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Horst K, Marzi I, Leenen L, Hildebrand F. Editorial: Translational immunology in trauma - To provide new insights for improving outcomes. Front Med (Lausanne) 2022; 9:1118290. [PMID: 36600890 PMCID: PMC9806419 DOI: 10.3389/fmed.2022.1118290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Klemens Horst
- Department of Orthopaedics, Traumatology and Reconstructive Surgery, Rheinisch Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany,*Correspondence: Klemens Horst ✉
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Goethe University Frankfurt, Frankfurt, Germany
| | - Luke Leenen
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Frank Hildebrand
- Department of Orthopaedics, Traumatology and Reconstructive Surgery, Rheinisch Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
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Scherer J, Coimbra R, Mariani D, Leenen L, Komadina R, Peralta R, Fattori L, Marzi I, Wendt K, Gaarder C, Pape HC, Pfeifer R. Standards of fracture care in polytrauma: results of a Europe-wide survey by the ESTES polytrauma section. Eur J Trauma Emerg Surg 2022:10.1007/s00068-022-02126-3. [PMID: 36227354 DOI: 10.1007/s00068-022-02126-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 10/01/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Fixation of major fractures plays a pivotal role in the surgical treatment of polytrauma patients. In addition to ongoing discussions regarding the optimal timing in level I trauma centers, it appears that the respective trauma systems impact the implementation of both, damage control and safe definitive surgery strategies. This study aimed to assess current standards of polytrauma treatment in a Europe-wide survey. METHODS A survey, developed by members of the polytrauma section of ESTES, was sent online via SurveyMonkey®, between July and November 2020, to 450 members of ESTES (European Society of Trauma and Emergency Surgery). Participation was voluntary and anonymity was granted. The questionnaire consisted of demographic data and included questions about the definition of "polytrauma" and the local standards for the timing of fracture fixation. RESULTS In total, questionnaires of 87 participants (19.3% response rate) were included. The majority of participants were senior consultants (50.57%). The mean work experience was 19 years, and on average, 17 multiple-injured patients were treated monthly. Most of the participants stated that a polytrauma patient is defined by ISS ≥ 16 (44.16%), followed by the "Berlin Definition" (25.97%). Systolic blood pressure < 90 mmHg, tachycardia or vasopressor administration (86.84%), pH deviation, base excess shift (48.68%), and lactate > 4 mmol (40.79%) or coagulopathy defined by ROTEM (40.79%) were the three most often stated indicators for shock. Local guidelines (33.77%) and the S-3 Guideline by the DGU® (23.38%) were mostly stated as a reference for the treatment of polytrauma patients. Normal coagulation (79.69%), missing administration of vasopressors (62.50%), and missing clinical signs of "SIRS" (67.19%) were stated as criteria for safe definite secondary surgery. CONCLUSION Different definitions of polytrauma are used in the clinical setting. Indication for and the extent of secondary (definitive) surgery are mainly dependent on the polytrauma patient`s physiology. The «Window of Opportunity» plays a less important role in decision making.
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Affiliation(s)
- Julian Scherer
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistr. 100, 8091, Zurich, Switzerland.
| | - Raul Coimbra
- Riverside University Health System and Loma Linda University, Riverside, CA, USA
| | - Diego Mariani
- Department of Emergency General Surgery, Legnano Hospital, ASST Ovest Milanese, Legnano, MI, Italy
| | - Luke Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, 3000, Celje, Slovenia
| | - Ruben Peralta
- Surgical Department (Hamad General Hospital), Hamad Medical Corporation, HMC, Doha, Qatar
| | - Luka Fattori
- Department of Surgery, San Gerardo Hospital, University of Milan Bicocca, G.B. Pergolesi 33, Monza, Italy
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - Klaus Wendt
- Department of Trauma Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ullevål, Kirkeveien 166, 0450, Oslo, Norway
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistr. 100, 8091, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma Surgery, University Hospital Zurich, University of Zurich, Raemistr. 100, 8091, Zurich, Switzerland
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Sweere D, Moelands S, Klinkenberg S, Leenen L, Hendriksen J, Braakman H. P.208 The neurocognitive phenotype of childhood Myotonic dystrophy type 1: A multicenter pooled analysis. Neuromuscul Disord 2022. [DOI: 10.1016/j.nmd.2022.07.370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
BACKGROUND Trauma resuscitation in the emergency department involves coordinated, well-equipped, and trained health care providers to make essential, prudent, and expedient management decisions. During resuscitation, health care providers' knowledge and skills are critical in minimizing the potential risks of mortality and morbidity. OBJECTIVE This study aimed to evaluate the impact of training on nurses' knowledge and confidence regarding trauma resuscitation and whether there was any difference between participants with and without previous trauma training. METHODS This study used a pre- and posttraining test study design to evaluate the effects of an intensive 8-hr trauma resuscitation training program on nurses' knowledge from January 2018 to August 2021. The training program consisted of lectures and patient scenarios covering initial assessment, resuscitation, and management priorities for trauma patients in life-threatening situations, stressing the principles of the trauma team approach. RESULTS A total of 128 nurses participated in 16 courses conducted during the study period. This study found significant improvement in nurses' knowledge after the training (pre- and posttraining median [interquartile range, IQR] test scores 5 [4-6] vs. 9 [8-9], p < .001). There was no significant difference in pretraining test scores between the participants with previous trauma training and those without training (median [IQR] test scores 5 [4-6] vs. 4 [4-5], p = .751). CONCLUSIONS Trauma resuscitation training affects nurses' knowledge improvement, emphasizing the need for training trauma care professionals to provide adequate care.
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Affiliation(s)
- Sharfuddin Chowdhury
- Trauma Center, King Saud Medical City, Riyadh, Saudi Arabia (Dr Chowdhury and Ms Varghese); Emergency and Critical Care Nursing, Faculty of Nursing, King Abdulaziz University, Jeddah, Saudi Arabia (Ms Almarhabi); and Department of Trauma, University Medical Center Utrecht, Utrecht, the Netherlands (Dr Leenen)
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Teuben MPJ, Pfeifer R, Horst K, Simon TP, Heeres M, Kalbas Y, Blokhuis T, Hildebrand F, Koenderman L, Pape HC, Leenen L. Standardized porcine unilateral femoral nailing is associated with changes in PMN activation status, rather than aberrant systemic PMN prevalence. Eur J Trauma Emerg Surg 2022; 48:1601-1611. [PMID: 34114052 PMCID: PMC9192391 DOI: 10.1007/s00068-021-01703-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/13/2021] [Indexed: 10/26/2022]
Abstract
PURPOSE Intramedullary nailing (IMN) of fractures is associated with increased rates of inflammatory complications. The pathological mechanism underlying this phenomenon is unclear. However, polymorphonuclear granulocytes (PMNs) seem to play an important role. We hypothesized that a femur fracture and standardized IMN in pigs is associated with altered appearance of PMNs in circulation and enhanced activation status of these cells. METHODS A porcine model including a femur fracture and IMN was utilized. Animals were randomized for control [anesthesia + mechanical ventilation only (A/MV)] and intervention [A/MV and unilateral femur fracture (FF) + IMN] conditions. PMN numbers and responsiveness, integrin (CD11b), L-selectin (CD62L) and Fcγ-receptor (CD16 and CD32)-expression levels were measured by flowcytometry of blood samples. Animals were observed for 72 h. RESULTS Circulatory PMN numbers did not differ between groups. Early PMN-responsiveness was retained after insult. PMN-CD11b expression increased significantly upon insult and peaked after 24 h, whereas CD11b in control animals remained unaltered (P = 0.016). PMN-CD16 expression levels in the FF + IMN-group rose gradually over time and were significantly higher compared with control animals, after 48 h (P = 0.016) and 72 h (P = 0.032). PMN-CD62L and CD32 expression did not differ significantly between conditions. CONCLUSION This study reveals that a femur fracture and subsequent IMN in a controlled setting in pigs is associated with enhanced activation status of circulatory PMNs, preserved PMN-responsiveness and unaltered circulatory PMN-presence. Indicating that monotrauma plus IMN is a specific and substantial stimulus for the cellular immune system. Early alterations of circulatory PMN receptor expression dynamics may be predictive for the intensity of the post traumatic response.
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Affiliation(s)
- Michel Paul Johan Teuben
- Department of Traumatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Department of Traumatology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Laboratory for Translational Immunology, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Klemens Horst
- Department of Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Tim-Philipp Simon
- Department of Intensive Care and Intermediate Care, RWTH University Hospital Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Marjolein Heeres
- Department of Traumatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Laboratory for Translational Immunology, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Yannik Kalbas
- Department of Traumatology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Taco Blokhuis
- Department of Surgery, University Hospital Maastricht, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
| | - Frank Hildebrand
- Department of Trauma and Reconstructive Surgery, RWTH University Hospital Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Leo Koenderman
- Laboratory for Translational Immunology, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
- Department of Pulmonology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Hans-Christoph Pape
- Department of Traumatology, University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
- Harald Tscherne Laboratory for Orthopaedic and Trauma Research, Raemistrasse 100, 8091 Zurich, Switzerland
| | - Luke Leenen
- Department of Traumatology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Kobes T, Sweet A, Verstegen S, Houwert M, Veldhuis W, Leenen L, de Jong P, van Baal M. Computed Tomography-Based L1 Bone Mineral Density in 624 Dutch Trauma Patients—Are North American Reference Values Valid in Europe? J Pers Med 2022; 12:jpm12030472. [PMID: 35330472 PMCID: PMC8954020 DOI: 10.3390/jpm12030472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/02/2022] [Accepted: 03/14/2022] [Indexed: 11/16/2022] Open
Abstract
Opportunistic screening for bone mineral density (BMD) of the first lumbar vertebra (L1) using computed tomography (CT) is increasingly used to identify patients at risk for osteoporosis. An extensive study in the United States has reported sex-specific normative values of CT-based BMD across all ages. The current study aims to validate North American reference values of CT-based bone mineral density in a Dutch population of level-1 trauma patients. All trauma patients aged 16 or older, admitted to our level-1 trauma center during 2017, who underwent a CT scan of the chest or abdomen at 120 kVp within 7 days of hospital admission, were retrospectively included. BMD measurements in Hounsfield Units (HU) were performed manually in L1 or an adjacent vertebra. Student’s t-tests were performed to compare the Dutch mean BMD value per age group to the North American reference values. Linear regression analysis and Pearson’s correlation coefficient (ρ) calculations were performed to assess the correlation between BMD and age. In total, 624 patients were included (68.4% men, aged 16–95). Mean BMD decreased linearly with 2.4 HU per year of age (ρ = −0.77). Sex-specific analysis showed that BMD of premenopausal women was higher than BMD of men at these ages. Dutch mean BMD values in the age groups over 35 years were significantly lower than the North American reference values. Our findings indicate that using North American BMD thresholds in Dutch clinical practice would result in overdiagnosis of osteoporosis and osteopenia. Dutch guidelines may benefit from population-specific thresholds.
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Affiliation(s)
- Tim Kobes
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; (A.S.); (S.V.); (M.H.); (L.L.); (M.v.B.)
- Department of Radiology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands;
- Correspondence: (T.K.); (P.d.J.)
| | - Arthur Sweet
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; (A.S.); (S.V.); (M.H.); (L.L.); (M.v.B.)
- Department of Radiology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands;
| | - Sophie Verstegen
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; (A.S.); (S.V.); (M.H.); (L.L.); (M.v.B.)
| | - Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; (A.S.); (S.V.); (M.H.); (L.L.); (M.v.B.)
| | - Wouter Veldhuis
- Department of Radiology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands;
| | - Luke Leenen
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; (A.S.); (S.V.); (M.H.); (L.L.); (M.v.B.)
| | - Pim de Jong
- Department of Radiology, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands;
- Correspondence: (T.K.); (P.d.J.)
| | - Mark van Baal
- Department of Surgery, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; (A.S.); (S.V.); (M.H.); (L.L.); (M.v.B.)
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Abstract
A dedicated network-based trauma system ensures optimal care to injured patients. Considering the significant burden of trauma, the Kingdom of Saudi Arabia is striving to develop a nationwide trauma system. This article describes the recent design, development, and implementation of the Saudi Arabian trauma system in line with Vision 2030. The basis of our strategy was the find, organize, clarify, understand, select-plan, do, check, and act (FOCUS-PDCA) model, developed by engaging key stakeholders, including patients. More than 300 healthcare professionals and patients from around the Riyadh region assessed the current system with three solutions and roadmap workshops. Subsequently, the national clinical advisory group (CAG) for trauma was formed to develop the Saudi Arabian trauma system, and CAG members analyzed and collated internationally recognized trauma systems and guidelines. The guidelines' applicability in the kingdom was discussed and reviewed, and an interactive document was developed to support socialization and implementation. The CAG team members agreed on the guiding principles for the trauma pathway, identified the challenges, and finalized the new system design. They also developed a trauma care standard document to support and guide the rollout of new trauma networks across the kingdom. The CAG members and other stakeholders are at the forefront of implementing the trauma system across the Riyadh region. Recent trauma system development in Saudi Arabia is the first step in improving national trauma care and may guide development in other locations, regionally and internationally, to improve outcomes.
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Affiliation(s)
- Sharfuddin Chowdhury
- Trauma Center, King Saud Medical City, Riyadh, Saudi Arabia,* Corresponding Author: Sharfuddin Chowdhury, Director of Trauma Center, King Saud Medical City, Riyadh, Saudi Arabia. Phone: +966 11 837 1777 (Ext: 75537); E-mail:
| | - Dennis Mok
- Medical Management Consulting, Birkdale, Queensland, Australia
| | - Luke Leenen
- Department of Trauma, University Medical Center Utrecht, Utrecht, Netherlands
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Chowdhury S, Parameaswari PJ, Leenen L. Outcomes of Trauma Patients Present to the Emergency Department with a Shock Index of ≥1.0. J Emerg Trauma Shock 2022; 15:17-22. [PMID: 35431481 PMCID: PMC9006726 DOI: 10.4103/jets.jets_86_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/11/2021] [Accepted: 11/23/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction The study aimed primarily to evaluate the association between the initial shock index (SI) ≥1.0 with blood transfusion requirement in the emergency department (ED) after acute trauma. The study's secondary aim was to look at the outcomes regarding patients' disposition from ED, intensive care unit (ICU) and hospital length of stay, and deaths. Methods It was a retrospective, cross-sectional study and utilized secondary data from the Saudi Trauma Registry (STAR) between September 2017 and August 2020. We extracted the data related to patient demographics, mechanism of injuries, the intent of injuries, mode of arrival at the hospital, characteristics on presentation to ED, length of stay, and deaths from the database and compared between two groups of SI <1.0 and SI ≥1.0. A P < 0.05 was statistically considered significant. Results Of 6667 patients in STAR, 908 (13.6%) had SI ≥1.0. With SI ≥1.0, there was a significantly higher incidence of blood transfusion in ED compared to SI <1.0 (8.9% vs. 2.4%, P < 0.001). Furthermore, SI ≥ 1.0 was associated with significant ICU admission (26.4% vs. 12.3%, P < 0.001), emergency surgical intervention (8.5% vs. 2.8%, P < 0.001), longer ICU stay (5.0 ± 0.36 vs. 2.2 ± 0.11days, P < 0.001), longer hospital stays (14.8 ± 0.61 vs. 13.3 ± 0.24 days, P < 0.001), and higher deaths (8.4% vs. 2.8%, P < 0.001) compared to the patient with SI <1.0. Conclusions In our cohort, a SI ≥ 1.0 on the presentation at the ED carried significantly worse outcomes. This simple calculation based on initial vital signs may be used as a screening tool and therefore incorporated into initial assessment protocols to manage trauma patients.
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Affiliation(s)
| | - P J Parameaswari
- Research and Innovation Center, King Saud Medical City, Riyadh, Saudi Arabia
| | - Luke Leenen
- Department of Trauma, University Medical Center Utrecht, Utrecht, Netherlands
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Abstract
This is a review of changes in the practice of treating polytrauma managemtent within the years prior to 2020. It focuses on five different topics, 1. The development of an evidence based definition of Polytrauma, 2. Resuscitation Associated Coagulopathy (RAC), 3. neutrophil guided initial resuscitation, 4. perioperative Scoring to evaluate patients at risk, and 5. evolution of fracture fixation strategies according to protocols1,2 (Early total care, ETC, damage control orthopedics, DCO, early appropriate care, EAC, safe definitive surgery, SDS).
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Affiliation(s)
- H.C. Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland,Corresponding author.
| | - L. Leenen
- Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585, GA, Utrecht, the Netherlands
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van Wessem K, Hietbrink F, Leenen L. Dilemma of crystalloid resuscitation in non-exsanguinating polytrauma: what is too much? Trauma Surg Acute Care Open 2020; 5:e000593. [PMID: 33178897 PMCID: PMC7594544 DOI: 10.1136/tsaco-2020-000593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 11/21/2022] Open
Abstract
Background Aggressive crystalloid resuscitation increases morbidity and mortality in exsanguinating patients. Polytrauma patients with severe tissue injury and subsequent inflammatory response without major blood loss also need resuscitation. This study investigated crystalloid and blood product resuscitation in non-exsanguinating polytrauma patients and studied possible adverse outcomes. Methods A 6.5-year prospective cohort study included consecutive trauma patients admitted to a Level 1 Trauma Center intensive care unit (ICU) who survived 48 hours. Demographics, physiologic and resuscitation parameters in first 24 hours, Denver Multiple Organ Failure scores, adult respiratory distress syndrome (ARDS) data and infectious complications were prospectively collected. Patients were divided in 5 L crystalloid volume subgroups (0–5, 5–10, 10–15 and >15 L) to make clinically relevant comparisons. Data are presented as median (IQR); p value <0.05 was considered significant. Results 367 patients (70% men) were included with median age of 46 (28–61) years, median Injury Severity Score was 29 (22–35) and 95% sustained blunt injuries. 17% developed multiple organ dysfunction syndrome (MODS), 4% ARDS and 14% died. Increasing injury severity, acidosis and coagulopathy were associated with more crystalloid administration. Increasing crystalloid volumes were associated with more blood products, increased ventilator days, ICU length of stay, hospital length of stay, MODS, infectious complications and mortality rates. Urgent laparotomy was found to be the most important independent predictor for crystalloid resuscitation in multinominal regression analysis. Further, fresh frozen plasma (FFP) <8 hours was less likely to be administered in patients >5 L compared with the group 0–5 L. With increasing crystalloid volume, the adjusted odds of MODS, ARDS and infectious complications increased 3–4-fold, although not statistically significant. Mortality increased 6-fold in patients who received >15 L crystalloids (p=0.03). Discussion Polytrauma patients received large amounts of crystalloids with few FFPs <24 hours. In patients with <10 L crystalloids, <24-hour mortality and MODS rates were not influenced by crystalloid resuscitation. Mortality increased 6-fold in patients who received >15 L crystalloids ≤24 hours. Efforts should be made to balance resuscitation with modest crystalloids and sufficient amount of FFPs. Level of evidence Level 3. Study type Population-based cohort study.
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Affiliation(s)
- Karlijn van Wessem
- Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Luke Leenen
- Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Pfeifer R, Kalbas Y, Coimbra R, Leenen L, Komadina R, Hildebrand F, Halvachizadeh S, Akhtar M, Peralta R, Fattori L, Mariani D, Hasler RM, Lefering R, Marzi I, Pitance F, Osterhoff G, Volpin G, Weil Y, Wendt K, Pape HC. Indications and interventions of damage control orthopedic surgeries: an expert opinion survey. Eur J Trauma Emerg Surg 2020; 47:2081-2092. [PMID: 32458046 DOI: 10.1007/s00068-020-01386-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 05/02/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The objectives of this study were to gather an expert opinion survey and to evaluate the suitability of summarized indications and interventions for DCO. BACKGROUND The indications to perform temporary surgery in musculoskeletal injuries may vary during the hospitalization and have not been defined. We performed a literature review and an expert opinion survey about the indications for damage control orthopaedics (DCO). METHODS Part I: A literature review was performed on the basis of the PubMed library search. Publications were screened for damage control interventions in the following anatomic regions: "Spine", "Pelvis", "Extremities" and "Soft Tissues". A standardized questionnaire was developed including a list of damage control interventions and associated indications. Part II: Development of the expert opinion survey: experienced trauma and orthopaedic surgeons participated in the consensus process. RESULTS Part I: A total of 646 references were obtained on the basis of the MeSH terms search. 74 manuscripts were included. Part II: Twelve experts in the field of polytrauma management met at three consensus meetings. We identified 12 interventions and 79 indications for DCO. In spinal trauma, percutaneous interventions were determined beneficial. Traction was considered harmful. For isolated injuries, a new terminology should be used: "MusculoSkeletal Temporary Surgery". CONCLUSION This review demonstrates a detailed description of the management consensus for abbreviated musculoskeletal surgeries. It was consented that early fixation is crucial for all major fractures, and certain indications for DCO were dropped. Authors propose a distinct terminology to separate local (MuST surgery) versus systemic (polytrauma: DCO) scenarios.
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Affiliation(s)
- Roman Pfeifer
- Department of Trauma, University of Zurich, UniversitätsSpital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - Yannik Kalbas
- Department of Trauma, University of Zurich, UniversitätsSpital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Raul Coimbra
- Riverside University Health System and Loma Linda University, Riverside, CA, USA
| | - Luke Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, 3000, Celje, Slovenia
| | - Frank Hildebrand
- Department of Trauma, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Sascha Halvachizadeh
- Department of Trauma, University of Zurich, UniversitätsSpital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Meraj Akhtar
- Department of Trauma, University of Zurich, UniversitätsSpital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ruben Peralta
- Surgical Department (Hamad General Hospital), Hamad Medical Corporation, HMC, Doha, Qatar
| | - Luka Fattori
- Department of Surgery, San Gerardo Hospital, University of Milan Bicocca, G.B. Pergolesi 33, Monza, Italy
| | - Diego Mariani
- Department of Emergency General Surgery, Legnano Hospital, ASST Ovest Milanese, Legnano, MI, Italy
| | - Rebecca Maria Hasler
- Department of Trauma, University of Zurich, UniversitätsSpital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Rolf Lefering
- IFOM, Institute for Research in Operative Medicine, Faculty of Health, University Witten/Herdecke, Ostmerheimer Straße 200, 51109, Cologne, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe-University, Frankfurt, Germany
| | - François Pitance
- Anesthesiology and Intensive Care Unit, CHR De La Citadelle, Liege, Belgium
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma, and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Gershon Volpin
- Department of Orthopedic Surgery, EMMS Hospital, Nazareth, Affiliated to Galilee Medical Faculty Zfat, Bar Ilan University, Ramat Gan, Israel
| | - Yoram Weil
- Orthopaedic Trauma Unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
| | - Klaus Wendt
- Department of Trauma Surgery, University Medical Center Groningen (UMCG), Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Hans-Christoph Pape
- Department of Trauma, University of Zurich, UniversitätsSpital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
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Teuben M, Spijkerman R, Teuber H, Pfeifer R, Pape HC, Kramer W, Leenen L. Splenic injury severity, not admission hemodynamics, predicts need for surgery in pediatric blunt splenic trauma. Patient Saf Surg 2020; 14:1. [PMID: 31911819 PMCID: PMC6942310 DOI: 10.1186/s13037-019-0218-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/31/2019] [Indexed: 11/10/2022] Open
Affiliation(s)
- Michel Teuben
- 1Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA Utrecht, The Netherlands
| | - Roy Spijkerman
- 1Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA Utrecht, The Netherlands
| | - Henrik Teuber
- 2Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- 2Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | | | - William Kramer
- 3Department of Pediatric Surgery, University Medical Centre Utrecht/ Wilhelmina Children's Hospital Utrecht, Utrecht, The Netherlands
| | - Luke Leenen
- 1Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA Utrecht, The Netherlands
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Teuben M, Spijkerman R, Blokhuis T, Pfeifer R, Teuber H, Pape HC, Leenen L. Nonoperative management of splenic injury in closely monitored patients with reduced consciousness is safe and feasible. Scand J Trauma Resusc Emerg Med 2019; 27:108. [PMID: 31805978 PMCID: PMC6896516 DOI: 10.1186/s13049-019-0668-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 09/13/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Treatment of blunt splenic injury has changed over the past decades. Nonoperative management (NOM) is the treatment of choice. Adequate patient selection is a prerequisite for successful NOM. Impaired mental status is considered as a relative contra indication for NOM. However, the impact of altered consciousness in well-equipped trauma institutes is unclear. We hypothesized that impaired mental status does not affect outcome in patients with splenic trauma. METHODS Our prospectively composed trauma database was used and adult patients with blunt splenic injury were included during a 14-year time period. Treatment guidelines remained unaltered over time. Patients were grouped based on the presence (Group GCS: < 14) or absence (Group GCS: 14-15) of impaired mental status. Outcome was compared. RESULTS A total of 161 patients were included, of whom 82 were selected for NOM. 36% of patients had a GCS-score < 14 (N = 20). The median GCS-score in patients with reduced consciousness was 9 (range 6-12). Groups were comparable except for significantly higher injury severity scores in the impaired mental status group (19 vs. 17, p = 0.007). Length of stay (28 vs. 9 days, p < 0.001) and ICU-stay (8 vs. 0 days, p = 0.005) were longer in patients with decreased GCS-scores. Failure of NOM, total splenectomy rates, complications and mortality did not differ between both study groups. CONCLUSION This study shows that NOM for blunt splenic trauma is a viable treatment modality in well-equipped institutions, regardless of the patients mental status. However, the presence of neurologic impairment is associated with prolonged ICU-stay and hospitalization. We recommend, in institutions with adequate monitoring facilities, to attempt nonoperative management for blunt splenic injury, in all hemodynamically stable patients without hollow organ injuries, also in the case of reduced consciousness.
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Affiliation(s)
- Michel Teuben
- Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Suite G04.232, The Netherlands. .,Department of Traumatology, University Hospital Zurich, Zurich, Switzerland.
| | - Roy Spijkerman
- Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Suite G04.232, The Netherlands
| | - Taco Blokhuis
- Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Suite G04.232, The Netherlands
| | - Roman Pfeifer
- Department of Traumatology, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Teuber
- Department of Traumatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Luke Leenen
- Department of Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, Suite G04.232, The Netherlands
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14
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Pape HC, Halvachizadeh S, Leenen L, Velmahos GD, Buckley R, Giannoudis PV. Timing of major fracture care in polytrauma patients - An update on principles, parameters and strategies for 2020. Injury 2019; 50:1656-1670. [PMID: 31558277 DOI: 10.1016/j.injury.2019.09.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Sustained changes in resuscitation and transfusion management have been observed since the turn of the millennium, along with an ongoing discussion of surgical management strategies. The aims of this study are threefold: a) to evaluate the objective changes in resuscitation and mass transfusion protocols undertaken in major level I trauma centers; b) to summarize the improvements in diagnostic options for early risk profiling in multiply injured patients and c) to assess the improvements in surgical treatment for acute major fractures in the multiply injured patient. METHODS I. A systematic review of the literature (comprehensive search of the MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases) and a concomitant data base (from a single Level I center) analysis were performed. Two authors independently extracted data using a pre-designed form. A pooled analysis was performed to determine the changes in the management of polytraumatized patients after the change of the millennium. II. A data base from a level I trauma center was utilized to test any effects of treatment changes on outcome. INCLUSION CRITERIA adult patients, ISS > 16, admission < less than 24 h post trauma. Exclusion: Oncological diseases, genetic disorders that affect the musculoskeletal system. Parameters evaluated were mortality, ICU stay, ICU complications (Sepsis, Pneumonia, Multiple organ failure). RESULTS I. From the electronic databases, 5141 articles were deemed to be relevant. 169 articles met the inclusion criteria and a manual review of reference lists of key articles identified an additional 22 articles. II. Out of 3668 patients, 2694 (73.4%) were male, the mean ISS was 28.2 (SD 15.1), mean NISS was 37.2 points (SD 17.4 points) and the average length of stay was 17.0 days (SD 18.7 days) with a mean length of ICU stay of 8.2 days (SD 10.5 days), and a mean ventilation time of 5.1 days (SD 8.1 days). Both surgical management and nonsurgical strategies have changed over time. Damage control resuscitation, dynamic analyses of coagulopathy and lactate clearance proved to sharpen the view of the worsening trauma patient and facilitated the prevention of further complications. The subsequent surgical care has become safer and more balanced, avoiding overzealous initial surgeries, while performing early fixation, when patients are physiologically stable or rapidly improving. Severe chest trauma and soft tissue injuries require further evaluation. CONCLUSIONS Multiple changes in management (resuscitation, transfusion protocols and balanced surgical care) have taken place. Moreover, improvement in mortality rates and complications associated with several factors were also observed. These findings support the view that the management of polytrauma patients has been substantially improved over the past 3 decades.
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Affiliation(s)
- H-C Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| | - S Halvachizadeh
- Department of Trauma, University Hospital Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - L Leenen
- Department of Trauma, University Medical Centre Utrecht, Suite G04.228, Heidelberglaan 100, 3585 GA, Utrecht, the Netherlands.
| | - G D Velmahos
- Dept. of Trauma, Emergency Surgery and Critical Care, Harvard University, Mass. General Hospital, 55 Fruit St., Boston, MA, 02114, USA
| | - R Buckley
- Section of Orthopedic Trauma, University of Calgary, Foothills Medical Center, 0490 McCaig Tower, 3134 University Drive NW Calgary, Alberta, T2N 5A1, Canada.
| | - P V Giannoudis
- Trauma & Orthopaedic Surgery, Clarendon Wing, A Floor, Great George Street, Leeds General Infirmary University Hospital, University of Leeds, Leeds, LS1 3EX, UK.
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Beks RB, de Jong MB, Sweet A, Peek J, van Wageningen B, Tromp T, IJpma F, Wouters R, Lansink K, Bemelman M, van Baal M, Hoogendoorn J, Saltzherr T, Groenwold R, Leenen L, Houwert RM. Multicentre prospective cohort study of nonoperative versus operative treatment for flail chest and multiple rib fractures after blunt thoracic trauma: study protocol. BMJ Open 2019; 9:e023660. [PMID: 31462458 PMCID: PMC6720131 DOI: 10.1136/bmjopen-2018-023660] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/15/2019] [Accepted: 06/07/2019] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION A trend has evolved towards rib fixation for flail chest although evidence is limited. Little is known about rib fixation for multiple rib fractures without flail chest. The aim of this study is to compare rib fixation with nonoperative treatment for both patients with flail chest and patients with multiple rib fractures. METHODS AND ANALYSIS In this study protocol for a multicentre prospective cohort study, all patients with three or more rib fractures admitted to one of the five participating centres will be included. In two centres, rib fixation is performed and in three centres nonoperative treatment is the standard-of-care for flail chest or multiple rib fractures. The primary outcome measures are intensive care unit length of stay and hospital length of stay for patients with a flail chest and patients with multiple rib fractures, respectively. Propensity score matching will be used to control for potential confounding of the relation between treatment modality and length of stay. All analyses will be performed separately for patients with flail chest and patients with multiple rib fractures without flail chest. ETHICS AND DISSEMINATION The regional Medical Research Ethics Committee UMC Utrecht approved a waiver of consent (reference number WAG/mb/17/024787 and METC protocol number 17-544/C). Patients will be fully informed of the purpose and procedures of the study, and signed informed consent will be obtained in agreement with the General Data Protection Regulation. Study results will be submitted for peer review publication. TRIAL REGISTRATION NUMBER NTR6833.
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Affiliation(s)
- Reinier B Beks
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Mirjam B de Jong
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Arthur Sweet
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Jesse Peek
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | | | - Tjarda Tromp
- Trauma Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Frank IJpma
- Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
| | - Roderick Wouters
- Trauma Surgery, Universitair Medisch Centrum Groningen, Groningen, The Netherlands
| | - Koen Lansink
- Trauma Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Mike Bemelman
- Trauma Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Mark van Baal
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
- Trauma Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | | | - Teun Saltzherr
- Trauma Surgery, Medisch Centrum Haaglanden, Den Haag, The Netherlands
| | | | - Luke Leenen
- Trauma Surgery, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
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Karhof S, Haverkort M, Simmermacher R, Hietbrink F, Leenen L, van Wessem K. Underlying disease determines the risk of an open abdomen treatment, final closure, however, is determined by the surgical abdominal history. Eur J Trauma Emerg Surg 2019; 47:113-120. [PMID: 31451863 PMCID: PMC7851030 DOI: 10.1007/s00068-019-01205-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 08/10/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Temporary abdominal closure is frequently used in several situations such as abbreviated surgery in damage control situations or when closing is impossible due to organ distention or increased abdominal pressure. The ultimate goal is to eventually close the fascia; however, little is known about factors predicting abdominal closure. The purpose of this study was to identify characteristics associated with the need for open abdomen as well as indicating the possibility of delayed fascial closure after a period of open abdominal treatment. METHODS A retrospective review of all patients that underwent midline laparotomy between January 2008 and December 2012 was performed. Both factors predicting open abdominal treatment and possibility to close the fascia afterwards were identified and analyzed by univariate and multivariate analyses. RESULTS 775 laparotomies in 525 patients (60% male) were included. 109 patients (21%) had an open abdomen with a mortality rate of 27%. Male gender and acidosis were associated with open abdominal treatment. In 54%, the open abdomen could be closed by delayed fascial closure. The number of laparotomies both before and during temporary abdominal treatment was associated with failure of closure. CONCLUSION In this study, male sex and physiological derangement, reflected by acidosis, were independent predictors of open abdominal treatment. Furthermore, the success of delayed fascial closure depends on number of abdominal surgical procedures. Moreover, based on our experiences, we suggest to change modalities early on, to prevent multiple fruitless attempts to close the abdomen.
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Affiliation(s)
- Steffi Karhof
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
| | - Mark Haverkort
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Rogier Simmermacher
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Falco Hietbrink
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Luke Leenen
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Karlijn van Wessem
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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17
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Hietbrink F, Smeeing D, Karhof S, Jonkers HF, Houwert M, van Wessem K, Simmermacher R, Govaert G, de Jong M, de Bruin I, Leenen L. Outcome of trauma-related emergency laparotomies, in an era of far-reaching specialization. World J Emerg Surg 2019; 14:40. [PMID: 31428187 PMCID: PMC6694503 DOI: 10.1186/s13017-019-0257-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/17/2019] [Indexed: 11/23/2022] Open
Abstract
Background Far reaching sub-specialization tends to become obligatory for surgeons in most Western countries. It is suggested that exposure of surgeons to emergency laparotomy after trauma is ever declining. Therefore, it can be questioned whether a generalist (i.e., general surgery) with additional differentiation such as the trauma surgeon, will still be needed and can remain sufficiently qualified. This study aimed to evaluate volume trends and outcomes of emergency laparotomies in trauma. Methods A retrospective cohort study was performed in the University Medical Center Utrecht between January 2008 and January 2018, in which all patients who underwent an emergency laparotomy for trauma were included. Collected data were demographics, trauma-related characteristics, and number of (planned and unplanned) laparotomies with their indications. Primary outcome was in-hospital mortality; secondary outcomes were complications, length of ICU, and overall hospital stay. Results A total of 268 index emergency laparotomies were evaluated. Total number of patients who presented with an abdominal AIS > 2 remained constant over the past 10 years, as did the percentage of patients that required an emergency laparotomy. Most were polytrauma patients with a mean ISS = 27.5 (SD ± 14.9). The most frequent indication for laparotomy was hemodynamic instability or ongoing blood loss (44%).Unplanned relaparotomies occurred in 21% of the patients, mostly due to relapse of bleeding. Other complications were anastomotic leakage (8.6%), intestinal leakage after bowel contusion (4%). In addition, an incisional hernia was found in 6.3%. Mortality rate was 16.7%, mostly due to neurologic origin (42%). Average length of stay was 16 days with an ICU stay of 5 days. Conclusion This study shows a persistent number of patients requiring emergency laparotomy after (blunt) abdominal trauma over 10 years in a European trauma center. When performed by a dedicated trauma team, this results in acceptable mortality and complication rates in this severely injured population.
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Affiliation(s)
- Falco Hietbrink
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Diederik Smeeing
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Steffi Karhof
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Henk Formijne Jonkers
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Marijn Houwert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Karlijn van Wessem
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Rogier Simmermacher
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Geertje Govaert
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Miriam de Jong
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ivar de Bruin
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Luke Leenen
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Bemelman M, Baal MV, Raaijmakers C, Lansink K, Leenen L, Long W. An Interobserver Agreement Study with a New Classification for Rib Fractures. Chirurgia (Bucur) 2019; 114:352-358. [PMID: 31264573 DOI: 10.21614/chirurgia.114.3.352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2019] [Indexed: 11/23/2022]
Abstract
Background: No consensus exists about the indication for surgical rib fixation in patients with rib fractures. Comparison between studies is difficult since a classification system is lacking for rib fractures. We introduced the first classification system for rib fractures, analogue to the Muller AO classification system and tested the classification with an interobserver agreement study. Methods: The classification is build up by four characters: the first one describes the rib number, the second character describes the location of the fracture in cranial-caudal fashion, the third character describes the fracture type and the fourth character described the subtype of the fracture. An interobserver agreement study was performed with the new classification. Results: Twenty CT scans of patients with rib fractures were analyzed. A total of 197 unilateral and bilateral rib fractures were scored by four reviewers. The interobserver agreement was substantial [Fleiss of 0.62 (95% CI 0.59 0.65)]. Conclusion: This is the first classification for rib fractures worldwide. The interobserver agreement of the classification was substantial. This classification is the first step in identifying patients who would benefit from surgical rib fixation.
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Teuben M, Spijkerman R, Pfeifer R, Blokhuis T, Huige J, Pape HC, Leenen L. Correction to: Selective non-operative management for penetrating splenic trauma: a systematic review. Eur J Trauma Emerg Surg 2019; 45:987. [PMID: 31111164 DOI: 10.1007/s00068-019-01136-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The original article has been corrected.
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Affiliation(s)
- Michel Teuben
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. .,Department of Trauma, University Hospital Zurich, Zurich, Switzerland.
| | - Roy Spijkerman
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Taco Blokhuis
- Department of Surgery, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Josephine Huige
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | | | - Luke Leenen
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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20
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Teuben M, Spijkerman R, Pfeifer R, Blokhuis T, Huige J, Pape HC, Leenen L. Selective non-operative management for penetrating splenic trauma: a systematic review. Eur J Trauma Emerg Surg 2019; 45:979-985. [PMID: 30972434 PMCID: PMC6910899 DOI: 10.1007/s00068-019-01117-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 03/27/2019] [Indexed: 12/02/2022]
Abstract
Introduction The treatment of abdominal solid organ injuries has shifted towards non-operative management (NOM). However, the feasibility of NOM for penetrating splenic trauma is unclear and outcome is believed to be worse than NOM for penetrating liver and kidney injuries. Hence, the aim of the current systematic review was to evaluate the feasibility of selective NOM in penetrating splenic injury. Methods A review of literature was performed using Pubmed, Embase and Cochrane databases. Studies on adult patients treated by NOM for splenic injuries were included and outcome was documented and compared. Results Five articles from exclusively level-1 and level-2-traumacenters were selected and a total of 608 cases of penetrating splenic injury were included. Nonoperative management was applied in 123 patients (20.4%, range 17–33%). An overall failure rate of NOM of 18% was calculated. Mortality was not seen in patients selected for nonoperative management. Contra-indicatons for NOM included hemodynamic instability, absence of abdominal CT-scanning to rule out concurrent injuries and peritonitis. Conclusions This review demonstrates that non-operative management for penetrating splenic trauma in highly selected patients has been utilized in several well-equipped and experienced trauma centers. NOM of penetrating splenic injury in selected patients is not associated with increased morbidity nor mortality. Data on the less well-equipped and experienced trauma centers are not available. More prospective studies are required to further define exact selection criteria for non-operative management in splenic trauma. Electronic supplementary material The online version of this article (10.1007/s00068-019-01117-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michel Teuben
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland.
| | - Roy Spijkerman
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Taco Blokhuis
- Department of Surgery, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Josephine Huige
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | | | - Luke Leenen
- Department of Trauma, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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Moore L, Champion H, Tardif PA, Kuimi BL, O'Reilly G, Leppaniemi A, Cameron P, Palmer CS, Abu-Zidan FM, Gabbe B, Gaarder C, Yanchar N, Stelfox HT, Coimbra R, Kortbeek J, Noonan VK, Gunning A, Gordon M, Khajanchi M, Porgo TV, Turgeon AF, Leenen L. Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis. World J Surg 2018; 42:1327-1339. [PMID: 29071424 DOI: 10.1007/s00268-017-4292-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes. METHODS We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria. RESULTS We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65-0.80]) and helicopter transport (OR = 0.70 [0.55-0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4-7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44-1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [-0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68-0.85]). Quality of evidence was low or very low for mortality and healthcare utilization. CONCLUSIONS This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.
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Affiliation(s)
- Lynne Moore
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada. .,Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada.
| | - Howard Champion
- Department of Surgery, University of the Health Sciences, Annapolis, MD, USA
| | - Pier-Alexandre Tardif
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada.,Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada
| | - Brice-Lionel Kuimi
- Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada
| | - Gerard O'Reilly
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ari Leppaniemi
- Abdominal Center, Helsinki University hospital, Helsinki, Finland
| | - Peter Cameron
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christine Gaarder
- Department of Traumatology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Natalie Yanchar
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Henry Thomas Stelfox
- Departments of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Raul Coimbra
- Division of Trauma, Surgical Critical Care, Burns, and Acute Care Surgery, University of California, San Diego Health System, San Diego, CA, USA
| | - John Kortbeek
- Department of Surgery, Division of General Surgery and Division of Critical Care, University of Calgary, Calgary, AB, Canada
| | | | - Amy Gunning
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Malcolm Gordon
- Department of Emergency Medicine, University of Glasgow, Glasgow, UK
| | | | - Teegwendé V Porgo
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada.,Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec, QC, Canada.,Axe Santé des Populations et Pratiques Optimales en Santé (Population Health and Optimal Health Practices Research Unit), Traumatologie - Urgence - Soins intensifs (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center (Enfant-Jésus Hospital), Québec, QC, Canada
| | - Luke Leenen
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Bemelman M, de Kruijf MW, van Baal M, Leenen L. Rib Fractures: To Fix or Not to Fix? An Evidence-Based Algorithm. Korean J Thorac Cardiovasc Surg 2017; 50:229-234. [PMID: 28795026 PMCID: PMC5548197 DOI: 10.5090/kjtcs.2017.50.4.229] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 07/21/2017] [Accepted: 07/22/2017] [Indexed: 12/19/2022]
Abstract
Rib fractures are a common injury resulting from blunt chest trauma. The most important complications associated with rib fractures include death, pneumonia, and the need for mechanical ventilation. The development of new osteosynthesis materials has stimulated increased interest in the surgical treatment of rib fractures. Surgical stabilisation, however, is not needed for every patient with rib fractures or for every patient with flail chest. This paper presents an easy-to-use evidence-based algorithm, developed by the authors, for the treatment of patients with flail chest and isolated rib fractures.
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Affiliation(s)
| | | | | | - Luke Leenen
- Department of Surgery, University Medical Centre Utrecht
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23
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Gunning A, van Heijl M, van Wessem K, Leenen L. The association of patient and trauma characteristics with the health-related quality of life in a Dutch trauma population. Scand J Trauma Resusc Emerg Med 2017; 25:41. [PMID: 28410604 PMCID: PMC5391585 DOI: 10.1186/s13049-017-0375-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 03/20/2017] [Indexed: 02/03/2023] Open
Abstract
Background It is suggested in literature to use the Health Related Quality of Life (HRQoL) as an outcome indicator for evaluating trauma centre performances. In order to predict HRQoL, characteristics that could be of influence on a predictive model should be identified. This study identifies patient and injury characteristics associated with the HRQoL in a general trauma population. Methods Retrospective study of trauma patients admitted from 1st January 2007 through 31th December 2012. Patients were aged ≥18 years and discharged alive from the level I trauma centre. A combined health survey (SF-36 and EQ-5D) was sent to all traceable patients. The subdomain outcomes and EQ-5D index value (EQ-5Di) were compared with the reference population. A linear regression analysis was performed to identify parameters associated parameters with the HRQoL outcome. Results A total of 1870 patients were included for analyses. Compared to the eligible population, included patients were significantly older, more severely injured, more often admitted in the ICU and had a longer admission duration. The SF-36 and EQ-5Di were significantly lower compared to the Dutch reference population. The variables age, Injury Severity Score, hospital length of stay, ICU length of stay, Revised Trauma Score, probability of survival, and severe injury to the head and extremities were associated with the HRQoL in the majority of the subdomains. Discussion In order to use HRQoL as an indicator for trauma centre performances, there should be a consensus of the ideal timing for the measurement of HRQoL post-injury and the appropriate HRQoL instrument. Furthermore, standardised HRQoL outcomes must be developed. Conclusion This study revealed eight factors (described above) which could be used to predict the HRQoL in trauma patients.
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Affiliation(s)
- Amy Gunning
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Mark van Heijl
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Karlijn van Wessem
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Luke Leenen
- Department of Trauma Surgery, University Medical Center Utrecht, Suite: G04.228, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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24
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Bemelman M, van Baal M, Yuan JZ, Leenen L. The Role of Minimally Invasive Plate Osteosynthesis in Rib Fixation: A Review. Korean J Thorac Cardiovasc Surg 2016; 49:1-8. [PMID: 26889439 PMCID: PMC4757390 DOI: 10.5090/kjtcs.2016.49.1.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 01/21/2016] [Accepted: 01/21/2016] [Indexed: 11/20/2022]
Abstract
More than a century ago, the first scientific report was published about fracture fixation with plates. During the 1950’s, open reduction and plate fixation for fractures were standardized by the founders of Arbeitsgemeinschaft für osteosynthesefragen/Association for the Study of Internal Fixation. Since the introduction of plate fixation for fractures, several plates and screws have been developed, all with their own characteristics. To accomplice more fracture stability, it was thought the bigger the plate, the better. The counter side was a compromised blood supply of the bone, often resulting in bone necrosis and ultimately delayed or non-union. With the search and development of new materials and techniques for fracture fixation, less invasive procedures have become increasingly popular. This resulted in the minimally invasive plate osteosynthesis (MIPO) technique for fracture fixation. With the MIPO technique, procedures could be performed with smaller incisions and thus with less soft tissue damage and a better preserved blood supply. The last 5 years rib fixation has become increasingly popular, rising evidence has become available suggesting that surgical rib fixation improves outcome of patients with a flail chest or isolated rib fractures. Many surgical approaches for rib fixation have been described in the old literature, however, most of these techniques are obscure nowadays. Currently mostly large incisions with considerable surgical insult are used to stabilize rib fractures. We think that MIPO deserves a place in the surgical treatment of rib fractures. We present the aspects of diagnosis, preoperative planning and operative techniques in regard to MIPO rib fixation.
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Affiliation(s)
| | - Mark van Baal
- Department of Surgery, Elisabeth-Tweesteden Hospital
| | | | - Luke Leenen
- Department of Surgery, University Medical Centre Utrecht
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25
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Hoencamp R, Idenburg F, Vermetten E, Leenen L, Hamming J. Lessons learned from Dutch deployed surgeons and anesthesiologists to Afghanistan: 2006-2010. Mil Med 2016; 179:711-6. [PMID: 25003854 DOI: 10.7205/milmed-d-13-00548] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Care for battle casualties demands special skills from surgeons and anesthesiologists. The experiences of Dutch military surgeons and anesthesiologists that deployed to South Afghanistan provided an opportunity to evaluate predeployment training and preparation of military medical specialists. METHOD A survey was conducted among all surgeons and anesthesiologists (n = 40) that deployed to South Afghanistan between February 2006 and November 2010. They were asked about their medical preparedness, deployment experience, and postdeployment impact. RESULTS Most (35/40) participants reported high levels of preparedness before their deployment. All (40/40) surgeons and anesthesiologists described a positive influence of their deployment on their professional skills and 33/40 described a positive effect on their personal development. Knowledge of maxillofacial, ophthalmic, neurological, urological, gynecological, vascular, and thoracic surgery scored below average. Impact on mental health and social support network was reported as negative by 11/40 participants, 24/40 reported a neutral, and 5/40 a positive effect. CONCLUSION A standardized predeployment training program to prepare Dutch surgeons and anesthesiologists for combat surgery is currently lacking. These results emphasize the need for a standardized predeployment medical training, despite high levels of perceived preparedness. Also, the high mental and psychological impact on the deployed surgeons and anesthesiologists warrants further assessment.
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Affiliation(s)
- Rigo Hoencamp
- Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Floris Idenburg
- Medical Centre Haaglanden, Lijnbaan 32, 2512 VA The Hague, The Netherlands
| | - Eric Vermetten
- Military Mental Health Research, Lundlaan 1, 3584 EZ Utrecht, The Netherlands
| | - Luke Leenen
- University Medical Center Utrecht, Heidelberglaan 100, 3585 GA Utrecht, The Netherlands
| | - Jaap Hamming
- Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
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26
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Huizinga E, Hoencamp R, van Dongen T, Leenen L. Cross-sectional analysis of Dutch repatriated service members from southern Afghanistan (2003-2014). Mil Med 2015; 180:310-4. [PMID: 25735022 DOI: 10.7205/milmed-d-14-00474] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND A systematic analysis of the complete medical support organization of the Dutch Armed Forces regarding repatriated service members from Afghanistan has not been performed so far. METHODS All information were collated in a specifically designed electronic database and gathered from the archive of the Central Military Hospital for all Dutch service members receiving treatment for wounds or diseases sustained in the Afghan theater from July 2003 till January 2014. RESULTS Traumatic injuries were the main cause (63%, 141/223) of repatriation, and improvised explosive devices the major (67%, 60/89) mechanism of injury in the battle casualty group. The mean time between injury and medical evacuation from Afghanistan was 8 days, and this was reduced to 3.6 days in case of polytrauma casualties (ISS > 15). CONCLUSIONS Sixty percent of all Dutch medical evacuations from Afghanistan were not directly related to combat operations. A standard medical examination/endurance test in the predeployment phase could be useful as screening tool in reduction of the disease nonbattle injury casualty rate. Shorter transport intervals might improve morbidity and mortality of casualties, a timeframe of 48 to 72 hours for receiving definitive treatment seems feasible. Further research is necessary to identify delay factors and possible improvements in the medical support organization.
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Affiliation(s)
- Eelco Huizinga
- University Medical Centre Utrecht, Heidelberglaan 100, 3585 GA Utrecht, The Netherlands
| | - Rigo Hoencamp
- Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Thijs van Dongen
- University Medical Centre Utrecht, Heidelberglaan 100, 3585 GA Utrecht, The Netherlands
| | - Luke Leenen
- University Medical Centre Utrecht, Heidelberglaan 100, 3585 GA Utrecht, The Netherlands
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Klinkenberg S, van den Borne CJH, Aalbers MW, Verschuure P, Kessels AG, Leenen L, Rijkers K, Aldenkamp AP, Vles JSH, Majoie HJM. The effects of vagus nerve stimulation on tryptophan metabolites in children with intractable epilepsy. Epilepsy Behav 2014; 37:133-8. [PMID: 25022821 DOI: 10.1016/j.yebeh.2014.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Revised: 06/02/2014] [Accepted: 06/04/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The mechanism of action of vagus nerve stimulation (VNS) in intractable epilepsy is not entirely clarified. It is believed that VNS causes alterations in cytokines, which can lead to rebalancing the release of neurotoxic and neuroprotective tryptophan metabolites. We aimed to evaluate VNS effects on tryptophan metabolites and on epileptic seizures and investigated whether the antiepileptic effectiveness correlated with changes in tryptophan metabolism. METHODS Forty-one children with intractable epilepsy were included in a randomized, active-controlled, double-blind study. After a baseline period of 12 weeks, all children underwent implantation of a vagus nerve stimulator and entered a blinded active-controlled phase of 20 weeks. Half of the children received high-output (therapeutic) stimulation (n=21), while the other half received low-output (active control) stimulation (n=20). Subsequently, all children received high-output stimulation for another 19 weeks (add-on phase). Tryptophan metabolites were assessed in plasma and cerebrospinal fluid (CSF) by use of liquid chromatography-tandem mass spectrometry (LC-MS/MS) and compared between high- and low-output groups and between the end of both study phases and baseline. Seizure frequency was recorded using seizure diaries. Mood was assessed using Profile of Mood States (POMS) questionnaires. RESULTS Regarding tryptophan metabolites, anthranilic acid (AA) levels were significantly higher at the end of the add-on phase compared with baseline (p=0.002) and correlated significantly with improvement of mood (τ=-0.39, p=0.037) and seizure frequency reduction (τ=-0.33, p<0.01). No significant changes were found between high- and low-output groups regarding seizure frequency. CONCLUSION Vagus nerve stimulation induces a consistent increase in AA, a neuroprotective and anticonvulsant tryptophan metabolite. Moreover, increased AA levels are associated with improvement in mood and reduction of seizure frequency.
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Affiliation(s)
- S Klinkenberg
- Department of Neurology, Maastricht University Medical Center, The Netherlands; School for Mental Health and Neuroscience, Maastricht University, The Netherlands.
| | | | - M W Aalbers
- Department of Neurology, Maastricht University Medical Center, The Netherlands; School for Mental Health and Neuroscience, Maastricht University, The Netherlands
| | - P Verschuure
- Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - A G Kessels
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, The Netherlands
| | - L Leenen
- Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - K Rijkers
- School for Mental Health and Neuroscience, Maastricht University, The Netherlands; Department of Neurosurgery, Maastricht University Medical Center, The Netherlands
| | - A P Aldenkamp
- Department of Neurology, Maastricht University Medical Center, The Netherlands; Epilepsy Center Kempenhaeghe, Heeze, The Netherlands; Eindhoven University of Technology, Eindhoven, The Netherlands
| | - J S H Vles
- Department of Neurology, Maastricht University Medical Center, The Netherlands; School for Mental Health and Neuroscience, Maastricht University, The Netherlands; Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
| | - H J M Majoie
- Department of Neurology, Maastricht University Medical Center, The Netherlands; School for Mental Health and Neuroscience, Maastricht University, The Netherlands; Epilepsy Center Kempenhaeghe, Heeze, The Netherlands
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Abstract
The introduction of trauma teams has improved patient outcome independently. The aim of establishing a trauma team is to ensure the early mobilization and involvement of more experienced medical staff and thereby to improve patient outcome. The team approach allows for distribution of the several tasks in assessment and resuscitation of the patient in a 'horizontal approach', which may lead to a reduction in time from injury to critical interventions and thus have a direct bearing on the patient's ultimate outcome. A trauma team leader or supervisor, who coordinates the resuscitation and ensures adherence to guidelines, should lead the trauma team. There is a major national and international variety in trauma team composition, however crucial are a surgeon, an Emergency Medicine physician or both and anaesthetist. Advanced Trauma Life Support training, simulation-based training, and video review have all improved patient outcome and trauma team performance. Developments in the radiology, such as the use of computed tomography scanning in the emergency room and the endovascular treatment of bleeding foci, have changed treatment algorithms in selected patients. These developments and new insights in shock management may have a future impact on patient management and trauma team composition.
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Affiliation(s)
- D Tiel Groenestege-Kreb
- Department of Trauma, University Medical Centre Utrecht (UMCU), HP G04·228, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - O van Maarseveen
- Department of Trauma, University Medical Centre Utrecht (UMCU), HP G04·228, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - L Leenen
- Department of Trauma, University Medical Centre Utrecht (UMCU), HP G04·228, PO Box 85500, 3508 GA Utrecht, The Netherlands
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29
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Leenen L. Editorial Comment. Eur J Trauma Emerg Surg 2012; 38:529. [PMID: 26816255 DOI: 10.1007/s00068-012-0214-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- L Leenen
- University Medical Center Utrecht, Surgery Heidelberglaan 88, 3485 CX, Utrecht, The Netherlands.
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Frima H, Eshuis R, Mulder P, Leenen L. The ICI classification for calcaneal injuries: a validation study. Injury 2012; 43:784-7. [PMID: 21975555 DOI: 10.1016/j.injury.2011.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2011] [Revised: 08/27/2011] [Accepted: 09/08/2011] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The integral classification of injuries (ICI), by Zwipp et al. has been developed as a classification system for injuries of the bones, joints, cartilage and ligaments of the foot. It follows the principles of the comprehensive classification of fractures by Müller et al. The ICI was developed for 'everyday use' and scientific purposes. Our aim was to perform a validation study for this classification system applied to the calcaneal injuries. METHODS A panel of five experienced trauma and orthopaedic surgeons evaluated the ICI score in 20 calcaneal injuries. After 2 months, a second classification was performed in a different order. Inter- and intra-observer variability were evaluated by kappa statistics. RESULTS Panel members were not able to evaluate capsule and ligamental injuries based on X-ray and computed tomography (CT) films. Two injuries were excluded for logistical reasons. The inter-observer agreement based on 18 injuries of bone and joints was slight; kappa 0.14 (90% confidence interval (CI): 0.05-0.22). The intra-observer agreement was fair; kappa 0.31 (90% CI: 0.22-0.41). Overall, the panel rated the system as very complicated and not practical. CONCLUSION The ICI is a complicated classification system with slight to fair inter- and intra-observer variabilities. It might not be a practical classification system for calcaneal injuries in 'everyday use' or scientific purposes.
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Affiliation(s)
- Herman Frima
- Department of Surgery, Amphia Hospital, P.O. Box 90158, 4800 RK Breda, The Netherlands.
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Abstract
Apart from their pivotal role in the host defense against pathogens, leukocytes are also essential for bone repair, as fracture healing is initiated and directed by a physiological inflammatory response. Leukocytes infiltrate the fracture hematoma and produce several growth and differentiation factors that regulate essential downstream processes of fracture healing. Systemic inflammation alters the numbers and properties of circulating leukocytes, and we hypothesize that these changes are maintained in tissue leukocytes and will lead to impairment of fracture healing after major trauma. The underlying mechanisms will be discussed in this review.
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Affiliation(s)
- Okan Bastian
- Departments of Surgery, University Medical Center Utrecht, The Netherlands
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32
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Leenen L. Special Issue on rib fixation. Eur J Trauma Emerg Surg 2010; 36:405. [PMID: 21841951 PMCID: PMC3150804 DOI: 10.1007/s00068-010-0049-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Luke Leenen
- Department of Surgery, UMC Utrecht, Utrecht, The Netherlands
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Van Wagenberg L, Ramnarain D, Kesecioglu J, Leenen L. Value of peripheral tissue oxygen tension in animal experimental models of haemorrhagic and septic shock. Crit Care 2010. [PMCID: PMC2934535 DOI: 10.1186/cc8382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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34
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Timmers T, Verhofstad M, Moons K, Leenen L. Long-term survival after surgical intensive care admission: 50% die within 10 years. Crit Care 2009. [PMCID: PMC4084401 DOI: 10.1186/cc7679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Abstract
OBJECTIVE In the Netherlands, major incidents are sparse, and so there is a general feeling of a relatively low risk. Upon evaluating multiple casualty events (MCEs) in the Netherlands over the last 60 years, it is worth noting 39 major events. Our objective was to report the experiences from a mass casualty incident in an urban area, performing a critical evaluation of the response and outcome related to the scenario in order to learn from our past and to train for the future. MATERIALS AND METHODS In a retrospective patient record analysis we collected all of the data concerning an MCE we encountered in August 2006. RESULTS There were 21 casualties at the scene. Of our 19 patients, 12 were seen in the crash room. The average age of the patients was 30 years (range 22-53). In all, 87 X-rays, 1 ultrasound and 15 CT scans were performed. Four patients were admitted: ten patients received definitive wound treatment in the ED. Psychological support was given to all patients. One patient died three days later. CONCLUSION Triage supported by one person and two trauma teams worked well. The amount of over- and undertriage was in line with the literature. Numbering the patients worked well but also caused enormous problems with the supporting facilities. Centralizing the trauma care yielded certain advantages; however, we must respect our surge capacity of 20 patients. When the number of patients surpasses 20, an alternative plan must be followed. This event has been an eye-opener for our organization; it has given us new tools to prepare for a potential new disaster.
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Affiliation(s)
- Michael Bemelman
- Department of Surgery and Trauma, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Luke Leenen
- Department of Surgery and Trauma, University Medical Centre, Utrecht, The Netherlands
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36
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Bootsma HPR, Vos AM, Hulsman J, Lambrechts D, Leenen L, Majoie M, Savelkoul M, Schellekens A, Aldenkamp AP. Lamotrigine in clinical practice: long-term experience in patients with refractory epilepsy referred to a tertiary epilepsy center. Epilepsy Behav 2008; 12:262-8. [PMID: 18093878 DOI: 10.1016/j.yebeh.2007.10.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2007] [Revised: 10/11/2007] [Accepted: 10/15/2007] [Indexed: 10/22/2022]
Abstract
Lamotrigine (LTG, Lamictal), one of the newer antiepileptic drugs, was admitted to the Dutch market in 1996. It was first used as adjunctive therapy and later as a monotherapy in partial and generalized epilepsy. All patients who started on LTG in 1996 or 1997 in the Epilepsy Centre Kempenhaeghe (n=314) were enrolled in this study and followed for 48 months. The data indicate that the retention rates for LTG after 1, 2, 3, and 4 years are respectively 74.4, 69.3, 63.1, and 55.6%. Patients with normal cognitive function were more likely to continue than patients with mental retardation. The main reason for discontinuing LTG therapy was lack of efficacy (19.1%). Four patients (1.4%) were seizure-free for the total follow-up period of 48 months. The most frequently reported negative side effects were dizziness and headache, both in patients who continued and in those who discontinued therapy. A large percentage of patients also reported positive side effects like "feeling/being more active" and "feeling more clear/more responsive." For the whole patient group, the plasma level of LTG was measured 277 times. Plasma levels of LTG were influenced by the patients' comedications. Plasma levels of LTG in groups taking LTG in monotherapy, LTG plus an inducer, and LTG plus valproate were 8.7, 4.8, and 8.7 mg/L, respectively. The correlation between measured plasma level and dose confirm the manufacturer's dose recommendations. The manufacturer recommends half the dosage of lamotrigine monotherapy when the patient also uses valproate. When the patient uses an inducer, the dosage of LTG must be two times the dose used in monotherapy.
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Affiliation(s)
- H P R Bootsma
- Department of Neurology, Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands
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37
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Bootsma HPR, Ricker L, Diepman L, Gehring J, Hulsman J, Lambrechts D, Leenen L, Majoie M, Schellekens A, de Krom M, Aldenkamp AP. Long-term effects of levetiracetam and topiramate in clinical practice: A head-to-head comparison. Seizure 2007; 17:19-26. [PMID: 17618131 DOI: 10.1016/j.seizure.2007.05.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Revised: 04/19/2007] [Accepted: 05/25/2007] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Two of the most commonly prescribed new antiepileptic drugs as add-on therapy for patients with chronic refractory epilepsies are topiramate and levetiracetam. In regulatory trials, both drugs were characterized as very promising new antiepileptic drugs. However, results from these highly controlled short-term clinical trials cannot simply be extrapolated to everyday clinical practice, also because head-to-head comparisons are lacking. Therefore, results from long-term open label observational studies that compare two or more new AEDs are crucial to determine the long-term performance of competing new antiepileptic drugs in clinical practice. METHOD We analyzed all patients referred to a tertiary epilepsy centre who had been treated with topiramate from the introduction of the drug in spring 1993 up to a final assessment point mid-2002 and all patients who had been treated with LEV in the same centre from the introduction of the drug in early 2001 up to a final assessment point end-2003 using a medical information system. RESULTS Three hundred and one patients were included for levetiracetam and 429 patients for TPM. Retention rate after 1 year was 65.6% for LEV-treated patients and 51.7% for TPM-treated patients (p=0.0015). Similarly, retention rates for LEV were higher at the 24-month mark: 45.8% of LEV-treated patients and 38.3% of TPM-treated patients were still continuing treatment (p=0.0046). Adverse events led to drug discontinuation in 21.9% of TPM-treated patients compared to 6.0% of LEV-treated patients (p<0.001). The number of patients discontinuing treatment because of lack of efficacy was similar for both groups. Seizure freedom rates varied between 11.6 and 20.0% for TPM and between 11.1 and 14.3% for LEV per 6-months interval. Several important AED specific adverse events leading to drug discontinuation were identified, including neurocognitive side effects from TPM and mood disorders from LEV. CONCLUSION The retention rate for LEV is significantly higher than for TPM. LEV had a more favourable side effect profile than TPM with comparable efficacy. Patients on TPM discontinued treatment mainly because of neurocognitive side effects. In the treatment with LEV, the effects on mood must not be underestimated.
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Affiliation(s)
- H P R Bootsma
- Department of Neurology, Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands.
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Bootsma HPR, Ricker L, Diepman L, Gehring J, Hulsman J, Lambrechts D, Leenen L, Majoie M, Schellekens A, de Krom M, Aldenkamp AP. Levetiracetam in clinical practice: long-term experience in patients with refractory epilepsy referred to a tertiary epilepsy center. Epilepsy Behav 2007; 10:296-303. [PMID: 17317325 DOI: 10.1016/j.yebeh.2006.11.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2006] [Revised: 10/31/2006] [Accepted: 11/22/2006] [Indexed: 11/20/2022]
Abstract
OBJECTIVE For the treatment of patients with chronic refractory epilepsies, development of new antiepileptic drugs is crucial. Three regulatory trials have demonstrated that add-on levetiracetam is efficacious in patients with localization-related epilepsy. However, results from these highly controlled short-term clinical trials cannot simply be extrapolated to everyday clinical practice. Therefore, more information is needed about the long-term profile of a new antiepileptic drug in clinical practice. METHOD We analyzed all patients who had been treated with levetiracetam in the Epilepsy Centre Kempenhaeghe from the introduction of the drug in early 2001 up to a final assessment point, at the end of 2003, using a medical information system. RESULTS In total, 301 patients were included. One hundred thirty-eight patients (45.8%) discontinued LEV treatment during the 24-month follow-up period. Reasons for discontinuation were lack of efficacy in 15.9% of patients, adverse events in 6.0% of patients, and a combination of lack of efficacy and adverse events in 16.3% of patients. By Kaplan-Meier survival analysis, the continuation rate was 65.6% after 1 year and 45.8% after 2 years. About 15% of patients in this highly refractory group had a 3-month remission, whereas 10% of patients became seizure-free for longer periods. The most frequently reported side effects at the time of discontinuation were mood disorders, tiredness, and sleepiness. Variables predicting (dis)continuation of levetiracetam treatment could not be identified. CONCLUSION Levetiracetam is a new antiepileptic drug that appears to be a useful add-on treatment in patients with refractory epilepsy. Its side effect profile is mild, with mood disorders being the most dominant adverse event.
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Affiliation(s)
- H P R Bootsma
- Departments of Neurology, Clinical Neurophysiology, Neuropsychology, and Pharmacology, Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands.
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Abstract
A systemic inflammatory response often follows severe trauma. Priming (preactivation) of polymorphonuclear phagocytes (PMNs) is an essential first step in the processes that lead to damage caused by the systemic activation of innate immune response. Until recently, priming could only accurately be measured by functional assays, which require isolation of cells, thereby potentially inducing artificial activation. The aim of this study was to identify primed PMNs in response to trauma by using a whole blood analysis with a broad detection range. Twenty-two trauma patients were analyzed for PMN priming with novel developed antibodies recognizing priming epitopes by flow cytometric analysis. Expression of priming epitopes on PMNs was analyzed with respect to time, injury, and disease severity. Expression of priming epitopes in the circulation was compared with expression profiles of PMNs obtained from lung fluid. Fourteen healthy volunteers served as controls. Expression of priming epitopes on peripheral blood PMNs of injured patients was similar, as found in healthy controls, whereas highly primed cells were found in the lung fluid of injured patients (increase of >50 times as compared with peripheral blood cells). In fact, the responsiveness of PMNs toward the bacteria-derived stimulus N-formyl-methionyl-leucyl-phenylalanine was markedly decreased in trauma patients. Lack of expression of priming epitopes and the unresponsiveness to N-formyl-methionyl-leucyl-phenylalanine demonstrates the presence of partially refractory cells in the circulation of trauma patients. An increased expression of epitopes found on pulmonary PMNs suggests that optimal (pre)activation of these cells only occurs in the tissues.
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Affiliation(s)
- Falco Hietbrink
- Department of Surgery, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands.
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Bootsma HPR, Coolen F, Aldenkamp AP, Arends J, Diepman L, Hulsman J, Lambrechts D, Leenen L, Majoie M, Schellekens A, de Krom M. Topiramate in clinical practice: long-term experience in patients with refractory epilepsy referred to a tertiary epilepsy center. Epilepsy Behav 2004; 5:380-7. [PMID: 15145308 DOI: 10.1016/j.yebeh.2004.03.002] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2003] [Revised: 03/01/2004] [Accepted: 03/02/2004] [Indexed: 11/30/2022]
Abstract
For the treatment of patients with chronic refractory epilepsies, information about the long-term efficacy and safety profile of any new antiepileptic drug is crucial. Topiramate has been proven to be effective in patients with refractory chronic partial epilepsies in short-term controlled clinical trials, but the long-term retention, long-term efficacy, and long-term side-effect profile have not been sufficiently investigated. We analyzed all patients who had been treated with topiramate in the Epilepsy Centre Kempenhaeghe from the introduction of the drug in the spring of 1993 up to a final assessment point in mid-2002. In total, 470 patients were identified. The data show that the clinical dose achieved was about 200mg/day, reached after approximately 6 months of treatment. Further dose escalation in the survivors was slow, with a mean dose of about 300 mg/day after 24 months of treatment. Mean titration dose is 25mg/week, but titration strategy is mostly individual and responds to patient complaints. With respect to seizure frequency, 10-15% of the patients were seizure-free at the 6-month evaluation; 4 patients achieved a 2-year remission. Retention rate was 53% after 1 year, 45% after 2 years, 38% after 3 years, and 30% after 4 years. At 4 years, almost 70% of the patients had discontinued topiramate. The main reason was adverse events, which accounted for about 65% of the discontinuations. Behavioral side effects were dominant, with mental slowing (27.6%), dysphasia (16.0%), and mood problems (agitation: 11.9%) being the most frequently reported side effects. In about 10% of the patients side effects led to discontinuation despite the obvious favorable effects on seizure frequency. Comparisons between the patients who discontinued topiramate treatment and those who continued topiramate showed that discontinuation was associated with comedication (vigabatrin and lamotrigine). Our conclusion is that TPM is associated with a high incidence of side effects in clinical practice, affecting long-term retention. Meaningful prognostic factors that may help us in clinical decision making, i.e., to prevent the side effects or to help us identify those at risk, have not been found.
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Affiliation(s)
- H P R Bootsma
- Department of Neurology, Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands.
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Ramnarain D, Braams R, Leenen L. Crit Care 2004; 8:P54. [DOI: 10.1186/cc2521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Bos M, Braams R, Leenen L. Crit Care 2004; 8:P62. [DOI: 10.1186/cc2529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Aldenkamp AP, Arends J, Bootsma HPR, Diepman L, Hulsman J, Lambrechts D, Leenen L, Majoie M, Schellekens A, de Vocht J. Randomized double-blind parallel-group study comparing cognitive effects of a low-dose lamotrigine with valproate and placebo in healthy volunteers. Epilepsia 2002; 43:19-26. [PMID: 11879382 DOI: 10.1046/j.1528-1157.2002.29201.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE This study aimed at investigating the cognitive and mood effects of lamotrigine (LTG) versus valproate (VPA) and placebo (PBO). METHODS By studying the effects in healthy volunteers, it is possible to separate the genuine effects of LTG from the cognitive improvements, caused by better seizure control. The study used a pretest-posttest comparison of 50 mg LTG, 900 mg VPA, or PBO in a double-blind single-dummy parallel-group design with 30 healthy volunteers. Study duration was 12 days (with a last control on day 13). Outcome measures included cognitive tests (FePsy neuropsychological test battery), mood scales (ASL; mood-rating scale), and a scale for subjective complaints (ABNAS Neurotoxicity scale). Total sleep time was controlled with actigraphic recordings. The results were analyzed by comparing the change over time (pretest with posttest) for the three treatments with Student's t tests. RESULTS COGNITIVE TESTS: significant differences between the treatments were found for measurements of cognitive activation (i.e., three of the four simple reaction-time measurements showed statistically significant differences in change between PBO and LTG in favor of LTG (p=0.03; 0.03; 0.04); two of four tests showed statistically significant differences in change between LTG and VPA, both in favor of LTG (p=0.03; 0.05). SUBJECTIVE COMPLAINTS: the ABNAS-neurotoxicity scale reveals a significant reduction of drug-related cognitive complaints for the subjects taking LTG, relative to VPA (p=0.02). MOOD RATING: significant changes were found on the scale assessing "tiredness," showing increased tiredness/sedation for VPA relative to PBO (p=0.02) and on the "timid scale" for LTG reporting "being more at ease" compared with both PBO and VPA (p=0.02; 0.02). The general direction of change for the mood scales was toward "activation" for LTG (five of six scales improved), whereas for VPA, the reverse effect was found (four of six scales showed a change in the direction of "tiredness/sedation"). CONCLUSIONS Short-term treatment in normal volunteers with a low dose of LTG resulted in improved cognitive activation on simple reaction-time measurements, a more positive subjective report about the impact of drug treatment relative to VPA, and mood changes concurring with the activating effect demonstrated by the cognitive tests.
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Affiliation(s)
- A P Aldenkamp
- Department of Neurology of the Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands.
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Pape HC, Oestern H, Leenen L, Yates D, Stalp M, Grimme K, Tscherne H, Krettek C. Documentation of Blunt Trauma in Europe Survey of the Current Status of Documentation and Appraisal of the Value of Standardization. ACTA ACUST UNITED AC 2000. [DOI: 10.1007/pl00002447] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Turk PS, Belliveau JF, Darnowski JW, Weinberg MC, Leenen L, Wanebo HJ. Isolated pelvic perfusion for unresectable cancer using a balloon occlusion technique. Arch Surg 1993; 128:533-8; discussion 538-9. [PMID: 7683872 DOI: 10.1001/archsurg.1993.01420170067009] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Previously irradiated recurrent pelvic malignancy is refractory to most treatment modalities. Ten patients with local recurrences (six with rectal cancer; three, anal cancer; and one, anorectal melanoma) were treated with a total of 17 courses of isolated pelvic perfusion chemotherapy (12 with multiple agents) using standard hemodialysis technology. Aortic and inferior vena caval occlusion was maintained via transfemoral balloon catheters, with a single intraoperative balloon disruption. Mean pelvic-systemic drug exposure ratios were 9.8:1 for fluorouracil, 4.8:1 for cisplatin, and 4.4:1 for mitomycin C. Results were three partial responses (two patients subsequently underwent resection) and three minor responses, all in patients with a visible tumor. Pelvic pain was relieved in six of eight symptomatic patients (mean duration, 4 months). Using limited access, this procedure produces high pelvic-systemic concentration gradients, prolonged palliation for recurrent pelvic cancers, and increased resectability in selected patients.
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Affiliation(s)
- P S Turk
- Department of Surgery, Roger Williams Medical Center, Providence, RI 02908
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Wolters JG, de Boer-van Huizen R, ten Donkelaar HJ, Leenen L. Collateralization of descending pathways from the brainstem to the spinal cord in a lizard, Varanus exanthematicus. J Comp Neurol 1986; 251:317-33. [PMID: 3021824 DOI: 10.1002/cne.902510304] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
With the multiple fluorescent retrograde tracer technique, the collateralization in the spinal cord of descending supraspinal pathways was studied in a lizard, Varanus exanthematicus. Fast Blue (FB) gels were implanted unilaterally in the spinal gray matter of the cervical enlargement and Nuclear Yellow (NY) gels were implanted ipsilaterally in two series of experiments in all spinal funiculi of the lumbar enlargement or in midthoracic spinal segments, respectively. All brainstem nuclei known to project to the spinal cord in reptiles were found to give rise to branching axons that may influence widely separate levels of the spinal cord. The number of double-labeled FB-NY cells varied in these brainstem nuclei from none to half the number of neurons projecting to the cervical enlargement. Highly collateralizing projections (expressed as the percentage of double-labeled neurons, DL) were found to arise from the nucleus raphes inferior, the contralateral nucleus reticularis superior pars lateralis, the contralateral nuclei vestibulares ventromedialis and descendens, and the ipsilateral nucleus reticularis inferior pars ventralis. A lower percentage of DL neurons was noted for the contralateral nucleus ruber and bilaterally for the nucleus reticularis medius and nucleus reticularis inferior. Extensive brainstem projections directed to cervical and high thoracic spinal levels originate from the area lateralis hypothalami, the nucleus of the fasciculus longitudinalis medialis, the contralateral nucleus cerebellaris medialis, and from the nucleus tractus solitarii. Projections preferentially directed to midthoracic or lower levels of the spinal cord were found to arise from the ipsilateral locus coeruleus, the contralateral nucleus reticularis superior pars lateralis, the nucleus reticularis inferior pars ventralis, the nucleus reticularis inferior, and the nucleus raphes inferior. In contrast to findings in mammals, in Varanus exanthematicus the red nucleus, the nucleus vestibularis ventrolateralis, and certain parts of the reticular formation did not display a clear-cut somatotopic organization. In general two different patterns of collateralization can grossly be discerned: a gradual decrease of spinal collaterals caudalward, which can be interpreted as a certain specificity of such projections; and a constant number of collateral nerve fibers throughout the spinal cord that can be interpreted as either a nonspecific or, in contrast, a highly specific system, focussed exclusively on the cervical and lumbar enlargements.
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