bertil bouillon

Abstract: Although patients with severe multiple injuries may have other reasons for unconsciousness, traumatic brain injury (TBI) in these patients is frequently defined by the Glasgow Coma Scale (GCS). Nevertheless, the diagnostic value of GCS for severe TBI in the multiple-injured patient is unknown. Therefore, we investigated the diagnostic value of GCS to identify severe TBI in multiple-injured patients. The records of 18,002 severely injured adult (ISS >16) patients from the Trauma Register of the German Society for Trauma Surgery were analyzed and initial GCS and Abbreviated Injury Scale (head) (AIS(head)) were recorded. A severe TBI was defined by an AIS(head) ≥ 3. On the other hand, unconsciousness was defined by an initial GCS ≤ 8. By these criteria, 6546 patients (36.3%) were unconscious, and 8746 patients (48.6%) had severe TBI. Nine percent of all cases (n=1643) had a GCS ≤ 8 without severe TBI. Only 56.1% of patients with severe TBI (n=4903) had been unconscious. Decreasing levels of unconsciousness (as defined by GCS) showed consistent rising prevalence of severe TBI (correlation coefficient r=-0.52). Approximately 20% of all multiple-injured patients arriving in the emergency department with an initial GCS of 15 had severe TBI (AIS(head) ≥ 3). The diagnostic value of GCS ≤ 8 for severe TBI in patients with multiple injuries has low sensitivity (56.1%) but higher specificity (82.2%). Our study indicates that the GCS (as defined ≤ 8) in unconsciousness patients with multiple injuries shows only a moderate correlation with the diagnosis of severe TBI. Nevertheless, the main reason for unconsciousness in patients with multiple injuries is TBI, since only 9% of these patients had another reason for unconsciousness. However, due to the poor sensitivity of GCS, we suggest the use of the anatomical scoring system with AIS(head) ≥ 3 to define severe TBI in patients with multiple injuries.

Abstract: Benefits of high ratios of fresh frozen plasma (FFP) to packed red blood cells (pRBC) in massively transfused trauma patients have been reported previously. This study aimed to assess the effect of higher FFP:pRBC ratios on outcome in patients receiving less than massive transfusion during acute trauma care.

Abstract: BACKGROUND: The implementation of the 'Surgical Safety Checklist' caused a significant reduction in the incidence of complications and mortality among patients undergoing surgery. The aim of the present study was to evaluate perioperative safety standards and the quality of interprofessional cooperation before and after the introduction of a safety checklist from staff members' point of view. METHODS: Employees' attitude concerning safety-relevant aspects of the perioperative period, work processes, and quality of interprofessional cooperation was surveyed before and 3 months after introducing an adapted form of the 'Surgical Safety Checklist' by a 19-item questionnaire. RESULTS: After the implementation of the checklist, the cognizance of the names and functions of the individual operating room (OR) staff members, verification of the patient's written consent for surgery, indication for antibiotics before the surgical incision, and the quality of interprofessional cooperation were rated more positively. Traumatology physicians were more convinced that all artifacts had been removed from the surgical field. Finally, communication about intraoperative complications had improved. CONCLUSIONS: Our attitude surveys demonstrate that from the OR staff's perspective, in the perioperative setting, safety-relevant factors can be handled significantly better and with greater awareness by implementing a safety checklist as proposed by the World Health Organization.

Abstract: Inpatient psychotherapeutic support has been shown to reduce mental health problems in severely injured patients. However, this effect mostly disappears after discharge. The aim of this study was to compare short-term inpatient versus continued long-term outpatient psychotherapeutic support.

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Abstract: The objectives of this study were 1) to assess potential changes in the incidence and outcome of sepsis after multiple trauma in Germany between 1993 and 2008 and 2) to evaluate independent risk factors for posttraumatic sepsis.

Abstract: The Trauma Associated Severe Haemorrhage (TASH)-Score has been recognized as an easy-to-calculate scoring system to predict the probability for massive transfusion (MT) as a surrogate for life-threatening haemorrhage after injury. Changes with respect to management and outcome of these patients over time prompted a revalidation and an update of the TASH-Score.

Abstract: The empiric use of a high plasma to packed red-blood-cell [fresh frozen plasma:red-blood-cells (FFP:RBC)] ratio in trauma resuscitation for patients with massive bleeding has become well accepted without clear or objective indications. Increased plasma transfusion is associated with worse outcome in some patient populations. While previous studies analyse only patients who received a massive transfusion, this study analyses those that are at risk to receive a massive transfusion, based on the trauma-associated severe haemorrhage (TASH) score, to objectively determine which patients after severe trauma would benefit or have increased complications by the use of a high FFP:RBC ratio.

Abstract: Safety data on recombinant activated factor VII (rFVIIa, NovoSeven; Novo Nordisk A/S, Bagsværd, Denmark) in actively hemorrhaging trauma patients are limited. We present detailed safety data from a large multicenter, randomized, placebo-controlled phase III study (the CONTROL trial).

Abstract: The aim of this study was to validate the precision of navigated tunnel positioning using a fluoroscopy-based computer-assisted technique.

Abstract: The role of acute coagulopathy after severe trauma as a major contributor to exsanguination and death has recently gained increasing appreciation, but the causes and mechanisms are not fully understood. This study was conducted to assess the risk factors associated with acute traumatic coagulopathy together with quantitative estimates of their importance.

Abstract: The morphology of painful impingement of the infrapatellar fat pad (Hoffa's disease), which is characterized by inflammation, swelling, hypertrophy, fibrosis, and/or calcifications, has been well described. The purpose of this study was to investigate whether corresponding characteristic MRI findings could be assessed in patients with infrapatellar fat pad impingement.

Abstract: The role of acute coagulopathy after traumatic brain injury (TBI) on outcome has gained increasing appreciation over the recent years. This study was conducted to assess the frequency, outcome, and risk factors associated with this complication.

Abstract: A number of occupational risk factors are discussed in relation to the development and progress of knee joint diseases (for example, working in a kneeling or squatting posture, lifting and carrying heavy weights). Besides the occupational factors, a number of individual risk factors are important. The distinction between work-related and other factors is crucial in assessing the risk and in deriving preventive measures in occupational health.

Abstract: There is clinical evidence that a standardized management of trauma patients in the emergency room improves outcome. ATLS is a training course that teaches a systematic approach to the trauma patient in the emergency room. The aims are a rapid and accurate assessment of the patient's physiologic status, treatment according to priorities, and making decisions on whether the local resources are sufficient for adequate definitive treatment of the patient or if transfer to a trauma center is necessary. Above all it is important to prevent secondary injury, to realize timing as a relevant factor in the initial treatment, and to assure a high standard of care. A standard operating procedure (SOP) exactly regulates the approach to trauma patients and determines the responsibilities of the involved faculties. An SOP moreover incorporates the organizational structure in the treatment of trauma patients as well as the necessary technical equipment and staff requirements. To optimize process and result quality, priorities are in the fields of medical fundamentals of trauma care, education, and fault management. SOPs and training courses increase the process and result quality in the treatment of the trauma patient in the emergency room. These programs should be based on the special demands of the physiology of the trauma as well as the structural specifics of the hospital. ATLS does not equal an SOP but it qualifies as a standardized concept for management of trauma patients in the emergency room.

Abstract: Lateral dislocation of the patella (LPD) leads to cartilaginous injuries, which have been reported to be associated with retropatellar complaints and the development of patellofemoral osteoarthritis. Therefore, the purpose of this study was to determine the reliability of MRI for cartilage diagnostics after a first and recurrent LPD.

Abstract: Little is known about sports activity after total hip resurfacing.

Abstract: Venous thromboembolic events (VTEs) are common life-threatening complications after trauma, but epidemiology and reported risk factors still vary. The purpose of this investigation was to determine the incidence of VTEs among hospitalised trauma patients, to identify potential risk factors and to assess whether their presence was associated with: (a) the magnitude and pattern of injury, (b) therapeutic interventions and (c) outcome, all by using a large population-based registry.

Abstract: Navigation technology is a widely available tool in spine surgery and has become a part of clinical routine in many centers. The issue of where and when navigation technology should be used is still an issue of debate. It is the aim of this study to give an overview on the current knowledge concerning the technical capabilities of image-guided approaches and to discuss possible future directions of research and implementation of this technique. Based on a Medline search total of 1,462 publications published until October 2008 were retrieved. The abstracts were scanned manually for relevance to the topics of navigated spine surgery in the cervical spine, the thoracic spine, the lumbar spine, as well as ventral spine surgery, radiation exposure, tumor surgery and cost-effectivity in navigated spine surgery. Papers not contributing to these subjects were deleted resulting in 276 papers that were included in the analysis. Image-guided approaches have been investigated and partially implemented into clinical routine in virtually any field of spine surgery. However, the data available is mostly limited to small clinical series, case reports or retrospective studies. Only two RCTs and one metaanalysis have been retrieved. Concerning the most popular application of image-guided approaches, pedicle screw insertion, the evidence of clinical benefit in the most critical areas, e.g. the thoracic spine, is still lacking. In many other areas of spine surgery, e.g. ventral spine surgery or tumor surgery, image-guided approaches are still in an experimental stage. The technical development of image-guided techniques has reached a high level as the accuracies that can be achieved technically meet the anatomical demands. However, there is evidence that the interaction between the surgeon ('human factor') and the navigation system is a source of inaccuracy. It is concluded that more effort needs to be spend to understand this interaction.

Abstract: The Educational Initiative on Critical Bleeding in Trauma was formed to assess current data and to guide future research and practice in the management of coagulopathy after severe trauma. The Educational Initiative on Critical Bleeding in Trauma recently published structured literature reviews on animal models and mechanisms of trauma-associated coagulopathy and the results of a survey of international clinical practice. The authors convened a symposium in July 2008 and invited researchers and opinion leaders in trauma care, transfusion medicine, and coagulation research to discuss current understanding and management and to identify future areas of exploration. This document reviews the content and conclusions of the meeting. The association between trauma and bleeding from patient registries, basic science, and clinical studies was confirmed, as was the association between the coagulopathy that presents early after major injury and excess mortality. Meeting participants identified the need for consensus definitions and common terminology to describe coagulopathy after trauma, including the term acute coagulopathy of trauma shock to describe the early coagulopathy induced by tissue injury/shock and the global term trauma-induced coagulopathy to describe coagulopathy after injury and its sequelae (loss, consumption, acidemia, acute coagulopathy, and dilution). Other conclusions included the need for increased clinical awareness, new methods and tools for early diagnosis, consistent early preventative strategies, and evidence-based therapies for these conditions.

Abstract: Traumatic coagulopathy contributes to early death by exsanguination and late death in multiple organ failure. Recombinant Factor VIIa (rFVIIa, NovoSeven) is a procoagulant that might limit bleeding and improve trauma outcomes.

Abstract: In patients with osteoarthritis, a detailed assessment of degenerative cartilage disease is important to recommend adequate treatment. Using a representative sample of patients, this study investigated whether MRI is reliable for a detailed cartilage assessment in patients with osteoarthritis of the knee.

Abstract: Evidence-based recommendations are needed to guide the acute management of the bleeding trauma patient, which when implemented may improve patient outcomes.

Abstract: With over 1 million certified physicians in more than 50 countries worldwide, the Advanced Trauma Life Support (ATLS) concept is one of the most successful international education programs. The concept is simple, priority-orientated (ABCDE scheme) and assesses the situation of the trauma patient on the basis of vital signs to treat the life-threatening injuries immediately. With over 100 ATLS provider courses and 10 instruction courses accomplished in less than 6 years, no other land in the world has successfully established this concept in such a short time as Germany. Meanwhile nearly 1,600 colleagues have been trained and certified. Evaluation of the first 100 ATLS courses in Germany supports this concept. The total evaluation of all courses is 1.36 (1.06-1.8, n=100). The individual parts of the course were marked as followed: presentations 1.6 (1.0-2.81, n=100), practical skills stations 1.46 (1.0-2.4, n=100) and surgical skills stations 1.38 (1.0-2.38, n=100). In 2009 a total of 47 ATLS courses were accomplished which will clearly increase in 2010. Other ATLS formats, such as ATCN (Advanced Trauma Care for Nurses) and refresher courses are planned for the beginning of 2010.

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Abstract: Fractures of the long bones and femur fractures in particular are common in multiple trauma patients, but the optimal management of femur fractures in these patients is not yet resolved. Although there is a trend towards the concept of "Damage Control Orthopedics" (DCO) in the management of multiple trauma patients with long bone fractures as reflected by a significant increase in primary external fixation of femur fractures, current literature is insufficient. Thus, in the era of "evidence-based medicine", there is the need for a more specific, clarifying trial.

Abstract: Clinical research in trauma patients poses multiple challenges in study design. These reflect the heterogeneity of injury and treatment, the paucity of acceptable study endpoints aside from mortality, and the difficulties inherent in obtaining informed consent in acutely ill populations. A current example of this problem is the study of recombinant factor VIIa (rFVIIa), which has attracted considerable interest as a systemic procoagulant agent for use in trauma patients with exsanguinating hemorrhage.

Abstract: Damage Control Orthopedics is a strategy for treatment of fractures in severely injured patients. The aim is to reduce secondary damage and thereby improve the patient's outcome. The relevant fractures are primarily stabilized with external fixators instead of a primary definitive osteosynthesis. The less traumatic and shorter surgical procedure is thought to reduce the additional trauma load and should thereby minimize the "second hit" situation. After stabilization of the patient on the intensive care unit secondary definitive ostesynthesis can then be performed after 4-14 days.The available animal studies, retrospective clinical studies and prospective cohort studies seem to support the concept of damage control. The only available randomized study shows an advantage of this strategy in a subgroup of borderline patients. A meta-analysis could not find convincing evidence that definitively proves the advantage of this concept. A new multi-center randomized study has been started to evaluate the concept of damage control in a defined group of critically injured patients with femoral shaft fractures.

Abstract: To evaluate transfusion practices in multiple injured patients and to demonstrate changes in the pattern of packed red blood cell (pRBC) transfusions over the last one-and-half decade (1993-2006). A retrospective analysis using the German Trauma Registry database (DGU-Traumaregister) including 29 353 multiple injured patients was conducted. The study population included primary admissions presenting to the emergency room (ER) with clinical and laboratory signs of active haemorrhage [haemoglobin < 9 g x dL(-1), platelets < 90000 xmicroL(-1) and prothrombin time (Quick-value) < 60%]. The pattern of pRBC transfusions was followed from ER to intensive care unit (ICU) admission. A total of 5389 patients with complete data sets were divided into the following three groups according to the year of treatment and analysed: (a) group 1: 1993-1998 (n = 870), (b) group 2: 1999-2002 (n = 2044) and (c) group 3: 2003-2006 (n = 2475). Patients had a mean age of 40.5 (+/-20) years and were predominantly male (67.2%). All patients were substantially injured (mean injury severity score = 32 +/- 15.5) and in 93% the mechanism of injury was blunt. The percentage of patients who received pRBC transfusions between ER and ICU dropped from 72% in 1993-1998 to 54% in 2003-2006 (P < 0.005). Similarly, the percentage of patients receiving mass transfusions (> 10 pRBC units) dropped from 51.3 to 17.1%. This decline was accompanied by lower incidence rates for septic complications, ventilator days, ICU length-of-stay and mortality. pRBC transfusion practices in acute trauma care have changed substantially over the last one-and-half decade and were associated with better outcome.

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Abstract: Early estimation of the mortality risk of severely injured patients is mandatory. To estimate the seriousness of the condition of patients with trauma, we developed the emergency trauma score (EMTRAS) for ease of use, with simple parameters that are available within 30 minutes.

Abstract: Nowadays, there is a trend towards the concept of damage control in the management of multiple trauma patients. However, the question remains whether all patients benefit from this concept. We report the primary total definitive treatment of a patient with multiple fractures of the lower extremities. Postoperative respiratory insufficiency was treated successfully by non-invasive ventilation.

Abstract: The case of an upper oesophageal perforation as a concomitant injury of an isolated fracture of the upper thoracic spine without neurological compromise has not been described so far. A Case report and review of the literature is presented here. Concomitant oesophageal perforations carry a high risk of being missed initially. CT alone can visualize the subtle indirect signs like peri-oesophageal air. The literature revealed that only peri-oesophageal air might be a valid indicator of oesophageal injury. There are no systematic data on thoracic spine fractures with concomitant oesophageal perforations. Mediastinitis secondary to oesophageal perforation might be treated conservatively with endoscopic stent placement rather than surgically. As the radiological signs of concomitant soft tissue injury, like oesophageal perforations, in fractures of the upper thoracic spine are subtle and easily missed initially only anticipation of concomitant injuries by the treating physician based on the trauma mechanism ensures a timely diagnosis.

Abstract: To test whether an acute transfusion practice of packed red blood cells (pRBC) : fresh-frozen plasma (FFP) 1 : 1 would be associated with reduced mortality in acute bleeding multiply injury.

Abstract: Bleeding is the most frequent cause of preventable death after severe injury. Coagulopathy associated with severe injury complicates the control of bleeding and is associated with increased morbidity and mortality in trauma patients. The causes and mechanisms are multiple and yet to be clearly defined.

Abstract: Bleeding is one of the leading causes of preventable death after traumatic injury. Trauma-associated coagulopathy complicates the control of bleeding. The published approaches on the management of this coagulopathy differ significantly.

Abstract: The development of coagulopathy associated with trauma is a complex process that involves a combination of many factors. It is important to be able to model experimental trauma-related coagulopathy to explore preventative and therapeutic strategies, and numerous models of traumatic coagulopathy have been explored. This systematic review assessed the primary question "What are relevant experimental models with which to study early traumatic coagulopathy?" and secondary questions on mechanisms.

Abstract: Severe head injury (HI) is known to be a major determinant of mortality in patients with multiple injuries but additional injuries also contribute to the clinical outcome. The Trauma Registry of the German Society for Trauma Surgery offers sufficient data for comparative outcome analysis in relation to the injury pattern.

Abstract: There is clinical evidence that standardized management of trauma patients in the emergency department improves outcome. Standardized prehospital management has been established for stroke patients and those suffering acute coronary syndrome. Prehospital treatment of trauma patients differs quite significantly from one system to another. The data from the German Trauma Registry show that the average time from accident until arrival in the emergency department is 72 min. This needs improvement.

Abstract: The American College of Surgeons Committee on Trauma's Advanced Trauma Life Support Course is currently taught in 50 countries. The 8th edition has been revised following broad input by the International ATLS subcommittee. Graded levels of evidence were used to evaluate and approve changes to the course content. New materials related to principles of disaster management have been added. ATLS is a common language teaching one safe way of initial trauma assessment and management.

Abstract: The trauma registry of the German Society of Trauma Surgery is a multicentric prospective record of the treatment of severely injured patients.

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Abstract: Trust is an important aspect of physician-patient-interaction, both in terms of compliance and patient- and physician-reported outcomes. Trust-building communication is especially important in terms of severely injured patients because of severity of their injuries and frequently associated physical and psychological consequences. Patients preferences concerning medical treatment (patient type) is also regarded to be important in terms of trust. The objective of this study was to investigate the relationships between patients perceived trust, supportive communication of physicians and patient type of severely injured patients.

Abstract: A technical report of fluoroscopy guided placement of augmented iliosacral screws in osteoporotic insufficiency fractures of the sacrum.

Abstract: Knee osteoarthritis (OA) is one of the frequent and functionally impairing disorders of the musculoskeletal system. In the literature, a number of occupational risk factors are discussed as being related to the development and progress of knee joint diseases, e.g. working in kneeling or squatting posture, lifting and carrying of heavy weights. The importance of the single risk factors and the possibility of prevention are currently under discussion. Besides the occupational factors, a number of individual risk factors are important, too. The distinction between work-related factors and individual factors is crucial in assessing the risk and in deriving preventive measures in occupational health. In existing studies, the occupational stress is determined mainly by surveys in employees and/or by making assumptions about individual occupations. Direct evaluation of occupational exposure has been performed only exceptionally. The aim of the research project ArGon is the assessment of different occupational factors in relation to individual factors (e.g. constitutional factors, leisure time activities, sports), which might influence the development and/or progression of knee (OA). The project is designed as a case control study.

Abstract: There is increasing evidence for acute traumatic coagulopathy occurring prior to emergency room (ER) admission but detailed information is lacking.

Abstract: The aim of this study was to improve health-related quality of life (HRQOL) related to depression, anxiety, pain, physical functioning and social aspects for severely injured trauma survivors by early onset cognitive behavioural therapy applied on the surgical ward.

Abstract: Transplantation of embryonic stem (ES) cells may provide cures for the damaged nervous system. Pre-differentiated ES or neuronal precursor cells have been investigated in various animal models of neurodegenerative diseases including traumatic brain injury (TBI). To our knowledge, no study has yet examined the effects of undifferentiated, murine ES cells on functional recovery and tumorigenity following implantation into injured rat brains. We evaluated the effect of transplantation of undifferentiated, murine embryonic cells on the recovery of motor function following lateral fluid percussion brain injury in Sprague-Dawley rats. At 3 days post-injury, animals received stereotactic injections of either embryonic stem cell suspension or injections of phosphate buffered saline without cells (control) into the injured cortex. Neurological motor function assessments were performed before injury, 72 h, 1, 3, and 6 weeks after transplantation using a Rotatrod and a Composite Neuroscore test. During this time period brain injured animals receiving ES cell transplantation showed a significant improvement in the Rotarod Test and in the Composite Neuroscore Test as compared to phosphate buffered saline (PBS)-treated animals. At 1 week post-transplantation, ES cells were detectable in 100% of transplanted animals. At 7 weeks following transplantation, EScells were detectable in only one animal. Two of 10 xenotransplanted animals revealed tumor formation over the observation period. These findings provide evidence for therapeutic potency of embryonic stem cell transplantation after TBI in rat, but also raise serious safety concerns about the use of such cells in human.

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Abstract: Post-traumatic pulmonary pseudocyst is a rare manifestation of blunt thoracic injury. Young adults and adolescents are predominantly affected. Here we report the successful outcome of post-traumatic pseudocysts secondary to severe lung contusion with severe intrathoracic haemorrhage in both lower lobes and the upper right lobe by aggressive coagulation management, kinetic therapy/postural drainage and control of secondary infection.

Abstract: Advanced Trauma Life Support (ATLS) provides a structured and efficient approach to the treatment of patients with multiple trauma in the emergency department. The performance of a well functioning interdisciplinary trauma team coordinated by an experienced trauma leader plays a pivotal role during the initial phase of patient care. The team's primary task is to establish and maintain stable vital signs by ensuring adequate oxygenation and fluid resuscitation while diagnostic or immediate life saving interventions and procedures are initiated. The following article describes the management of patients with multiple injuries in the emergency department based on the ATLS algorithm.

Abstract: Valid epidemiological data on incidence and outcome of traumatic brain injury (TBI) show great variability. A study on incidence, severity and outcome of TBI was conducted in an urban area of one million inhabitants.

Abstract: Cytokine-mediated immunoresponses are consequences of isolated traumatic brain injury (TBI) and muskuloskeletal trauma but little is known when both impacts occur simulanteously in combined neurotrauma (CNT), i. e. TBI + muskuloskeletal trauma (bone fracture).

Abstract: Postoperative care for ankle fractures is generally 1 of 2 regimens: 1) functional treatment combined with early weightbearing (EWB), or 2) immobilization in a cast/orthosis for 6 weeks without weightbearing (6WC). The objective of this study was 2-fold: 1) to follow a prospective group treated with EWB as to long-term subjective and objective outcomes, and 2) to compare a subset of this group with a matched group of historic controls treated with 6WC.

Abstract: In Germany, a total of more than 30,000 polytraumatized patients are treated in level I-IV trauma centers. The exact number of hospitals fulfilling the requirements for the treatment of severely injured patients is unknown. We analyzed the number of hospitals in Germany capable of managing polytraumatized patients. We further analyzed the influence of various geographic and infrastructure conditions on the management of severely injured patients in the various Federal States in Germany.

Abstract: Following the 2004 tsunami disaster in southeast Asia severely injured tourists were repatriated via airlift to Germany. One cohort was triaged to the Cologne-Merheim Medical Center (Germany) for further medical care. We report on the tertiary medical care provided to this cohort of patients.

Abstract: General political and legal changes in the German health care system will increase the importance of patient surveys. Patient satisfaction with medical and organizational care during their stay in a hospital is a relevant outcome of quality assurance. Satisfied patients also show a higher compliance with treatment and therefore increase the probability of a successful outcome. The objective of this analysis was to identify determinants of satisfaction with hospital stay of severely injured patients.

Abstract: Although the word evidence-based medicine (EBM) has gained wide popularity, only a few studies have evaluated how EBM works in clinical practice.

Abstract: To develop a simple scoring system that allows an early and reliable estimation for the probability of mass transfusion (MT) as a surrogate for life threatening hemorrhage following multiple trauma.

Abstract: Femur-shaft fracture treatment (FSFT) follows controversial management concepts after multiple trauma: primary-definitive osteosynthesis, secondary-definitive osteosynthesis after temporary external fixation (EF) in all patients, or individualized primary- or secondary-definitive osteosynthesis ("risk-adapted damage control orthopedics"). This study compares the concepts by analyzing literature evidence and a prospective multicenter database.

Abstract: This study was designed to determine whether exposure to multimodal early onset stimulation (MEOS) combined with environmental enrichment (EE) after traumatic brain injury (TBI) would improve neurological recovery and to elucidate its morphological correlates. Male Sprague-Dawley rats were subjected to lateral fluid percussion (LFP) brain injury or to sham operation. After LFP, one-third of the animals (injured and sham) were placed under conditions of standard housing (SH), one-third were kept in EE only, and one-third received EE + MEOS. Assessment of neuromotor function 24 h post-injury using a standardized composite neuroscore test revealed an identical pattern of neurological impairment in all animals subjected to LFP. Neuromotor dysfunction in SH animals remained on a similar level throughout the experiment, while improvements were noted in both other groups 7 days post-injury (dpi). On 15 dpi, reversal of neuromotor dysfunction was significantly better in EE + MEOS animals vs. SH- and EE-only groups. In parallel, the comparison of lesion volume in EE + MEOS- vs. EE-only vs. SH rats revealed that animals exposed to EE + MEOS had consistently the lowest values (mm3, mean +/- SD; n = 6 rats in each group) as measured in serial brain sections immunostained for neuron-specific enolase (5.2 +/- 3.4 < or = 5.5 +/- 4.1 < 9.5 +/- 1.9), caspase 3-active/C3A (5.9 +/- 4.0 < or = 6.4 +/- 3.9 < 10.3 +/- 1.8) and glial fibrillary acidic protein (6.0 +/- 3.4 < or = 6.5 +/- 4.3 < 10.7 +/- 1.2). This first report on the effect of EE + MEOS treatment strongly indicates that the combined exposure reduces CNS scar formation and reverses neuromotor deficits after TBI in rats.

Abstract: On December 26, 2004, a giant earthquake shocked Southeast Asia, triggering deadly flood waves (tsunami) across the Indian Ocean. More than 310,000 people have been reported dead and millions left destitute. Shortly thereafter, European governments organized airborne home transfer of most severely injured tourists using MedEvac aircraft. On arrival, patients were distributed to various medical centers. One cohort of the severely injured was admitted to the Cologne-Merheim Medical Center (Germany) for further surgical and intensive care treatment. The objective of this report was to characterize typical injury patterns along with microbiological findings and psychoemotional aspects unique to the tsunami disaster.

Abstract: Traumatic brain injury (TBI) is present in two-thirds of patients with multiple injuries and in one-third combined with injuries of the extremities. Studies on interactive effects between central and peripheral injuries are scarce due to the absence of clinically relevant models. To meet the demand for "more-hit" models, an experimental model of combined neurotrauma (CNT) incorporating a standardized TBI via lateral fluid percussion (LFP) together with a peripheral bone fracture, i.e., tibia fracture, is introduced. Sprague-Dawley rats were randomized to four experimental groups: controls (n = 10), animals with TBI (n = 30), animals with tibia fracture (n = 30), and animals with CNT (n = 30). Morphological aspects of brain and bone injury were analyzed via standard histopathological procedures and x-ray. Trauma-induced neuromotor dysfunction was assessed using a standardized neuroscore. For interactive effects between injuries, we studied the extent and temporal pattern of circulating interleukin 6 (IL-6) levels via immunoassay and callus formation at fracture sites by means of microradiography. LFP produced an ipsilateral lesion with cortical contusion, hemorrhage, mass shift, and neuronal cell loss (adjacent cortex and hippocampus CA-2/-3), along with contralateral neuromotor dysfunction. X-rays confirmed complete fractures in the middle of the bone shaft. The type of injury (P < 0.001) and time (P = 0.022) were significantly associated with increased IL-6 levels. CNT produced the highest IL-6 plasma levels with a maximum peak at 6 h after trauma (P < 0.001). Similarly, callus formation at fracture sites in CNT was significantly increased versus fracture only (P < 0,01). The CNT model mimics a variety of clinically relevant features known from human multiple injury, including TBI, and offers novel approaches for investigation of interactive mechanisms and therapeutic approaches.

Abstract: Lower extremity injuries make up a substantial proportion of the injuries in multiply injured patients. The aim of this systematic literature analysis was to give an overview of the levels of evidence for different management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients to enable, in the presence of adequate evidence, the development of clinical management corridors or, if the evidence was found to be inadequate, to document the necessity for scientific proof.

Abstract: This study was designed to investigate the additional benefits of a multimodal early onset stimulation (MEOS) paradigm when combined with enriched environment (EE) versus EE only and standard housing (SH) on the recovery after experimental traumatic brain injury (TBI). Male Sprague- Dawley rats were subjected to moderate lateral fluid percussion (LFP) brain injury (n = 40) or sham operation (n = 6). Thereafter, the injured and sham/EE + MEOS and EE only groups were placed into a complex EE consisting of tunnel-connected wide-bodied cages with various beddings, inclining platforms, and toys. Along with group living and environmental complexity, injured and sham/EE + MEOS animals were additionally exposed to a standardized paradigm of multimodal stimulation including auditory, visual, olfactory, and motor stimuli. In contrast, injured and sham/SH groups were housed individually without stimulation. A standardized composite neuroscore (NS) test was used to assess acute post-traumatic neuromotor deficits (24 h after injury) and recovery on days 7 and 15; recovery of cognitive function was assessed on days 11-15 using the Barnes maze. Neuromotor impairment was comparable in all injured animals at 24 h post-injury, but braininjured EE + MEOS rats performed significantly better than both brain-injured SH and EE groups when tested on post-injury days 7 and 15 (p = 0.004). Similarly, latencies to locate the hidden box under the Barnes maze platform were significantly shortened in EE + MEOS animals at day 15 (p = 0.003). These results indicate that the reversal of neuromotor and cognitive dysfunction after TBI can be substantially enhanced when MEOS is added to EE.

Abstract: We present the case of a 44-year-old man who complained of cervical pain. He was treated with physiotherapy and analgetics. Because of persistent pain, computed tomography (CT) scan and MRI were performed. They revealed an osteolytic destruction of the fourth cervical vertebra. The patient was treated surgically for removal of the tumor and stabilization of his cervical spine. Histology of the osteolytic material led to the diagnosis of an eosinophilic granuloma of the cervical spine. This case report describes the incidence, clinical significance, background and therapy of an eosinophilic granuloma of the spine.

Abstract: Several studies have recently questioned whether routine radiographic screening for pelvic fractures is necessary in the initial evaluation of blunt trauma patients. Therefore, we assessed how sensitive and specific the clinical examination is in detecting fractures of the pelvis.

Abstract: There is clinical evidence, that a standardized management of trauma patients in the emergency room improves outcome.

Abstract: The aim of this study was to examine the indication for implant removal (IR) after percutaneous iliosacral screw fixation of unstable posterior pelvic ring disruptions by systematic literature analysis and clinical follow-up examination. Retrospective identification revealed 27 operatively stabilized patients [12 females, mean age: 35 years, ISS 22 points (range: 14-37)] between January 1996 and July 2001. Patient characteristics, AO classification, Hannover fracture scale pelvis, ISS, and DGU pelvis score points were analyzed. All cases showed a C-type lesion (C1:67%, C2:33%). A total of 21 patients were seen at follow-up, 12 with and 9 without IR. In ten cases with IR, clinical outcome improved after surgery according to the DGU pelvis score ( p=0.001, Wilcoxon's test). These mostly young patients also showed a better outcome compared with those cases without IR. Due to the good clinical results, implant removal seems to be beneficial for selected individual patients, especially when pain is present.

Abstract: The initial transfusion therapy after trauma has been identified as an independent risk factor for the incidence of multiple organ failure (MOF). Late occurrence of MOF in severely injured patients may be a clinical consequence of disturbed mediator homeostasis. For this reason, levels of interleukin (IL)-6, IL-10, and soluble tumor necrosis factor receptors (sTNFR) p55 and p75 were analyzed in the plasma of patients with comparable injury severity but with a different supply of packed red blood cells (PRBC). Thirty-eight multiple trauma patients with an injury severity score range of 25-54 points were separated into two groups according to their PRBC supply within the first 24 h after trauma. Patients who received at least 15 units of PRBC were analyzed in group 2 (n = 11); the remaining patients (n = 27) were assigned to group 1. The incidence of MOF was higher (P < 0.05) in group 2 patients. Correspondingly, levels of all assayed mediators were found significantly elevated at several time points in this patient group. We conclude that increases in mediator concentrations may be causally related to the extent of blood transfusion therapy itself or to the conditions for which it was needed.

Abstract: The important role of technical expertise, experience and intuition in the operative specialties may hamper both clinical research and evidence-based medicine (EBM). We assessed whether the results of EBM practice projects actually varied between surgery and medicine.

Abstract: We examined whether procalcitonin (PCT) or neopterin (NT) are useful in predicting sepsis, multiple organ failure (MOF), or death after multiple trauma (MT). In a prospective clinical study, a total of 137 consecutive trauma patients (mean age 39 years, median injury severity score [ISS] 27 points) and 34 healthy volunteers were enrolled. Blood samples were collected on arrival in the emergency room until day 28 after trauma. Plasma NT was detected by enzyme-linked immunoassay and PCT plasma levels were determined using an immunoluminometric assay. The incidence of sepsis was 65%, MOF 48%, and death in hospital within 28 days 11%. After adjustment for age, gender, and ISS, PCT and NT levels during the first 2 days after injury were unable to differentiate between patients who developed sepsis or not. On the contrary, patients who developed MOF had higher PCT plasma levels on day 0 (0.60 vs. 0.15 ng/mL), and on days 1 and 2 combined (1.95 vs. 0.32 ng/mL). This difference remained significant in multivariate logistic regression (P = 0.01) and additional subgroup analyses for early and late MOF (P = 0.048 and 0.002). For NT, smaller differences were observed (4.39 vs. 3.68 nmol/L, and 7.20 vs. 5.79 nmol/L), which lost significance in multivariate analysis. On the basis of PCT, ISS, and age, a MOF prediction rule was developed and had a good predictive power (area under the curve: 0.77; P < 0.001). These findings demonstrate that high plasma concentrations of PCT in the early posttraumatic phase are an independent predictor of MOF but not of sepsis.

Abstract: Clinical and experimental evidence suggests that traumatic brain injury (TBI) leads to a systemic immune response. To examine whether TBI causes a release of procalcitonin (PCT) or neopterin (NT) into the circulation, we compared plasmatic mediator levels among multiple injured patients with or without TBI. In total, 98 trauma patients (24 with TBI only, 39 with extracranial injuries excluding TBI, and 35 with combined injuries) and 35 healthy volunteers were studied. Blood was sampled at 15 predefined time points within 132 h after injury and analysed for NT and PCT. Multivariate statistical comparisons were adjusted for different severity of head, thorax, abdomen and extremity injuries, as quantified by the Abbreviated Injury Scale (AIS). PCT was normal 3 h after trauma, but 24 h after extracranial injuries a massive release (median 3 ng/mL) was observed. Significant positive associations between injury severity and posttraumatic PCT levels were found for abdominal and extremity, but not for cranial or thoracic injuries. Only modest changes of marginal statistical significance were detected for NT. The maximum increase per AIS point was 9% (95% confidence intervals [CI]: 3-16%). The effect of TBI on NT release was significant only at 108 h posttrauma with a 5% (95% CI: 1-10%) increase per AIS point. TBI induces a release of PCT and NT into the plasma, but this effect seems to be smaller for intra- than for extracranial injuries, probably due to more extensive surgery for abdominal and extremity injuries.

Abstract: From September 29 until October 2, 1999, a group of international experts met in Wermelskirchen, Germany, for a consensus conference on "Quality of Life after Multiple Trauma". The meeting was initiated and sponsored by the German Ministry of Education and Research. It was the aim of the group to develop evidence-based guidelines for the systematic evaluation and application of Quality of Life (QoL) measures in patients with severe trauma. The present paper describes the format of the meeting, the selection of the participants, the time schedule, and the proceeding, in order to facilitate the interpretation of the results. The work was structured according to the different types of injury: traumatic brain injury (TBI), multiple injuries without TBI, spinal cord injury, and children with TBI. For each injury group, a specific task force group with 9-13 members was established, consisting of methodologists as well as clinicians from different disciplines. The conference was organised as an alternate sequence of plenary sessions and small working group meetings. The work itself was structured according to the following five questions which have been agreed on and distributed to the participants in advance: 1. What is the major problem (ranking) of the patient at different time points after the accident? 2. Which domains of QoL are affected in the sequelae of trauma? 3. Which instruments are useful to evaluate QoL in trauma patients? 4. Which studies have assessed QoL aspects with which instruments? 5. What instruments should be used in which patient group at what time? The moderators of each task force group summarised the respective results and tried to give recommendations for future application of QoL assessment in trauma patients. As far as possible, the statements should be based on the existing evidence. Furthermore, the groups should recommend QoL measures for use across different patient groups and time points.

Abstract:

Abstract: In a prospective trial 266 multiple injured patients were included to evaluate clinical risk factors and immune parameters related to pneumonia.

Abstract: While the primary goal of trauma care continues to be the preservation of life, interest has begun to focus on disability and quality of life of those who survive. Numerous instruments have been developed to measure personal well-being, impairment, or subjective life-satisfaction. But there is no consensus regarding which instruments are most appropriate to use in multiply injured patients, and comparison of results are difficult.

Abstract: Our knowledge about the bidirectional interactions between brain and whole organism after trauma is still limited. It was the purpose of this prospective clinical study to determine the influence of severe head trauma (SHT) as well as trauma in different anatomic injury regions on posttraumatic inflammatory mediator levels from patients with multiple injuries.

Abstract: The aim of this prospective study was to identify prognostic factors predicting post-operative outcome in patients one year after their hip fracture.

Abstract:

Abstract: The rich and diverse heritage of the management of vascular injuries in the 45 independent European countries prevents the authors from revealing a uniform picture of the European experience, but some trends are clearly emerging. In countries with a low incidence of penetrating trauma and increasing use of interventional vascular procedures, the proportion of iatrogenic vascular trauma exceeds 40% of all vascular injuries, whereas on other parts of the continent, armed conflicts are still a major cause of vascular trauma. National vascular registries, mostly in the Scandinavian countries, produce useful, nationwide data about vascular trauma and its management but suffer still from inadequate data collection. Despite a relatively low incidence of vascular trauma in most European countries, the results are satisfactory, probably in most cases because of active and early management by surgeons on call, whether with vascular training or not, treating all kinds of vascular surgical emergencies. In some countries, attempts at developing a trauma and emergency surgical specialty, including expertise in the management of vascular injuries, are on their way.

Abstract: In October 1999, an international and interdisciplinary consensus conference was held about the assessment and application of quality of life (QoL) measures after multiple trauma. Four working groups represented the following patients: children with traumatic brain injury (TBI); adults with TBI, adults with multiple injuries (but without TBI), and adults with spinal cord injury. According to predefined questions, the groups tried to identify the relevant problems of the patients, at different time points after the traumatic event. A review of the existing instruments for quality of life assessment and the evidence of their application in trauma patients in the scientific literature was performed by each group. Based on the results of these literature reviews it was concluded that there are not enough data to establish "evidence-based" guidelines for QoL assessments in these patients. Nevertheless, the groups comprised of experts clinicians and methodologists, agreed on the Glasgow Outcome Scale and the SF-36 as generic tools for QoL assessment across all trauma patients. It was further recommended to use these generic tools in combination with condition-specific instruments to better reflect the specific problems of the patients. Finally, the whole group suggested that it was not appropriate to view this conference as a "final report" about QoL assessment in trauma patients, but rather it should be seen as a starting point for increased efforts to initiate clinical research projects using QoL as an outcome, to develop better instruments, and to include QoL assessments into daily routines.

Abstract: Even years after having sustained multiple injuries patients often suffer from its sequelae. These comprise restrictions in physical function, but also pain, social and psychological impairments. Although the Meran Consensus Conference in 1990 defined the contents of "quality of life" (QoL) measures in surgery, still no instrument is available for the valid assessment of all relevant QoL domains in multiple injured patients. This paper describes the systematic development of a modular instrument for the assessment of health related QoL. Within three phases (phase I: generation of items, phase II: item reduction, phase III: pre-testing in 70 multiple injured and control patients) a questionnaire of 57 items was developed, which measures all relevant trauma-related aspects of QoL after acute hospital care. In combination with the Glascow Outcome Scale (GOS), the EUROQOL and the SF-36, the newly developed instrument builds the Polytrauma Outcome Chart (POLO-Chart) which will also be used as "Part E" for outcome assessment within the "Trauma registry" of the German Society for Trauma Surgery. In phase IV, the POLO-Chart will finally be validated in five trauma centres (Celle, Essen, Hanover, Cologne und Munich).

Abstract: Severe trauma is accompanied not only with functional disabilities, but also with pain, social and psychological problems of the patient. Those four aspects are important components of the construct quality of life (QoL). The purpose of this study was to evaluate different questionnaires and to compare results between multiply injured patients and healthy controls.

Abstract: No general agreement exists on the operative therapy of displaced proximal humeral fractures. The purpose of this study is to evaluate different internal fixation techniques (plate fixation, figure-of-eight tension wiring, lagscrew) and to verify if the plate fixation is still an adequate therapy in the treatment of displaced proximal humeral fractures. A follow-up investigation was conducted in 51 patients after an average of 4.2 years. A T-plate fixation was performed in 62.7%, a minimal invasive technique in 21.6% and a shoulder prosthesis in 15.7% of these patients. At follow-up 60.7% of the patients with a 3- or 4-part fracture had good or excellent results in the Constant score (59% T-plate, 66% minimal invasive). Humeral head necrosis was seen in 15.9% of the patients with a T-plate fixation and in 9.1% of the patients with minimal invasive techniques. Based on our results and the reviewed literature we can confirm advantages of the minimal invasive techniques in the treatment of 4-part fractures. However, good results can be obtained with T-plate fixation in 2- or 3-part fractures especially in younger patients.

Abstract: On hospital admission numerous variables are documented from multiple trauma patients. The value of these variables to predict outcome are discussed controversially. The aim was the ability to initially determine the probability of death of multiple trauma patients. Thus, a multivariate probability model was developed based on data obtained from the trauma registry of the Deutsche Gesellschaft für Unfallchirurgie (DGU).

Abstract: Suture techniques are the standard for fixation of meniscus bucket-handle lesions. In 1993 a new method for meniscus repair with self-reinforced biodegradable "arrows" was introduced. Currently, various meniscus implants are available in Germany and are widely used clinically. The purpose of this paper was to evaluate and discuss the literature on biodegradable meniscus implants. Relevant articles were retrieved from Medline of the National Library of Medicine (1966 until July 2000) using the combined search strategy for the keywords "meniscal repair" and "arrow." Ten publications were found. The reported advantages of meniscus arrows are the reduced operation time, the easy surgical technique, and the reduced risk of neurovascular injury. In most experimental studies, lower failure strength of meniscus arrows was found compared to meniscus sutures. In clinical studies, the meniscal healing rates comparing the arrow technique and suture technique are comparable. Various complications of the new arrow technique have been reported such as inflammatory foreign-body reaction, cartilage lesions, and arrow displacement. Based on the existing literature, no final judgment is possible. Currently, individual indications depending on the kind of meniscal lesion and location are recommended. A combination of suture and arrow technique might be a treatment option, but further prospective randomized studies and longer follow-ups are necessary.

Abstract: There is no general agreement on the operative treatment of displaced proximal humeral fractures. While T-plate fixation was the method of choice until the end of the 1980s, minimally invasive techniques have been favoured during the past decade. The indication for primary shoulder prosthesis is controversial. The purpose of this report was to evaluate the scientific evidence of current treatment recommendations.

Abstract: There are no generally accepted concepts for the treatment of traumatic anterior shoulder dislocation. The objective of this study was to ascertain the current treatment for traumatic shoulder dislocations in German hospitals and to compare this with the data reported in the literature. A total of 210 orthopedic surgery departments were asked for their treatment strategy in an anonymous country-wide survey; 103 questionnaires (49%) were returned for evaluation. Additional imaging (ultrasound, CT, MRI) beyond the routine X-rays is performed in 82% of clinics for primary shoulder dislocation (94% in recurrent dislocation). A young, athletic patient (< 30 years old) would be operated on for a primary traumatic shoulder dislocation in 73% of hospitals (98% in recurrent dislocation). In contrast, a patient of the same age, with a moderate level of sporting activity would be treated conservatively in 67% of cases (14% in recurrent dislocation). Similarly, for an active, middle-aged patient with a demanding job, 74% of responses favored conservative treatment after a primary dislocation and 6% after a recurrent dislocation. Older patients (> 65 years old) are usually treated conservatively after a primary or recurrent shoulder dislocation (99%, 69%). For a primary shoulder dislocation the most popular surgical reconstruction is a Bankart repair (75%). For recurrent shoulder dislocation several different operative techniques are seen (Bankart 29%, T-shift 26%, Putti-Platt 8%, Eden-Lange-Hybbinette 22%, Weber osteotomy 13%). Based on our literature review, we found: (1) The clinical examination of both shoulders is important to diagnose hyperlaxity; (2) Routine CT or MRI is not necessary for primary traumatic shoulder dislocations; (3) A young, athletic patient should undergo surgical reconstruction after a primary shoulder dislocation; (4) The operation of choice for primary and recurrent dislocation is the Bankart repair; (5) There is no sufficient evidence that an arthroscopic Bankart repair is as good as an open procedure; (6) There are limited indications for other operative techniques, as they are associated with a higher recurrence and arthrosis rate.

Abstract: We report on a 29-year-old motorcyclist, who had suffered a traumatic right side arm plexus lesion. The myelo-CT image showed a avulsion of the cervical roots C7/C8. Five days after the accident the patient complained of phantom pain in the right plegic arm and was presented to our acute pain service (APS). The patient complained of lancinating attacks of severe phantom pain in the right arm (visual analogue scale intensity of 80-100 pts.). The initial pain treatment was performed with PCA (piritramide), and because of the lancinating pain character carbamazepine treatment was introduced. The pain intensity increased under carbamazepine (VAS = 100 pts.), and after treatment with five cycles of salmon-calcitonin infusion the pain intensity decreased (VAS = 10 pts). After withdrawal of the infusion therapy with salmon calcitonin the pain intensity increased up to VAS = 70 pts. TENS therapy five times per day showed no analgetic effect. We repeated the calcitonin-infusion therapy and after five i.v. cycles we continued with 200 I.U. salmon calcitonin intranasal per day. The initial phantompain intensity decreased (VAS = 40 pts.), but showed no long term analgesia. The additional psychological treatment with relaxation techniques (Jacobson/Bensen) showed the desired phantom pain relief. An interdisciplinary and multimodal cooperation between anesthesiologists, trauma surgeons, neurosurgeons and psychologists is needed for successful phantom pain treatment after traumatic brachial plexus lesion. Intravenous salmon calcitonin showed only short-term analgetic effect.

Abstract: The therapy of acromioclavicular dislocations remains controversial. In particular, for injuries classified as Rockwood/Tossy Type III good results have been reported with different operative techniques as well as with conservative treatment. The objective of this study was to obtain data about the current treatment for Rockwood/Tossy III injuries in German trauma departments. In a countrywide anonymous survey 210 German trauma departments were asked about their diagnostic procedures and their treatment strategies for acromioclavicular injuries. 104 questionnaires (49%) were returned and evaluated. In Rockwood/Tossy I/II injuries most clinics recommend conservative treatment (Rockwood/Tossy I/II: 99%/87%). On the other hand, 84% of the clinics would operate on Type III acromioclavicular injuries--especially in athletes or overhead workers. Although 38 percent of the clinics believe that conservative treatment is equal or better than operative treatment, only 13 percent manage Type III injuries conservatively. For more severe acromioclavicular injuries (Rockwood IV to VI) all clinics recommend an operative treatment. The operative techniques of choice for acromioclavicular injuries are K-wire fixation (37%) or a coraco-clavicular cerclage (32%). Of the latter, 73% use a resorbable material, while the remainder use wires.

Abstract: This prospective, multi-center, observational study of 2069 multiple trauma patients evaluated the prognostic significance of the posttrauma base deficit (BD) on hospital and intensive care unit (ICU) admission to hemodynamic changes, volume and transfusion requirements, lactate and coagulation, as well as mortality. Furthermore, the importance of the BD development throughout a patient's course of critical illness from the time of injury to ICU admission is analyzed as a prognostic factor for fatal outcome. The data were obtained by the trauma registry of the 'Deutsche Gesellschaft für Unfallchirurgie.' The patients were subdivided into five categories of increasing BD values on hospital and ICU admission: Category I, BD < or = -2; Category II, -2 < BD < or = 2; Category III, 2 < BD < or = 6; Category IV, 6 < BD < or = 10; and Category V, BD > 10. A statistical analysis was performed by means of the ANOVA and chi-square tests. In 1264 (61.1%) of 2069 multiple trauma patients (age 39 +/- 19 years, 70.0% males, injury severity score 22 +/- 13, 18.6% mortality), the BD was documented on hospital and in 1536 (74.2%) patients on ICU admission. At both points in time, an increase in the BD category was associated with a significant decrease in systolic blood pressure and prothrombin time as well as increases in heart rate, lactate level and mortality (P < 0.0001). Also transfusion requirements (Category I: 4.5 +/- 7.7 and Category V: 13.7 +/- 13.0 packed red blood cells) increased significantly on hospital admission (P < 0.0001) with a worsening in the BD category. Mortality increased significantly (P < 0.0001) with a worsening of BD from hospital to ICU admission (from a mortality of 13% in patients with a hospital and an ICU admission BD of <6 to 45% in patients with a hospital and an ICU admission BD of >6). These data show that the base deficit is an early available important indicator to identify trauma patients with hemodynamic instability, high transfusion requirements, metabolic and coagulatory decompensation, as well as a high probability of death. The base deficit development may help to guide an early and aggressive therapy for the trauma/hemorrhage induced tissue hypoxia.

Abstract: The process of care of a severely injured patient from the site of the accident up to rehabilitation is complex and the result may be influenced by many factors. The outcome of the patient is determined by the primary injury caused by the accident but also by the secondary injury which is influenced by the quality of the diagnostic and therapeutic procedures. Different studies observed a negative correlation between the duration of diagnostic procedures in the initial phase in the emergency room and the outcome of the patient. It could be shown that a standardized documentation of emergency room procedures and the discussion of the resulting data in quality circles contributed to an improved survival of patients. Beside these internal quality circles the trauma registry of the German Trauma Society provides the possibility of external comparison.

Abstract: For young athletic patients with a primary traumatic shoulder dislocation a surgical treatment is recommended. The operation of choice is the Bankart-Repair.

Abstract: The Constant- and the Neer-Score are widely used to assess shoulder function after trauma or shoulder diseases. The objective of this study was to compare the correlation of score result with the patient subjective assessment. We hypothesized that there is a clinically relevant difference between the score result and the patient assessment, especially for highly selective patient groups.

Abstract: Dorsal dislocation of the fifth carpometacarpal joint after injury is rare. Only five cases are reported in the literature. We report on two cases of dorsal dislocation of the fifth carpometacarpal joint after injury and we give a review of related literature. There are two interesting aspects concerning diagnostic and therapy of dorsal dislocation of the fifth carpometacarpal joint. Anterior-posterior and lateral radiographs do not always provide adequate visualisation of this joint so a dislocation may be misdiagnosed. A radiograph taken with the forearm pronated 45 degrees from the routine anterior-posterior position better shows the dislocation. The adequate therapy consists in closed reduction, Kirschner wire fixation and cast immobilisation. A reduction without following Kirschner wire fixation - even in those dislocations that were found to be stable after closed reduction - is not recommended because of the risk of persisting pain after heavy manual work. In our two cases an instability of the fifth carpometacarpal joint existed after closed reduction. After Kirschner wire fixation and cast immobilisation for 6 weeks both patients showed 3 months after operative therapy a full range of movement and a powerful grip without any pain in the fifth carpometacarpal joint.

Abstract: There is controversy about the therapy for third-degree acromioclavicular dislocation according to Tossy and Rockwood's classification. Both operative and non-operative treatment is reported to have satisfactory results in the literature. The purpose of this study was to analyze the literature in a systematic manner based on the criteria of evidence-based medicine. It was our hypothesis that there is no scientific evidence for the superiority of one treatment over the other. A total of 370 papers were retrieved and classified into three groups: (1) randomized controlled trials; (2) comparative retrospective studies; and (3) retrospective studies. In three studies that were graded with high evidence, the major outcome for both operative and non-operative treatment was similar. The advantages of non-operative treatment include a shorter period of rehabilitation and a significantly lower complication rate while the advantages of operative treatment include a low rate of persisting subluxation of the AC joint. Similar results were found for retrospective comparative and long-term studies. For retrospective studies without controls, both operative and conservative therapy are described with good and excellent results, ranging between 80 and 97%. In conclusion, there is good evidence on the therapy of third-degree acromioclaviculary dislocation studies. The functional result according to the literature is similar, and complications associated with therapy occur more often with operative treatment. Conservative treatment appears to be the method of choice for third-degree acromioclavicular dislocations unless the patient's preference is operative therapy.

Abstract: Besides interleukin (IL)-10, accumulating evidence from in vitro studies has indicated a strong antiinflammatory capacity for IL-13. A prospective clinical study was undertaken to assess the influence of additional brain injury on systemic IL-10 and IL-13 levels as markers for the antiinflammatory state in trauma patients.

Abstract: Epidemiological data on the incidence, the prehospital and hospital care and the outcome of traumatic brain injury in Germany are scarce. It is therefore difficult to estimate the importance of this injury with respect to magnitude as well as effectiveness and efficiency of therapeutic concepts. We therefore planned a study that was supposed to provide population based epidemiological data in the field of severe brain trauma from the site of the accident until discharge from hospital. All 90.000 prehospital emergencies that were cared for by emergency physicians in Cologne from January 1990 until December 1996 were screened for identification of severe brain trauma. Their clinical course was reviewed using standard records and patients were included if they had their accident within the city of Cologne and fullfilled the final inclusion criteria of GCS </= 8 or AIS(Head) >/=3. 650 eligible patients were identified of whom 530 had complete datasets (follow-up 80 %). Univariate statistical analysis was performed for all relevant variables. The main study endpoints were incidence and outcome of severe brain trauma. The annual incidence of severe brain trauma in Cologne (1 mio. inhabitants) was 93. The average age was 39 years and 71 % of the patients were male. The average prehospital GCS was 6.8, the average prehospital Trauma Score was 8.3 points. 49 % of the study population suffered from multiple injuries. The overall mortality rate was 46,6 %. 60 % of deaths occurred within the prehospital setting. The incidence of severe brain trauma in Cologne in this study was significantly lower compared to what could be expected from the litera-ture. The overall mortality was high, especially the high prehospital death rate is striking.

Abstract: In modern industrial countries traumatic brain injury (TBI) is a common sequel after different kinds of accidents especially amongst young male adults. Apart from medical and economic consequences Quality of Life (QoL) after TBI becomes increasingly important in outcome assessment. Besides the classical domains of QoL (physical, psychological, social) cognitive impairments are playing an important role especially for TBI patients. In 1991 the Meran conference set important standards and formulated basic guidelines for defining and measuring QoL in surgery, but a special index for TBI patients has not yet been developed. Instead, QoL research concentrates on physical, medical, psychological and social problems only. Based on the existing QoL concept extended by the cognitive aspect it was the aim of this review to give an overview about the recent QoL research in TBI patients since 1991. Sixteen studies in TBI patients mentioning at least 2 domains of QoL (physical, psychological, social, cognitive) were published since 1991. Five of them considered all 4 domains of QoL. All studies except of one dealt with psychological and social problems. Only half of the studies considered cognitive impairments. Four studies tried to define QoL, but none of them included the cognitive component. There was no consensus regarding the definition and the choice of measurement instrument for QoL after TBI. This review of 16 studies considering outcome and QoL after TBI confirms that a homogenous and clinically relevant QoL concept for this group of patients is still missing. Further research in TBI patients should include all 4 domains of QoL.

Abstract: Introduction: Three challenges that physicians and decision makers in the health care systems have to meet are a remarkable proportion of medical decisions without a sufficient base of scientific evidence, a slow and opaque process of integrating scientific knowledge into medical practice and a steadily decreasing half-life period of the medical knowledge. Discussion: During the last two decades, a number of projects have faced these problems and forced the development of evidence-based medicine (EBM). This concept claims the explicit conscientious use of current evidence from clinical research combined with the personal expertise in the process of medical decision making. The following article explains the main steps of practising and teaching EBM illustrated by a clinical example.

Abstract: Outcome refers to the different facets of consequences resulting from an event or intervention. These consequences may be relevant for an individual patient, but also for society. There is a growing recognition that clinical research needs to define and focus on the outcomes of medical care. Outcome research should help health care professionals to better evaluate the effectiveness of specific interventions or a therapeutic concept. This broader base of evidence should then benefit the patients.

Abstract: In this article a systematic technology assessment was used for ultrasound in blunt abdominal trauma. We found sonography to be a simple, fast and complication-free method with high sensitivity and specificity. Ruptures of the small bowel seemed to be extremely difficult to detect, especially in the early phase after blunt abdominal trauma. No basic definitions of significant free fluid and maximal limit for non-operative treatment are found in the international literature. Only the combination of prognostic factors such as mechanism of the accident, clinical examination, and the intuition of the surgeon leads to a decision.

Abstract: Our objective was to compare the effect of two methods of data collection on results in a functional knee score. Two Lysholm scores were obtained for 61 patients 1 year after anterior cruciate ligament surgery at the same clinic visit. First, the patients completed a self-administered questionnaire, and second, the Lysholm score form was completed by the investigator in the course of a patient interview. A comparison of the scores revealed that the mean score was significantly lower with self-administration (self, 89.3 +/- 10.6; interviewer, 92.2 +/- 7.4) (P = 0.0035, Wilcoxon rank sum test). The assignment to one of four categories (excellent, good, fair, poor) was also significantly altered by the manner of data collection. Nineteen patients (31%) were assigned to different categories based on the mode of data collection. We believe that the major reason for a better score result with an interview was the presence of interview bias. The more the investigator is involved in the treatment of the patient, the greater the influence of this bias may be. To avoid such potential bias we suggest that a standardized self-administered questionnaire be used as the method of choice for obtaining subjective data in clinical settings.

Abstract: Most standard trauma score systems have been developed and validated in the United States. However, trauma differs between the United States and Germany. This prospective study tested the validity of eight current trauma scoring systems (Glasgow Coma Scale, Trauma Score, Revised Trauma Score, Injury Severity Score, TRISSTS, TRISSRTS, Prehospital Index, Polytraumaschluessel) in 612 patients in Cologne.

Abstract: In a double-blind, randomized trial, 40 patients undergoing open anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft were randomly allocated to two groups: group A (n = 20) received an intra-articular instillation of 20 mL bupivacaine (0.25%) and a local infiltration of 20 mL bupivacaine (0.5%) 15 minutes before surgery. Group B (n = 20) received an injection of saline solution in the same manner. Patient-controlled on-demand analgesia (PCA) with intravenous piritramid was used for postoperative pain control. A significant decrease in pain scores on a visual analog scale (VAS scale, 0 to 10) was found in the bupivacaine group (group A) at bedrest on the day of surgery only (pain score, 5.5 v 7.3 (scale, 0 to 10), P < .05). At all other times, no significant differences were found. The overall supplemental opioid requirements were not different between the study groups (63.9 v 62.6 mg piritramid/72 hours). A long-lasting, clinically relevant, pain-reducing effect with infiltration of bupivacaine before surgery could not be shown with this study.

Abstract: The utility of scoring systems in intensive care and emergency medicine has been approved for the classification of severity of diseases, quality assurance and cost performance of patient groups. There are obvious methodological pitfalls in using probabilities of mortality, which are estimates of risk of death, to predict specific outcomes for individual patients. They can only be used as a supplement to clinical decision making. Use of daily scoring systems can help in the description of the disease course of patients under treatment (trend analysis).

Abstract: Trauma Score Systems attempt to summarize the severity of injury in a single value. They provide a better classification of trauma patients and translate different severities of injury in a common language. They enable thereby comparisons between hospitals or trauma systems. Young doctors can control their clinical judgement with scoring systems and will gain experience. Scoring systems therefore increase safety and can help in decision making. As accuracy of scoring systems is never 100% individual decisions can never rely on scores only. Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score and TRISS are the most often used international scores for severely injured patients. Their sensitivity and specificity, validity, reliability and practicability have been studied and proved in many trials. The role of these scoring systems for quality management purposes in the treatment of severe trauma is actually studied with the Trauma Registry of the German Society for Trauma Surgery.

Abstract: Comparisons of different emergency medical services (EMS) systems often are reduced to simple comparisons between distinct facilities or strategies (e.g., prehospital physician versus paramedic, "scoop and run" versus "stay and play").

Abstract: Posttraumatic cardiopulmonary resuscitation (CPR) is associated with a poor outcome. When evaluating the literature according to the Utstein method, there were only 2 survivors (0.18%) out of 1,135 CPR attempts after trauma (Table 1). Differences in the study populations and levels of prehospital trauma care led us to analyse the results of a physician-staffed prehospital trauma care system in Cologne. METHODS. From January 1987 to December 1990, a total of 49,054 emergency calls were registered using a standardised protocol. Among 9,595 trauma-related calls, 636 patients were found to be pulseless on arrival of the emergency team, 412 of these were pronounced dead. CPR was initiated in the remaining 224 patients, who comprise the study population (defined as 100%). All patients who were admitted to a hospital were followed using a second protocol. RESULTS. CPR in the field was successful in 68 (30.4%) patients, who were then admitted to a hospital; 42 of these died within the first 24 h. Four patients (1.8%) could be discharged from hospital alive and were still living 1 year later, 1 with a lasting neurological deficit (Fig. 1). In 156 (69.6%) cases resuscitative attempts were unsuccessful in the field. CONCLUSIONS. Even in a physician-staffed prehospital trauma care system, the chance of surviving a posttraumatic cardiac arrest is minimal. Survival has to be regarded as an individual fate; the overall results are discouraging. Even though this study analyses the largest population of posttraumatic CPR ever published, prognostic factors could not be identified due to the few survivors. Nevertheless, the result does not justify general omission of CPR after trauma as: (1) prognostic factors for survival have not been identified thus far; and (2) no significant additional costs arise from posttraumatic CPR.

Abstract: Trauma can be defined as either a somatic injury or a psychological reaction in the person affected. The emotional disturbances and psychosocial problems of trauma patients in particular, though still measurable a year or even longer after the event, have rarely been taken into account in surgical studies. Quality of life is a relevant endpoint in multiple trauma patients, insofar as rehabilitation seems to be complicated by non-efficient psychological coping. With reference to the prerequisites for a scientifically sound measuring method four instruments are described that seem to be suitable for measuring quality of life in multiple trauma patients. In addition, practical advice is given for the design of longitudinal studies focused on quality of life in trauma patients.

Abstract: Quality control requires the definition of a quality standard, followed by quality documentation and comparison. In the case of deviation from the standard, the first step in quality assurance is the search for the reasons. After identification of weak points, strategies for quality improvement must then be developed and implemented. With prehospital trauma care as an example, a practical model of quality assurance is presented. Data analysis was performed using the prospective database of 8792 trauma patients who received prehospital trauma care in Cologne from 1. 1. 87 to 31. 12. 90. The Trauma Score was used for classification of the severity of injury. The quality standard in prehospital treatment of severely injured patients is defined as institution of an intravenous line, early intubation and transportation to a trauma centre. The time at the scene of the accident should not exceed 31 min. Among the 8792 trauma patients, 834 had severe injuries, defined as a Trauma Score equal to or less than 12 or a Glasgow Coma Scale equal to or less than 7. An intravenous line was started in 91.6%, early intubation was performed in 82.7%, and transportation to a trauma centre was realized in 62.5% of the patients. The average time at the scene was 34 min. Obviously the standard was not always achieved. Reasons for deviation from the standard are discussed. The fascinating aspect of the model proposed is that it enables quality assurance of prehospital treatment without recourse to hospital data.

Abstract: Numerous scoring systems are available for various particular situations. Some clinicians consider scores as mandatory for daily clinical decision making, while others see them only as additional work with no proven benefit except for scientific aspects. Although scoring systems have their limitations, they can also be of value. This article provides an overview of existing systems used in emergency and intensive care medicine. The specific aims of different scoring systems are discussed and evaluated for the areas of disease classification, monitoring of individual patients and applications to individual decisions, quality assurance (comparison of patient groups and therapies), economic evaluation and global triage decisions. Despite the additional workload it is concluded that scoring systems are of proven benefit for classification of the degree of severity of a disease process, quality assurance, and better assessment of costs containment. These instruments will become increasingly important in our current discussion on changes in health care systems.

Abstract: The field strategy for trauma victims is still controversial. The first randomized study in penetrating truncal trauma by Martin et al. (1992) supported experimental findings (Gross et al., 1988, 1989; Kowalenko et al., 1992; Krausz et al., 1992b) that fluid therapy in uncontrolled haemorrhage increases mortality. No controlled data in blunt trauma are available. In this retrospective analysis of blunt trauma victims (n = 353), the parameters systolic blood pressure, capillary refilling time and Traumascore (Champion et al., 1981) were evaluated in the prehospital detection of uncontrolled bleeding. With the CART methodology (Breiman et al., 1984) systolic blood pressure (BP) was the most sensitive parameter. Uncontrolled haemorrhage was found in nearly 50% of patients whose BP was below 90 mmHg and in 66% of those whose BP was below 50 mmHg. An accompanying traumatic brain injury (TBI) impaired the ability of BP to detect uncontrolled bleeding. Future studies evaluating prehospital fluid therapy in severe blunt trauma with a mixture of injuries, should take into account that BP in our study population classified less than 50% patients with uncontrolled haemorrhage.

Abstract: Quality control in the treatment of trauma patients often consists in comparisons of survival rates. The trauma population under study is seldom defined with regard to severity of injury. Therefore crude survival rates are of little help when the quality of care is discussed. Trauma scores attempt to summarize the severity of injury of trauma patients in a single number. They attempt to translate differences in the severity of injury into a common language. This study tested the validity of seven common trauma score systems in the setting of Cologne in 1987. Six hundred and twelve trauma patients treated by physicians at the scene of the accident were prospectively followed up in 32 hospitals. Final diagnosis, treatment, complications, and survival were evaluated. Sensitivity and specificity in predicting survival were calculated for the following systems: Glasgow Coma Scale, Trauma Score, Revised Trauma Score, Injury Severity Score, TRISS, Prehospital Index, Polytraumaschlüssel. The average time from emergency call to arrival of the emergency physician at the scene of the accident was 6.5 min. Four hundred and one patients (65.5%) were male. One hundred and thirty-seven patients (22.4%) suffered from apnoea, 61 (10.0%) had a systolic blood pressure lower than 90 mmHg, 117 (19.1%) had had a cardiac arrest and 174 (28.4%) were unconscious. Four hundred and twenty-three patients (69.1%) left hospital alive. All trauma score systems tested showed sensitivities and specificities greater than 83%. They all proved their ability to classify trauma patients according to severity of injury. The TRISS performed best of all, with sensitivity of 93.1% and specificity of 93.7% at a cut-off point of 0.85.(ABSTRACT TRUNCATED AT 250 WORDS)

Abstract: There are many reasons for evaluation of an emergency care system, such as expenses (1.035 Bio. DM in 1985) and quality control. From January 1, 1987 to December 31, 1987 information on all patients seen by an emergency physician in the field have been recorded prospectively in a standard form by the Cologne emergency medical services. Cologne has 1,000,000 inhabitants and covers an area of 405 km2. The patients' status, diagnosis and therapeutic interventions were recorded. Trauma patients were further assessed as to time of accident, cause of accident, and trauma score. All trauma patients with a trauma score < 16 were followed up to their discharge from the hospital. In 1987, 2,073 trauma patients were treated. Overall mortality at the time of discharge was 9.2%. This result alone, however, is not sufficient for assessment of the trauma system. It is important to provide better information on the patient. The trauma evaluation score already used in the US became also a valid instrument in West-Germany. It shows a high correlation between survival and the patients' physiological status in the field. Standard curves could be established for comparing individual or regional trauma systems.

Abstract: Little information is available about the vital parameters of burns victims shortly after the accident. Therefore cases of burns, electrical and caustic injuries presenting to the Cologne Emergency Physician System over 3 years (n = 262) were prospectively studied and analysed. The average incidence in Cologne, Germany (population 1 million), of burns victims attended by the Emergency Medical System and emergency physicians at the scene was 74 adults and 14 children per year. Children are mainly injured by scalds (41.4 per cent); adults by fire accidents (43 per cent). A classification of the victims at the site of the accident according to their vital signs (Trauma Score (TS) after Champion H. R., Sacco W. J. and Carnazzo A. J. et al. (1981) Trauma Score. Crit. Care Med. 9, 672) showed, that in spite of a major burn injury, the vital signs were usually not or only slightly impaired. Subsequent measurements instituted by the emergency physician at the scene increased with decreasing initial TS. With TS = 14, 50 per cent of the patients were intubated; below 14 points nearly 100 per cent. The fluid administered also increased with a decreasing TS.

Abstract: Compared to the magnitude of the trauma problem few precise data exist on prehospital care of trauma patients. The aim of the study was the collection and careful evaluation of prehospital data on trauma patients concerning time sequences, patients' status and prehospital interventions. From 1. 1. 1987 to 31. 12. 1990 all 49,045 prehospital emergencies in Cologne were prospectively registered. 8792 trauma patients were treated by an emergency physician in the field. 9.5% were severely injured, defined by a trauma score less than or equal to 12. 9.9% of the trauma patients were intubated, 54.9% received an i.v. line, and 20.6% were triaged to a trauma center. Our data form a valid base for analysis of the effectiveness of prehospital trauma care.

Abstract: Promising effects of adjuvant drugs in experimental shock models often are not confirmed in subsequent clinical trials, e.g., steroids, fibronectin, naloxone, immunotherapeutics. A key difficulty in establishing a therapeutic benefit in clinical studies, apart from study design shortcomings, is the lack of knowledge and application of principles of clinical pharmacokinetics and -dynamics. In shock states the relationship between an administered fixed dose regimen and the drug effect is strongly influenced by dynamic changes in absorption, distribution, metabolism, and elimination of the drug, all of which vary between individual patients. This article describes several neglected aspects of clinical pharmacology relevant to shock research under clinical conditions and discusses the indications, prerequisites, and limitations of "applied pharmacokinetics." The inclusion of therapeutic drug monitoring in clinical shock studies should be applied more frequently to establish experimental results in the "real world" of ICU settings.

Abstract: The clinical use of glucocorticoids in trauma and sepsis has not yet been approved on the basis of clinical trials. Current knowledge in the area of pathogenesis is reviewed, and against this background the mechanisms of steroid action will be discussed, the current status of clinical testing in both trauma and sepsis will be evaluated, and ways of testing the effectiveness will be proposed. Although most trials up to now have shown a positive overall effect in trauma patients, a further prospective randomized controlled study with a more homogeneous study population and including trauma scores is necessary before trauma can be reliably accepted as a firm indication for glucocorticoid treatment. In the discussion on sepsis syndrome a variety of reasons are suggested for the failure of earlier studies to show beneficial effects. Besides methodological aspects, one of the main reasons is the neglected field of pharmacologic-pharmacokinetic principles. A new study should be performed under therapeutic drug-monitoring (TDM) conditions once more is known about the target concentration range.

Abstract: A cohort study of 202 patients showed that all different aspects of quality of life--physical function, psychological function, social function and symptoms--were altered after multiple injury. Sixty-three percent of the patients rated their quality of life after trauma as average or bad. Since the quality of life is a relevant problem after trauma, it is necessary to use it as an important endpoint to judge results after multiple injury. Findings from such studies must be integrated into existing diagnostic and therapeutic concepts.

Abstract: Biocompatibility and mechanical strength of 3 different dura mater preparations were studied during 1, 2 and 4 weeks in a rat model. Two preparations produced by conventional methods did not markedly differ, whereas the third one, which had been freeze-dried after addition of glycerol, exhibited some special properties, showing higher mechanical strength throughout the whole period of implantation, and lower tendency to form adhesions, and inducing weaker leucocytic reaction. For certain surgical problems this soft, strong and compatible dura preparation could be an appropriate alternative.

Abstract: Scoring systems are a technique for defining patients for scientific and management purposes. A hypothetical, severely ill patient with cirrhosis, peritonitis, renal insufficiency and coagulation problems can be precisely classified: Child C, Mannheim-Peritonitis-Index 34 and APACHE II score 27 which results in a mortality of at least 70% of patients. At our own hospital, the continuous APACHE score (CAPS) has been developed and tested. The CAPS performed better than daily APACHE scores and provided useful trend information for the individual patient.

Abstract: Surgery asks patients to trade present discomfort and risk for future gains. Although research reports on the effectiveness of surgery have largely focused on mortality, length of hospital stay, major complications, and laboratory analyses, the principal criteria guiding surgeons' clinical decisions and patients' acceptance of treatment are most often the patients' subjective feelings and capabilities, the quality of their lives. This is true for both major and minor surgical procedures. We discuss the role of information on functional capacity, overall well-being, and quality of life in the assessment of surgical outcomes. Broadening the choice of endpoints beyond traditional, so-called "hard" variables in surgical studies has advantages for both surgeons and patients.

Abstract:

Abstract: According to a strict definition of a benign gastric outlet obstruction i.e. delayed vomiting, changing of symptoms, weight loss and intraoperative test by Hegardilators (less than 14), 2.2% real stenoses among 619 operative treated duodenal ulcer patients were found. All patients were treated by SPV and digital dilatation of the stenosis through a gastrotomy. During up to a 10 year follow-up no reoperation was necessary. All patients showed Visick-classification of I and II. In conclusion SPV with digital dilatation showed good clinical results for patients with benign gastric outlet obstruction in long-term follow up.