创伤严重度ASCOT计量法及临床应用研究

创伤严重度ＡＳＣＯＴ计量法是以生理指标，解剖指标、损伤类型、年龄为基础参数，通过加权重和数学模型计算ＰＳ值的方法。该法是公认的最佳创伤严重度计量法之一。作者将原法构成中之简略损伤分级ＡＩＳ＿（－８５）更新为ＡＩＳ＿（－９０），且将ＡＳＣＯＴ法设计成能供临床应用之软件。通过４００例临床验证，结果表明：ＡＳＣＯＴ法通过软件可以准确实现临床应用，其灵敏度为９２．３％，特异度为９５．８％，假阴性率为７．７％，假阳性率为４．２％。作者认为：该法对以脑外伤为主的多发伤预测比单纯重型脑外伤灵敏，这有待于今后改进。作者还提出了以ＰＳ值为依据的伤情分类方案：ＰＳ＝０．７６～１．００为轻度伤，０．５１～０．７５为中度伤，０．００～０．５０为重度伤。此方案有待于今后以大量之前瞻性伤员资料验证修订。     

经尿道前列腺电汽化与经尿道前列腺电切对BPH的疗效比较

对２４０例有症状的前列腺增生症（ＢＰＨ）患者分别行经尿道前列腺电汽化术（ＴＶＰ）和经尿道前列腺电切术（ＴＵＲＰ）。结果显示：１２０例ＴＶＰ手术者，前列腺症状评分（ＩＰＳＳ）从术前的２０．９下降至术后３个月的５．１（Ｐ＜０．００１），最大尿流率由１０．６ｍｌ／ｓ上升至１９．２ｍｌ／ｓ（Ｐ＜０．０１）。ＴＵＲＰ组１２０例，ＩＰＳＳ从术前的２１．２下降至术后３个月的５．２（Ｐ＜０．００１），最大尿流率由１０．２ｍｌ／ｓ上升至１９．４ｍｌ／ｓ（Ｐ＜０．０１），两组比较无显著差异性（Ｐ＞０．０５）。平均留置导尿管时间：ＴＶＰ组２６．５小时，ＴＵＲＰ组５０．７小时，有显著性差异（Ｐ＜０．０１）。术后阳萎发生率：ＴＶＰ组２．４％，ＴＵＲＰ组１４．５％（Ｐ＜０．０５）。ＴＶＰ组术中无大出血及经尿道前列腺电切综合征（ＴＵＲＳ）发生，需输血者仅１例。ＴＵＲＰ组３例发生ＴＵＲＳ，输血１４例。比较结果：ＴＶＰ能达到与ＴＵＲＰ完全相同的治疗效果，且并发症少，价格相对较低，近期效果满意。     

胫骨定量超声测量及临床应用探讨

用ＳｏｕｎｄＳｃａｎ２０００骨定量超声（ＱＵＳ）仪测量胫骨超声速度（ＳＯＳ），同时与单光子吸收法（ＳＰＡ）测量前臂１／３处骨矿密度（ＢＭＤ）比较。两方法测得２０８例患者和健康志愿者结果相关（ｒ＝０．６７８，Ｐ＜０．００１）。４２例健康绝经妇女ＳＯＳ和ＢＭＤ与绝经时间呈负相关（ｒ＝－０．４１７和－０．４７９，Ｐ＜０．０１），７３例＞４０岁的健康志愿者ＳＯＳ和ＢＭＤ与年龄呈负相关（ｒ＝－０．２９３和－０．３７３，Ｐ＜０．０５）。与性别和年龄相匹配的正常参考值比较，结果＜ｘ－２ｓ者ＱＵＳ检出３４例，占１６．３％；ＳＰＡ２３例，占１１．０％，ＱＵＳ的诊断敏感度约是ＳＰＡ的１．５倍。     

创伤性休克患者血浆热休克蛋白70表达及其意义

目的　　检测创　伤性休克患者外周血中热休克蛋白７０（ＨＳＰ７０）的表达水平并探讨其与创伤性休克发生发展　的关系。方法　　采用Ｗｅｓｔｅｒｎ　ｂｌｏｔ法分别测定３６例创伤性休克患者　（观察组）及３０例正常人（对照组）血浆ＨＳＰ７０表达水平。结果　　ＨＳ　Ｐ７０在创伤性休克组为（４　３０１．３±１　１５５．３），与正常对照组（６　０９２．３±１　２３３．５）比较，差异　有高度显著性（Ｐ＜０．０１）；２２例休克得到控制者ＨＳＰ７０为（６　１０２．２±１　２９１．６）较入院时　（４　２７３．６±１　０９９．３）明显升高，差异有极显著意义（Ｐ＜０．０１）。结论　　创伤性休克患者血浆ＨＳＰ７０表达水平明显下降，可能是创伤后休克发生发展的一个　重要因素，而且与预后有密切关系。     

重度创伤病人加强治疗的临床效果分析

目的 对重度创伤病人在ＩＣＵ的治疗进行回顾性分析。结果 ４５例病人入ＩＣＵ时创伤指数评分（ＴＩＳ）均≥１８分,根据病情和监测参数进行合理的呼吸支持和抗休克等综合治疗。结果 ３４例病人转出ＩＣＵ,治愈率７５．５％;１１例死亡,病死率２４．５％。１３例发生多器官功能不全综合征（ＭＯＤＳ）,７例死亡（５３．８％）。直接收入组病死率（１７．１％）与转入组（５０．０％）差异明显（Ｐ〈０．０５）,误吸组ＭＯＤ     

APACHEⅡ评分对普外危重病监护的应用价值

应用ＡＰＡＣＨＥⅡ评分对我院ＳＩＣＵ１９９１年５月－１９９５年９月间连续的普外危重病１８２例严重度进行评估。用死亡率预测方程（ＭＰＭ）判定预后，结果显示平均ＡＰＡＣＨＥⅡ评分１８．２２±５．６分，预测病死率和实际病死率呈正相关（３１．３％ｖｓ３４．６％，γ＝０．９８），预测略低于实际（Ｐ〉０．０５）。２７例肝功能障碍者平均积分为２０．８±４．６分，预测病死率显著低于实际（３７．５％ｖｓ７０．４％，     

系膜增殖性肾炎患者肾生存率的研究

目的为了探讨系膜增殖性肾炎（ＭｅｓＰＧＮ）肾生存情况。方法采用Ｋａｐｌａｎ－Ｍｅｉｅｒ方法观察了１８３例１５～６０岁ＭｅｓＰＧＮ患者肾生存率（ＫＳＲ）。结果肾活检后３、６、１０年，ＫＳＲ分别是８８％、８１％、７５％；根据肾小球系膜损害程度将患者分３组，结果系膜损害越重，ＫＳＲ愈低（Ｐ＜０．０１）；分析了肾活检时高血压、尿蛋白排泄量与ＫＳＲ的关系，结果肾活检时，有高血压、尿蛋白≥３．５ｇ／ｄ，则肾生存率较对照组差。结论ＭｅｓＰＧＮ患者ＫＳＲ与肾小球系膜损害程度，高血压、大量尿蛋白有关     

腹腔镜胆囊切除术二氧化碳气腹对血流动力学的影响

通过对１０例腹腔镜胆囊切除术患者施以ｓｗａｎ—Ｇａｎｚ导管监测，探讨二氧化碳化气腹对血流动力学影响。于二氧化碳气腹前、充气后５分、２０分和放气后５分钟，分别测录血流动力学指标。结果：ＭＡＯ、ＣＶＰ、ＰＡＰ与ＰＣＷＰ于充气后５分钟，分别增加２８％、１７２％、８３％与１２１％；于充气后２ｏ分钟，分别增加３２％、２０９％、１４７％与１７３％，与充气前相比，变化非常显著（Ｐ＜０．０１）。与充气前相比，ＨＲ与ＰＶＲ于充气后５分和２０分钟均显著增加（Ｐ＜０．０１），ＳＶＲ、Ｃｌ、ＳＩ、ＬＶＳＷＩ与ＲＶＳＷＩ的变化无统计学意义（Ｐ＞０．０５）。提示我们应注意腹腔镜胆囊切除术中血流动力学的变化。     

严重多发性创伤胃肠外营养的疗效分析

作者分析了４７例严重多发性创伤伤员（ＩＳＳ≥１６）全胃肠外营养（ＴＰＮ）的治疗效果。随机选择了４７例严重多发伤伤员，ＩＳＳ平均２０．１６。经过１周以上的中心静脉的正规ＴＰＮ治疗后，末梢血淋巴细胞计数，血浆白蛋白水平提高（ｔ检验Ｐ＜０．０５）。另外设对照非ＴＰＮ组６６例，ＩＳＳ平均２０．５０。具有同等的创伤严重程度，ＩＳＳ评分与ＴＰＮ组相比无差异（Ｐ＞０．０５）。两组病例均对原发创伤进行了积极的治疗，而对照组无ＴＰＮ治疗。疗效对比如下：ＴＰＮ与非ＴＰＮ组病死率之比为２．１３％比１３．６７％（Ｘ２＝４．５８，Ｐ＜０．０５）差异有统计学意义。结果表明：ＴＰＮ是严重多发性创伤重要的有效支持治疗措施。     

尿草酸钙晶体基质蛋白的分离及理化特征

为了进一步了解晶体基质蛋白（ＣＭＰ）的理化特性和其在结石形成中的作用，利用ＤＥＡＥＳｅｐｈａｄｅｘＡ５０、ＳｅｐｈａｄｅｘＧ２００对草酸钙结晶中的基质蛋白进行了分离，并用ＳＤＳＰＡＧＥ、双向电泳和Ｗｅｓｔｅｒｎｂｌｏｔ进行检测。结果表明：ＣＭＰ是草酸钙过饱和方法制备的晶体基质中的主要成分，其分子量为３１０００，等电点为５．０～５．５；Ｗｅｓｔｅｒｎｂｌｏｔ证明与抗人凝血酶原抗体有交叉反应。结果认为ＣＭＰ是活化的人凝血酶原片段     

Analysis of Trauma Outcome Using the TRISS Method at a Tertiary Care Centre in Pune

Out of the various systems used to assess the outcome of polytrauma patients, trauma and injury severity score (TRISS) is considered as the standard tool for evaluating the performance of trauma centres. The present study was carried out to evaluate the outcome of severely injured patients using the TRISS method in a developing country like India and to compare it with the major trauma outcome study (MTOS). A prospective study of 300 patients of trauma was done. Outcome assessment was done for the severely injured patients using the TRISS method. Road traffic accidents (213 cases) were the most common cause of injury. Fifty-seven (19%) cases were severely injured defined as having an injury severity score ≥16. Outcome assessment was done for these patients using the TRISS method. The predicted mortality was 15.7%, while the observed mortality was 33.3%. The mean revised trauma score was 6.63 ± 1.79 and the mean injury severity score (ISS) was 23.7 ± 8.17. Compared to the MTOS, the patients in the present study had more severe injuries with higher mortality. The present method of comparison of trauma care, i.e. TRISS which uses the MTOS coefficients, does not accurately predict survival of trauma patients in the developing countries as indicated by the present and other studies. There is a need for developing a national trauma registry to derive new coefficients for trauma scoring for the Indian subcontinent so that the quality of trauma care can be compared with that in the developed countries.     

M-study; arguments for regional trauma databases

BACKGROUND: The TRISS methodology, in combination with coefficients derived from the Major Trauma Outcome Study (MTOS), is the most widely used outcome prediction model for the care of trauma patients. Utilizing the M-statistic, different populations of trauma patients can be compared with the population originally enrolled in the MTOS. PURPOSE: We hypothesized that databases outside of North-America would not be well matched to the MTOS study and thus the TRISS methodology would not accurately predict outcome in these different populations. METHODS: All trauma studies utilizing TRISS methodology that were published between 1990-2003 were reviewed and M-statistics calculated based on the population described in the study. The populations were grouped by the following geographic locations: Europe, Asia/Africa and North-America. RESULTS: The median M-statistic for Europe was 0.65, compared with 0.88 for Asian/African databases, and 0.90 for North-American studies. There was a significant difference between European and North-American studies (p < 0.05). CONCLUSION: The trauma populations described in European studies differ significantly from the MTOS with respect to injury severity match, indicating the need for the development of regional trauma databases and modified TRISS coefficients based on the geographic location of the injured population included.     

Outcome analysis of blunt injury in children

A group of 1,009 children less than 15 years of age and consecutively admitted to a Pediatric Trauma Center was used to compare outcomes with the adult (15-54 yrs) MTOS norm population using TRISS. Four pediatric age groups (0-1, 0-3, 0-8, 0-14 yrs) formed the study groups. TRISS analysis resulted in no statistically significant difference in predicted outcome between any of the four pediatric groups and the adult baseline group. There were only seven misclassified children (0.69%) with respect to survival/death outcome, indicating the usefulness of TRISS to characterize pediatric blunt trauma. In addition, TRISS was used to delineate the injury severity mix of the pediatric population. A TS less than or equal to 14 and ISS greater than 15 was found to serve as a useful definition of severity in this group of injured children.     

Identification of patients to include in trauma audit: a modification of the pre-chart

Trauma audit is commonly focused using a Pre-Chart to illustrate calculations made using the TRISS model. A line is drawn at Ps=0.5 to divide expected survivors and nonsurvivors. The use of this cut-off in a severely injured population was examined. The ‘M statistic’ for a group of injured patients selectively triaged to a Trauma Centre was calculated. The ideal cut-off point between predicted outcomes when using the TRISS model to focus trauma audit in this population was determined using a Receiver Operating Characteristic (ROC) curve. For this population the TRISS ‘M statistic’ was 0.71 (indicating a significantly different case mix from the reference database) and the best cut-off point was at Ps=0.76. Trauma audit in populations with a case mix of injury severity different from the reference database should use a different Ps line to define unexpected outcomes.     

Assessing quality of care in a trauma referral center: benchmarking performance by TRISS-based statistics or by analysis of stratified ISS data?

BACKGROUND: Using prospectively collected data from Ulleval University Hospital in Norway, standard TRISS-based methods with case mix correction were compared with analysis based on ISS stratified data. METHODS: Reference data were The Major Trauma Outcome Study (MTOS) controlled sites, used for calculation of AIS 90 based TRISS coefficients. Present TRISS convention requires RTS scoring on hospital admission, excluding many severely injured patients intubated before arrival. Therefore, all Ulleval patients were RTS scored using prehospital data if needed. RESULTS: There was 6.6% of MTOS controlled sites patients (mortality rate 26.7%) that had been excluded before estimation of TRISS coefficients because of lack of data for Ps calculation. Analyses based on ISS stratified data included these patients and indicated significant better performance at Ulleval for blunt, but not for penetrating trauma. No TRISS-based analysis detected this difference. CONCLUSIONS: The RTS convention should be changed to reduce patient exclusion. Presently, stratified ISS based data should also be analyzed.     

Validity of applying adult TRISS analysis to injured children

Injury severity measures are becoming increasingly important for quality assurance and injury research. TRISS analysis, which uses the Revised Trauma Score (RTS) and Injury Severity Score (ISS) to predict survival, is an effective tool for comparing outcomes between trauma centers. It has been argued that blunt trauma outcome differs between children and adults, yet the Major Trauma Outcome Study (MTOS) adult data base (ages 15-54 years) regression weights have been used by others to calculate TRISS scores for injured children. This study appears to be the first to perform TRISS analysis on groups of children and adults treated by the same surgeons using the same treatment protocols to assess the validity of applying "adult" TRISS analysis to children. The charts of 346 consecutive children (ages 0-14) and 346 random adults (ages 15-54) admitted to a regional trauma center for isolated blunt trauma over a 30-month period were reviewed for demographics, mechanism of injury, RTS, ISS, and survival. Statistical evaluation included TRISS survival analysis and calculation of the Z statistic. The median ISS was 10 for both children and adults. The Z statistics for children and adults were similar (1.85 and 1.81). Analysis demonstrated the groups to be statistically identical with a nonsignificant trend toward improved survival compared with the MTOS baseline group. These data support the use of existing TRISS analysis for evaluation of pediatric trauma care.     

TRISS analysis of trauma care: a Yugoslav perspective

The TRISS method has been claimed to be useful in the evaluation of trauma care. The aim of this study was to compare our data with Major Trauma Outcome Study (MTOS) results in North America, and to note differences and strive to improve care in our system. Data were collected from 163 consecutively admitted trauma patients to the Intensive Care Unit, Accident and Emergency Centre, Belgrade, Yugoslavia. Systolic blood pressure, respiration rate and Glasgow Coma Score were obtained on admission and the Abbreviated Injury Score was presented by anatomical area. Data were analysed on an Amstrad PCW computer, using a special non-commercial program. The calculated expected survival out of 163 cases was 131.7 and observed 111 patients. Distribution of severity of injury of the study population had a greater severity of injury than did the baseline. Thus, although the observed survival was less than expected, this is not conclusive evidence of worse care. This applies especially to the group of patients over 54 years of age who suffered blunt trauma, whose higher mortality (23 observed and 15.6 expected out of 50 patients) can be attributed to the ISS score being almost double that of the MTOS population of comparable age. Penetrating trauma patients, in spite of severe injuries, had better survival than predicted. The TRISS method, in spite of its limitations, proved a useful method of evaluating trauma care, and can be run on a small computer without the necessity for special staff.     

Evaluating trauma center quality: does the choice of the severity-adjustment model make a difference?

CONTEXT: The Major Trauma Outcome Study (MTOS) database was created by the American College of Surgeons over 20 years ago to establish national norms for trauma care. The primary trauma outcome prediction models used for evaluating the quality of trauma care, TRISS and ASCOT (A Severity Characterization of Trauma), were developed using the MTOS database. OBJECTIVE: First, to determine whether TRISS and ASCOT agree on hospital quality. Second, to determine whether TRISS and ASCOT accurately reflect contemporary outcomes in trauma care. DESIGN, SETTING AND PATIENTS: A retrospective cohort study based on 91,112 patients admitted to 69 hospitals between 2000 and 2001 in the National Trauma Databank. Using TRISS and ASCOT, the ratio of the observed to expected mortality rate (O/E ratio) was calculated for each hospital. Hospitals whose O/E ratio was statistically different from 1 were identified as quality outliers. Kappa analysis was used to assess the degree to which TRISS and ASCOT agreed on the identity of hospital quality outliers. RESULTS: TRISS and ASCOT disagreed on the outlier status of 35 of the 69 hospitals. Kappa analysis revealed only fair agreement (kappa = 0.23; p = 0.0015) between TRISS and ASCOT in identifying quality outliers. Thirty-eight hospitals were identified by the TRISS method as high-performance hospitals. CONCLUSION: First, TRISS and ASCOT exhibit substantial disagreement on the identity of quality outliers within the NTDB. Second, an unrealistically high number of hospitals were identified as high-performance outliers using either TRISS or ASCOT. These findings have important implications for the use of TRISS and ASCOT for benchmarking performance and quality improvement.     

Emergency interhospital transport of the major trauma patient: air versus ground

A prospective cohort study was undertaken to determine the effectiveness of air transport for major trauma patients when transferred to a trauma center from a rural Emergency Department. The null hypothesis evaluated was that there was no difference in outcome for patients transported by helicopter EMS (HEMS) when compared to patients transported by conventional ground EMS. The dependent variable of outcome was studied using the TRISS method in a group of 872 consecutive trauma patients admitted after long-distance transfer. Of this group, 110 patients transported by ground and 103 patients transported by air met the inclusion criteria. The ground EMS group had a mean TS of 14.4, a mean ISS of 25.2, and a mean Ps of 0.867. TRISS predicted 15 deaths and there were 15 actual deaths. The HEMS group had a mean TS of 11.4, a mean ISS of 34.9, and a mean Ps of 0.587. There were 46 predicted deaths and 33 actual deaths. This 25.4% reduction in predicted mortality was significant (Z = 3.95; p less than 0.001). Stratification of patients into Probability of Survival (Ps) bins allowed for outcome evaluation of groups with similar levels of injury severity. The benefit of HEMS transport was seen only in the patients with a probability of survival of less than 90%. We conclude that the major trauma patients transported by HEMS had a better outcome than those transported by ground EMS. The benefit seen with HEMS was directly related to injury severity and was demonstrated only in the patients with a Ps of less than 0.90.     

Evaluation of TRISS as a means of selecting trauma deaths for clinical peer review.

This study was carried out to evaluate the predictive power of a mathematical model called TRISS in identifying avoidable trauma deaths when compared with peer review (PR). The subjects studied comprised the 24 deaths that occurred among 81 severely injured patients (Injury Severity Score greater than or equal to 16) admitted to a trauma unit over a 1 year period. Sixteen patients who had a greater than 50% probability of survival (Ps) calculated by TRISS died. Peer review concluded that five of those were potentially avoidable deaths. Eight deaths occurred in patients with a Ps less than 50%. Peer review regarded those eight as inevitable deaths. The data, when analysed, showed TRISS to have a 100% sensitivity, 42% specificity, 31% positive predictive value and a negative predictive value of 100% when compared with peer review. It is concluded that TRISS tends to over-estimate potentially avoidable death, especially in patients with severe head injury. However it is a good audit filter as it reliably excludes inevitable death.