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Mitra B.,Emergency and Trauma Center | Mitra B.,Monash University | Mitra B.,National Trauma Research Institute | Fitzgerald M.,National Trauma Research Institute | Chan J.,Trauma Service
Injury | Year: 2014

Introduction and aims: The use of intravenous oxygen carriers (packed red blood cells (PRBC), whole blood and synthetic haemoglobins (HBOCs) for selected pre-hospital trauma resuscitation cases has been reported, despite a lack of validated clinical indications. The aim of this study was to retrospectively identify a sub-group of adult major trauma patients most likely to benefit from pre-hospital oxygen carrier administration and determine the predictive relationship between pre-hospital shock index (SI) [pulse rate/systolic blood pressure] and haemorrhagic shock, blood transfusion and mortality. Methods: A retrospective review of adult major trauma patients recorded in The Alfred Trauma Registry was conducted. Patients were included if they received at least 1 L of pre-hospital crystalloid and spent over 30 min in transit. The association of shock index and transfusion was determined. Patients were further sub-grouped by mode of transport to determine the population of trauma patients who could be included into prospective studies of intravenous oxygen carriers. Results: There were 1149 patients included of whom 311 (21.9%) received an acute blood transfusion. The SI correlated well with transfusion practice. A SI ≥ 1.0, calculated after at least 1 L of crystalloid transfusion, identified patients with a high specificity (93.5%; 95% CI: 91.8-94.8) for receiving a blood transfusion within 4 h of hospital arrival. While patients transported by helicopter had higher injury severity and blood transfusion requirement, there were no difference in physiological variables and outcomes when compared to patients transported by road car. Conclusions: A shock index ≥ 1.0 is an easily calculated variable that may identify patients for inclusion into trials for pre-hospital oxygen carriers. Shocked patients have high mortality rates whether transported by road car or by helicopter. The efficacy of pre-hospital intravenous oxygen carriers should be trialled using a shock index ≥ 1.0 despite fluid resuscitation as the clinical trigger for administration. © 2013 Elsevier Ltd. All rights reserved.


Rosenfeld J.V.,Monash University | Rosenfeld J.V.,National Trauma Research Institute | McFarlane A.C.,University of Adelaide | Bragge P.,National Trauma Research Institute | And 5 more authors.
The Lancet Neurology | Year: 2013

A bomb blast may cause the full severity range of traumatic brain injury (TBI), from mild concussion to severe, penetrating injury. The pathophysiology of blast-related TBI is distinctive, with injury magnitude dependent on several factors, including blast energy and distance from the blast epicentre. The prevalence of blast-related mild TBI in modern war zones has varied widely, but detection is optimised by battlefield assessment of concussion and follow-up screening of all personnel with potential concussive events. There is substantial overlap between post-concussive syndrome and post-traumatic stress disorder, and blast-related mild TBI seems to increase the risk of post-traumatic stress disorder. Post-concussive syndrome, post-traumatic stress disorder, and chronic pain are a clinical triad in this patient group. Persistent impairment after blast-related mild TBI might be largely attributable to psychological factors, although a causative link between repeated mild TBIs caused by blasts and chronic traumatic encephalopathy has not been established. The application of advanced neuroimaging and the identification of specific molecular biomarkers in serum for diagnosis and prognosis are rapidly advancing, and might help to further categorise these injuries. © 2013 Elsevier Ltd.


Bragge P.,National Trauma Research Institute | Gruen R.L.,National Trauma Research Institute | Chau M.,National Trauma Research Institute | Forbes A.,Monash University | Taylor H.R.,University of Melbourne
Archives of Ophthalmology | Year: 2011

Objectives: To examine how mydriasis and the medical qualifications of photographers who take retinal photographs influence the accuracy of screening for diabetic retinopathy (DR). Methods: Our meta-analysis included studies that measured the sensitivity and specificity of tests designed to detect any DR, sight-threatening DR, or macular edema. Using random-effects logistic regression, we examined the effect of variations in mydriatic status and in medical qualifications of photographers on sensitivity and specificity. Results: Only the category of "any DR" had sufficient consistency in definition, number of studies (n=20), and number of assessments (n=40) for meta-analysis. Variations in mydriatic status did not significantly influence sensitivity (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.56-1.41; P=.61) or specificity (OR, 0.94; 95% CI, 0.57-1.54; P=.80). Variations in medical qualifications of photographers did not significantly influence sensitivity (OR, 1.25; 95% CI, 0.31-5.12; P=.75). Specificity of detection of any DR was significantly higher for screening methods that use a photographer with specialist medical or eye qualifications (OR, 3.86; 95% CI, 1.78-8.37; P=.001). Conclusion: Outreach screening is an effective alternative to on-site specialist examination. It has potential to increase screening coverage of high-risk patients with DR in remote and resource-poor settings without the risk of missing DR and the opportunity to prevent vision loss. Our analysis was confined to the presence or absence of DR. Future studies should use consistent DR classification schemes to facilitate further analysis. © 2011 American Medical Association. All rights reserved.


Schonberger M.,Monash University | Schonberger M.,Monash Epworth Rehabilitation Research Center | Ponsford J.,Monash University | Ponsford J.,Monash Epworth Rehabilitation Research Center | Ponsford J.,National Trauma Research Institute
Psychiatry Research | Year: 2010

There is a lack of validated scales for screening for anxiety and depression in individuals with traumatic brain injury (TBI). The purpose of this study was to examine the factor structure of the Hospital Anxiety and Depression Scale (HADS) in individuals with TBI. A total of 294 individuals with TBI (72.1% male; mean age 37.1. years, S.D. 17.5, median post-traumatic amnesia (PTA) duration 17. days) completed the HADS 1 year post-injury. A series of confirmatory factor analyses was conducted to examine the fit of a one-, two- and three-factor solution, with and without controlling for item wording effects (Multi-Trait Multi-Method approach). The one-, two- or three-factor model fit the data only when controlling for negative item wording. The results are in support of the validity of the original anxiety and depression subscales of the HADS and demonstrate the importance of evaluating item wording effects when examining the factor structure of a questionnaire. The results would also justify the use of the HADS as a single scale of emotional distress. However, even though the three-factor solution fit the data, alternative scales should be used if the purpose of the assessment is to measure stress symptoms separately from anxiety and depression. © 2009 Elsevier Ltd.


Palmer C.S.,Royal Melbourne Hospital | Niggemeyer L.E.,Alfred Hospital | Niggemeyer L.E.,National Trauma Research Institute | Charman D.,Alfred Hospital
Injury | Year: 2010

Introduction: The 2005 version of the Abbreviated Injury Scale (AIS05) potentially represents a significant change in injury spectrum classification, due to a substantial increase in the codeset size and alterations to the agreed severity of many injuries compared to the previous version (AIS98). Whilst many trauma registries around the world are moving to adopt AIS05 or its 2008 update (AIS08), its effect on patient classification in existing registries, and the optimum method of comparing existing data collections with new AIS05 collections are unknown. The present study aimed to assess the potential impact of adopting the AIS05 codeset in an established trauma system, and to identify issues associated with this change. Methods: A current subset of consecutive major trauma patients admitted to two large hospitals in the Australian state of Victoria were double-coded in AIS98 and AIS05. Assigned codesets were also mapped to the other AIS version using code lists supplied in the AIS05 manual, giving up to four AIS codes per injury sustained. Resulting codesets were assessed for agreement in codes used, injury severity and calculated severity scores. Results: 602 injuries sustained by 109 patients were compared. Adopting AIS05 would lead to a decrease in the number of designated major trauma patients in Victoria, estimated at 22% (95% confidence interval, 15-31%). Differences in AIS level between versions were significantly more likely to occur amongst head and chest injuries. Data mapped to a different codeset performed better in paired comparisons than raw AIS98 and AIS05 codesets, with data mapping of AIS05 codes back to AIS98 giving significantly higher levels of agreement in AIS level, ISS and NISS than other potential comparisons, and resulting in significantly fewer conversion problems than attempting to map AIS98 codes to AIS05. Conclusions: This study provides new insights into AIS codeset change impact. Adoption of AIS05 or AIS08 in established registries will decrease major trauma patient numbers. Code mapping between AIS versions can improve comparisons between datasets in different AIS versions, although the injury profile of a trauma population will affect the degree of comparability. At present, mapping AIS05 data back to AIS98 is recommended. © 2009 Elsevier Ltd. All rights reserved.

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