhaus Berlin gGmH, Warener Str. 7, 12683 Berlin, Germany
| | - C Evans
- BG Kliniken Group of Hospitals, BG Klinikum Unfallkrankenhaus Berlin gGmH, Warener Str. 7, 12683 Berlin, Germany
| | - Bridget Kool
- BG Kliniken Group of Hospitals, BG Klinikum Unfallkrankenhaus Berlin gGmH, Warener Str. 7, 12683 Berlin, Germany
| | - O J Mauffrey
- BG Kliniken Group of Hospitals, BG Klinikum Unfallkrankenhaus Berlin gGmH, Warener Str. 7, 12683 Berlin, Germany
| | - Peter Giannoudis
- BG Kliniken Group of Hospitals, BG Klinikum Unfallkrankenhaus Berlin gGmH, Warener Str. 7, 12683 Berlin, Germany
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Fussi J, Perka C, Stengel D, Hönning A, Duda G, Bülow R, Schmidt CO. Verteilung der Ganzbeinachse auf Basis von MRT-Untersuchungen in einer Bevölkerungskohorte – Ist nur ein gerades Bein ein gesundes Bein? Das Gesundheitswesen 2017. [DOI: 10.1055/s-0037-1605918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- J Fussi
- Charité Berlin, CMSC, Berlin
| | - C Perka
- Charité Berlin, CMSC, Berlin
| | - D Stengel
- Unfallkrankenhaus Berlin, Centre for Clinical Research, Berlin
| | - A Hönning
- Unfallkrankenhaus Berlin, Centre for Clinical Research, Berlin
| | - G Duda
- Charité Berlin, Julius Wolff Institute for Biomechanics and Musculosceletal Regeneration, Berlin
| | - R Bülow
- Universitätsmedizin Greifswald, Institut for Community Medicine, Greifswald
| | - CO Schmidt
- Charité Berlin, Julius Wolff Institute for Biomechanics and Musculosceletal Regeneration, Berlin
- Universitätsmedizin Greifswald, Institut for Community Medicine, Greifswald
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32
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Affiliation(s)
- Dirk Stengel
- Unfallkrankenhaus Berlin; Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery; Berlin Germany 12683
| | - Alexander Hoenning
- Unfallkrankenhaus Berlin; Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery; Berlin Germany 12683
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Stengel D, Froese E, Mutschler W, Seifert J. Effektivität gepulsten Ultraschalls zur Beschleunigung der Knochenbruchheilung. Unfallchirurg 2017; 120:269-272. [DOI: 10.1007/s00113-017-0318-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Affiliation(s)
- Stefan Huber-Wagner
- Department of Trauma Surgery, Klinikum rechts der Isar Hospital, Technical University Munich, Munich D-81675, Germany.
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
| | - Karl-Georg Kanz
- Department of Trauma Surgery, Klinikum rechts der Isar Hospital, Technical University Munich, Munich D-81675, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar Hospital, Technical University Munich, Munich D-81675, Germany
| | - Dirk Stengel
- Centre for Clinical Research, Unfallkrankenhaus Berlin, Berlin, Germany
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Mauffrey C, Giannoudis P, Civil I, Gray AC, Roberts C, Pape HC, Evans C, Kool B, Mauffrey OJ, Stengel D. Pearls and pitfalls of open access: The immortal life of Henrietta Lacks. Injury 2017; 48:1-2. [PMID: 28017190 DOI: 10.1016/j.injury.2016.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Stengel D, Bartl C. Distale Radiusfrakturen – Evidence is Shlevidence. Unfallchirurg 2016; 119:706-7. [DOI: 10.1007/s00113-016-0220-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Affiliation(s)
- Theodoros H Tosounidis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK
| | - Dirk Stengel
- Center for Clinical Research at Unfallkrankenhaus Berlin West Yorkshire, Warener Str. 7, 12683 Berlin, Germany
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, UK.
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Abstract
The article "Evidence based medicine: what it is and what it isn't" published in the BMJ in 1996, is regarded as the foundation of the evidence-based medicine (EbM) movement. Approximately 5 years later David L. Sackett, one of the leaders of the movement, requested all experts to voluntarily abandon their position to make way for young researchers and fresh ideas. Since the term was first coined and the establishment of organizations and platforms fostering the idea, EbM has polarized clinicians and scientists around the world. Clinical and methodological developments during recent years have, however, overtaken the original principles of EbM. This review highlights the core concepts of EbM which have remained unchanged and valid for the current practice of trauma and orthopedic surgery and where revision is needed.
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Affiliation(s)
- D Stengel
- Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Deutschland.
| | - S Kirschner
- St. Vincentius-Kliniken gAG, Steinhäuserstraße 18, 76135, Karlsruhe, Deutschland
| | - A Ekkernkamp
- Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Deutschland
| | - C Bartl
- Ärztehaus Nymphenburg, Rosa-Bavarese-Str. 1, 80639, München, Deutschland
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Lemcke J, Stengel D, Stockhammer F, Güthoff C, Rohde V, Meier U. Nationwide Incidence of Normal Pressure Hydrocephalus (NPH) Assessed by Insurance Claim Data in Germany. Open Neurol J 2016; 10:15-24. [PMID: 27330575 PMCID: PMC4891984 DOI: 10.2174/1874205x01610010015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/08/2016] [Accepted: 03/02/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The purpose of this study is to investigate the epidemiology of the idiopathic normal pressure hydrocephalus (iNPH) in Germany. METHODS The database of the nationwide Barmer Health Insurance was queried for specific combinations of corresponding International Classification of Diseases, Ninth Revision (ICD-9) codes and OPS codes (German modification of the ICPM and official classification of surgical procedures) in order to assess the number of patients treated for iNPH and the number surgical procedures associated with the disease in a 10 years period between 2003 and 2012. RESULTS Between 2003 and 2012, the incidence of iNPH increased from zero to 1.36/100.000/year. CONCLUSION This is the first population-based epidemiologic study on iNPH in Germany covering a ten year period.
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Affiliation(s)
- Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Germany
| | - Dirk Stengel
- Center for Clinical Research, Department of Trauma and Orthopedic Surgery, Unfallkrankenhaus Berlin, Germany; Julius Wolff Institute, Charité Medical University Center, Berlin, Germany
| | | | - Claas Güthoff
- Center for Clinical Research, Department of Trauma and Orthopedic Surgery, Unfallkrankenhaus Berlin, Germany
| | - Veit Rohde
- Department of Neurosurgery, Georg August University of Göttingen, Germany
| | - Ullrich Meier
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Germany
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Abstract
BACKGROUND Ultrasonography (performed by means of a four-quadrant, focused assessment of sonography for trauma (FAST)) is regarded as a key instrument for the initial assessment of patients with suspected blunt abdominal and thoraco-abdominal trauma in the emergency department setting. FAST has a high specificity but low sensitivity in detecting and excluding visceral injuries. Proponents of FAST argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of unnecessary multi-detector computed tomography (MDCT) scans, and enable quicker triage to surgical and non-surgical care. Given the proven accuracy, increasing availability of, and indication for, MDCT among patients with blunt abdominal and multiple injuries, we aimed to compile the best available evidence of the use of FAST-based assessment compared with other primary trauma assessment protocols. OBJECTIVES To assess the effects of diagnostic algorithms using ultrasonography including in FAST examinations in the emergency department in relation to the early, late, and overall mortality of patients with suspected blunt abdominal trauma. SEARCH METHODS The most recent search was run on 30th June 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), clinical trials registers, and screened reference lists. Trial authors were contacted for further information and individual patient data. SELECTION CRITERIA We included randomised controlled trials (RCTs). Participants were patients with blunt torso, abdominal, or multiple trauma undergoing diagnostic investigations for abdominal organ injury. The intervention was diagnostic algorithms comprising emergency ultrasonography (US). The control was diagnostic algorithms without US examinations (for example, primary computed tomography (CT) or diagnostic peritoneal lavage (DPL)). Outcomes were mortality, use of CT or invasive procedures (DPL, laparoscopy, laparotomy), and cost-effectiveness. DATA COLLECTION AND ANALYSIS Two authors (DS and CG) independently selected trials for inclusion, assessed methodological quality, and extracted data. Methodological quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible, data were pooled and relative risks (RRs), risk differences (RDs), and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed-effect or random-effects models as appropriate. MAIN RESULTS We identified four studies meeting our inclusion criteria. Overall, trials were of poor to moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. Strong heterogeneity amongst the trials prompted discussion between the review authors as to whether the data should or should not be pooled; we decided in favour of a quantitative synthesis to provide a rough impression about the effect sizes achievable with US-based triage algorithms. We pooled mortality data from three trials involving 1254 patients; the RR in favour of the FAST arm was 1.00 (95% CI 0.50 to 2.00). FAST-based pathways reduced the number of CT scans (random-effects model RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result was unclear. AUTHORS' CONCLUSIONS The experimental evidence justifying FAST-based clinical pathways in diagnosing patients with suspected abdominal or multiple blunt trauma remains poor. Because of strong heterogeneity between the trial results, the quantitative information provided by this review may only be used in an exploratory fashion. It is unlikely that FAST will ever be investigated by means of a confirmatory, large-scale RCT in the future. Thus, this Cochrane Review may be regarded as a review which provides the best available evidence for clinical practice guidelines and management recommendations. It can only be concluded from the few head-to-head studies that negative US scans are likely to reduce the incidence of MDCT scans which, given the low sensitivity of FAST (or reliability of negative results), may adversely affect the diagnostic yield of the trauma survey. At best, US has no negative impact on mortality or morbidity. Assuming that major blunt abdominal or multiple trauma is associated with 15% mortality and a CT-based diagnostic work-up is considered the current standard of care, 874, 3495, or 21,838 patients are needed per intervention group to demonstrate non-inferiority of FAST to CT-based algorithms with non-inferiority margins of 5%, 2.5%, and 1%, power of 90%, and a type-I error alpha of 5%.
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Affiliation(s)
- Dirk Stengel
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryWarener Str 7BerlinGermany12683
| | - Grit Rademacher
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
| | - Axel Ekkernkamp
- University HospitalDepartment of Trauma and Reconstructive SurgeryFerdinand‐Sauerbruch‐StraßeGreifswaldGermany17475
| | - Claas Güthoff
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryWarener Str 7BerlinGermany12683
| | - Sven Mutze
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
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Bartl C, Stengel D, Bruckner T, Gebhard F. The treatment of displaced intra-articular distal radius fractures in elderly patients. Dtsch Arztebl Int 2015; 111:779-87. [PMID: 25491556 DOI: 10.3238/arztebl.2014.0779] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 09/30/2014] [Accepted: 09/30/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND From 2000 to 2012, the annual incidence of inpatient treatment for distal radius fracture in Germany rose from 65 to 86 per 100 000 persons. It is unclear whether open reduction and volar angle-stable plate osteosynthesis (ORIF), a currently advocated treatment, yields a better functional outcome or quality of life than closed reposition and casting. METHODS In the ORCHID multi-center trial, 185 patients aged 65 and older with an AO type C distal radial fracture were randomly assigned to ORIF or closed reposition and casting. Their health-related quality of life and hand/arm function were assessed 3 and 12 months afterward with the Short Form 36 (SF-36) questionnaire and the Disability of the Arm, Shoulder and Hand (DASH) questionnaire. The radiological findings, range of movement of the wrist, and EuroQol-5D (EQ-5D) scores were documented as well. RESULTS Among the 149 patients in the intention-to-treat-analysis, there was no significant difference in SF-36 scores between the two treatment groups at one year (mean difference, 3.3 points in favor of ORIF; 95% confidence interval, -0.2 +6.8 points; p = 0.058). The DASH scores showed moderately strong, but clinically unimportant effects in favor of ORIF, and there was no difference in EQ-5D scores. ORIF led to better radiological results and wrist mobility at 3 months, with comparable results at 12 months. 37 of the patients initially allotted to nonsurgical treatment underwent secondary surgery due to significant loss of reduction. CONCLUSION The findings with respect to mobility, functionality, and quality of life at 12 months provide marginal and inconsistent evidence for the superiority of volar angle-stable plate osteosynthesis over closed reduction and casting in the treatment of intra-articular distal radius fractures. Primary nonsurgical management is also effective in suitable patients.
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Affiliation(s)
- Christoph Bartl
- C. Bartl and D. Stengel have equally contributed to the article, Department of Orthopedic Trauma Surgery, University of Ulm, Center for Clinical Research, Trauma Hospital Berlin, Institute for Medical Biometry and Informatics (IMBI), University of Heidelberg, ORCHID Study Group (a complete list of the study centers and investigators can be found at the end of the article)
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Bartl C, Stengel D, Bruckner T, Gebhard F. In Reply. Dtsch Arztebl Int 2015. [PMID: 26214238 DOI: 10.3238/arztebl.2015.0487b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Meier U, Stengel D, Müller C, Fritsch MJ, Kehler U, Langer N, Kiefer M, Eymann R, Schuhmann MU, Speil A, Weber F, Remenez V, Rohde V, Ludwig HC, Lemcke J. Predictors of subsequent overdrainage and clinical outcomes after ventriculoperitoneal shunting for idiopathic normal pressure hydrocephalus. Neurosurgery 2014; 73:1054-60. [PMID: 24257332 DOI: 10.1227/neu.0000000000000155] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known about variables associated with overdrainage complications and neurofunctional and health-related quality of life outcomes in idiopathic normal-pressure hydrocephalus (iNPH) patients after shunt surgery. OBJECTIVE To identify candidate demographic and disease-specific predictors of overdrainage and patient-related outcomes, allowing for more personalized care of patients with iNPH. METHODS This was a secondary analysis of the dataset of the SVASONA study, a multicenter randomized trial comparing gravitational and conventional gravitational valves for treating iNPH. We evaluated the association between baseline items and the incidence of overdrainage, using different endpoint definitions. RESULTS We identified only a few variables associated with a possible increased risk of overdrainage. Apart from using conventional rather than gravitational valves, longer duration of surgery and female sex were associated with a higher risk of clinical signs and symptoms suggestive of overdrainage (hazard ratio: 1.02, 95% confidence interval: 1.01-1.04 and 1.84, 95% confidence interval: 0.81-4.16). The occurrence of clinical symptoms of overdrainage, and the need for exchanging a programmable by a gravitational valve may adversely affect disease-specific outcomes like the Kiefer score. CONCLUSION Few, if any, baseline and treatment characteristics may be helpful in estimating the individual risk of complications and clinical outcomes after shunt surgery for iNPH. Patients should be informed that longer surgery for any reason may increase the risk of later overdrainage. Also, women should be counseled about a sex-associated increased risk of the development of clinical symptoms of overdrainage, although the latter cannot be distinguished from a generally higher prevalence of headaches in the female population.
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Affiliation(s)
- Ullrich Meier
- ‡Department of Neurosurgery, Unfallkrankenhaus Berlin, Berlin, Germany; §Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin, Germany; ¶Julius Wolff Institute, Charité Medical University Centre, Germany; ‖Department of Neurosurgery, Ernst-Moritz-Arndt-University of Greifswald, Germany; #Department of Neurosurgery, Asklepios Hospital Altona, Hamburg, Germany; **Department of Neurosurgery, Saarland Medical University, Homburg/Saar, Germany; ‡‡Department of Neurosurgery, Eberhard-Karls-University of Tübingen, Germany; §§Department of Neurosurgery, Hospital Cologne-Merheim, Germany; ¶¶Department of Neurosurgery, Georg-August-University of Göttingen, Germany
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Abstract
The Bone & Joint Journal provides the latest evidence to guide the clinical practice of orthopaedic surgeons. The benefits of one intervention compared with another are presented using outcome measures; some may be specific to a limb or joint and some are more general health-related quality of life measures. Readers will be familiar with many of these outcome measures and will be able to judge the relative benefits of different interventions when measured using the same outcome tool; for example, different treatments for pain in the knee measured using a particular knee score. But, how should readers compare outcomes between different clinical areas using different outcome measures? This article explores the use of standardised effect sizes. Cite this article: Bone Joint J 2014;96-B:853–4.
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Affiliation(s)
- N. Parsons
- Warwick Medical School, University
of Warwick, Coventry, CV4
7AL, UK
| | - X. L. Griffin
- University of Warwick, Warwick Medical
School, Coventry, CV4 7AL, UK
| | - D. Stengel
- Centre for Clinical Research, Department
of Trauma and Orthopaedic Surgery, Unfalkrankenhaus
Berlin, Warener Street 7, 12683
Berlin, Germany
| | - R. Carey Smith
- Sir Charles Gairdner Hospital and The
University of Western Australia, Nedlands, Perth 6009, Western
Australia, Australia
| | - D. C. Perry
- University of Warwick, Warwick Medical
School, Coventry, CV4 7AL, UK
| | - M. L. Costa
- University of Warwick, Warwick Medical
School, Coventry, CV4 7AL, UK
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47
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Abstract
The importance for observing the intention-to-treat approach in clinical studies is explained. Cite this article: Bone Joint J 2013;95-B:1443–4.
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Affiliation(s)
- X. L. Griffin
- Warwick Orthopaedics, Warwick
Medical School, University of Warwick, Clinical Sciences
Research Laboratories, Clifford Bridge Road, Coventry
CV2 2DX, UK
| | - N. Parsons
- Statistics and Epidemiology, Warwick
Medical School, University of Warwick, Gibbet Hill
Road, Coventry CV4 7AL, UK
| | - R. Carey Smith
- Sir Charles Gairdner Hospital and The
University of Western Australia, Nedlands, Perth 6009, Western
Australia, Australia
| | - D. Stengel
- Unfallkrankenhaus Berlin, Centre
for Clinical Research, Department of Trauma
and Orthopaedic Surgery, Warener Street 7, 12683 Berlin, Germany
| | - M. L. Costa
- Clinical Trials Unit, Warwick Medical
School, University of Warwick, Gibbet
Hill Road, Coventry CV4 7AL, UK
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Lemcke J, Meier U, Müller C, Fritsch MJ, Kehler U, Langer N, Kiefer M, Eymann R, Schuhmann MU, Speil A, Weber F, Remenez V, Rohde V, Ludwig HC, Stengel D. Safety and efficacy of gravitational shunt valves in patients with idiopathic normal pressure hydrocephalus: a pragmatic, randomised, open label, multicentre trial (SVASONA). J Neurol Neurosurg Psychiatry 2013; 84:850-7. [PMID: 23457222 PMCID: PMC3717598 DOI: 10.1136/jnnp-2012-303936] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate whether gravitational valves reduce the risk of overdrainage complications compared with programmable valves in ventriculoperitoneal (VP) shunt surgery for idiopathic normal pressure hydrocephalus (iNPH). BACKGROUND Patients with iNPH may benefit from VP shunting but are prone to overdrainage complications during posture changes. Gravitational valves with tantalum balls are considered to reduce the risk of overdrainage but their clinical effectiveness is unclear. METHODS We conducted a pragmatic, randomised, multicentre trial comparing gravitational with non-gravitational programmable valves in patients with iNPH eligible for VP shunting. The primary endpoint was any clinical or radiological sign (headache, nausea, vomiting, subdural effusion or slit ventricle) of overdrainage 6 months after randomisation. We also assessed disease specific instruments (Black and Kiefer Scale) and Physical and Mental Component Scores of the Short Form 12 (SF-12) generic health questionnaire. RESULTS We enrolled 145 patients (mean (SD) age 71.9 (6.9) years), 137 of whom were available for endpoint analysis. After 6 months, 29 patients in the standard and five patients in the gravitational shunt group developed overdrainage (risk difference -36%, 95% CI -49% to -23%; p<0.001). This difference exceeded predetermined stopping rules and resulted in premature discontinuation of patient recruitment. Disease specific outcome scales did not differ between the groups although there was a significant advantage of the gravitational device in the SF-12 Mental Component Scores at the 6 and 12 month visits. CONCLUSIONS Implanting a gravitational rather than another type of valve will avoid one additional overdrainage complication in about every third patient undergoing VP shunting for iNPH.
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Affiliation(s)
- Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str 7, Berlin 12683, Germany.
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Stengel D, Bauwens K, Rademacher G, Ekkernkamp A, Güthoff C. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev 2013. [PMID: 23904141 DOI: 10.1002/14651858.cd004446.pub] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ultrasonography is regarded as the tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. Although its sensitivity is too low for definite exclusion of abdominal organ injury, proponents of ultrasound argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of computed tomography scans and cut costs. OBJECTIVES To assess the effects of trauma algorithms that include ultrasound examinations in patients with suspected blunt abdominal trauma. SEARCH METHODS We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (The Cochrane Library), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EBSCO), publishers' databases, controlled trials registers and the Internet. Bibliographies of identified articles and conference abstracts were searched for further elligible studies. Trial authors were contacted for further information and individual patient data. The searches were updated in February 2013. SELECTION CRITERIA STUDIES randomised controlled trials (RCTs) and quasi-randomised trials (qRCTs). PARTICIPANTS patients with blunt torso, abdominal or multiple trauma undergoing diagnostic investigations for abdominal organ injury. INTERVENTIONS diagnostic algorithms comprising emergency ultrasonography (US). CONTROLS diagnostic algorithms without ultrasound examinations (for example, primary computed tomography [CT] or diagnostic peritoneal lavage [DPL]). OUTCOME MEASURES mortality, use of CT and DPL, cost-effectiveness, laparotomy and negative laparotomy rates, delayed diagnoses, and quality of life. DATA COLLECTION AND ANALYSIS Two authors independently selected trials for inclusion, assessed methodological quality and extracted data. Where possible, data were pooled and relative risks (RRs), risk differences (RDs) and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed- or random-effects modelling, as appropriate. MAIN RESULTS We identified four studies meeting our inclusion criteria. Overall, trials were of moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. We pooled mortality data from three trials involving 1254 patients; relative risk in favour of the US arm was 1.00 (95% CI 0.50 to 2.00). US-based pathways significantly reduced the number of CT scans (random-effects RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result is unclear. Given the low sensitivity of ultrasound, the reduction in CT scans may either translate to a number needed to treat or number needed to harm of two. AUTHORS' CONCLUSIONS There is currently insufficient evidence from RCTs to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.
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Affiliation(s)
- Dirk Stengel
- Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin, Berlin, Germany.
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50
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Abstract
BACKGROUND Ultrasonography is regarded as the tool of choice for early diagnostic investigations in patients with suspected blunt abdominal trauma. Although its sensitivity is too low for definite exclusion of abdominal organ injury, proponents of ultrasound argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of computed tomography scans and cut costs. OBJECTIVES To assess the effects of trauma algorithms that include ultrasound examinations in patients with suspected blunt abdominal trauma. SEARCH METHODS We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (The Cochrane Library), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EBSCO), publishers' databases, controlled trials registers and the Internet. Bibliographies of identified articles and conference abstracts were searched for further elligible studies. Trial authors were contacted for further information and individual patient data. The searches were updated in February 2013. STUDIES randomised controlled trials (RCTs) and quasi-randomised trials (qRCTs). PARTICIPANTS patients with blunt torso, abdominal or multiple trauma undergoing diagnostic investigations for abdominal organ injury. INTERVENTIONS diagnostic algorithms comprising emergency ultrasonography (US). CONTROLS diagnostic algorithms without ultrasound examinations (for example, primary computed tomography [CT] or diagnostic peritoneal lavage [DPL]). OUTCOME MEASURES mortality, use of CT and DPL, cost-effectiveness, laparotomy and negative laparotomy rates, delayed diagnoses, and quality of life. DATA COLLECTION AND ANALYSIS Two authors independently selected trials for inclusion, assessed methodological quality and extracted data. Where possible, data were pooled and relative risks (RRs), risk differences (RDs) and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed- or random-effects modelling, as appropriate. MAIN RESULTS We identified four studies meeting our inclusion criteria. Overall, trials were of moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. We pooled mortality data from three trials involving 1254 patients; relative risk in favour of the US arm was 1.00 (95% CI 0.50 to 2.00). US-based pathways significantly reduced the number of CT scans (random-effects RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result is unclear. Given the low sensitivity of ultrasound, the reduction in CT scans may either translate to a number needed to treat or number needed to harm of two. AUTHORS' CONCLUSIONS There is currently insufficient evidence from RCTs to justify promotion of ultrasound-based clinical pathways in diagnosing patients with suspected blunt abdominal trauma.
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Affiliation(s)
- Dirk Stengel
- Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin, Berlin, Germany.
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