Publications by authors named "Loek P H Leenen"

26 Publications

  • Page 1 of 1

Traumatic rib fractures: a marker of severe injury. A nationwide study using the National Trauma Data Bank.

Trauma Surg Acute Care Open 2020 10;5(1):e000441. Epub 2020 Jun 10.

Department of Orthopaedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, Massachusetts, USA.

Background: In recent years, there has been increasing interest in the treatment of patients with rib fractures. However, the current literature on the epidemiology and outcomes of rib fractures is outdated and inconsistent. Furthermore, although it has been suggested that there is a large heterogeneity among patients with traumatic rib fractures, there is insufficient literature reporting on the outcomes of different subgroups.

Methods: A retrospective cohort study using the National Trauma Data Bank was performed. All adult patients with one or more traumatic rib fractures or flail chest who were admitted to a hospital between January 2010 and December 2016 were identified by the International Classification of Diseases Ninth Revision diagnostic codes.

Results: Of the 564 798 included patients with one or more rib fractures, 44.9% (n=2 53 564) were patients with polytrauma. Two per cent had open rib fractures (n=11 433, 2.0%) and flail chest was found in 4% (n=23 388, 4.1%) of all cases. Motor vehicle accidents (n=237 995, 51.6%) were the most common cause of rib fractures in patients with polytrauma and flail chest. Blunt chest injury accounted for 95.5% (n=5 39 422) of rib fractures. Rib fractures in elderly patients were predominantly caused by high and low energy falls (n=67 675, 51.9%). Ultimately, 49.5% (n=2 79 615) of all patients were admitted to an intensive care unit, of whom a quarter (n=146 191, 25.9%) required invasive mechanical ventilatory support. The overall mortality rate was 5.6% (n=31 524).

Discussion: Traumatic rib fractures are a marker of severe injury as approximately half of patients were patients with polytrauma. Furthermore, patients with rib fractures are a very heterogeneous group with a considerable difference in epidemiology, injury characteristics and in-hospital outcomes. Worse outcomes were predominantly observed among patients with polytrauma and flail chest. Future studies should recognize these differences and treatment should be evaluated accordingly.

Level Of Evidence: II/III.
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http://dx.doi.org/10.1136/tsaco-2020-000441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7292040PMC
June 2020

Epidemiology and outcome of rib fractures: a nationwide study in the Netherlands.

Eur J Trauma Emerg Surg 2020 Jun 6. Epub 2020 Jun 6.

Department of Surgery, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands.

Purpose: Rib fractures following thoracic trauma are frequently encountered injuries and associated with a significant morbidity and mortality. The aim of this study was to provide current data on the epidemiology, in-hospital outcomes and 30-day mortality of rib fractures, and to evaluate these results for different subgroups.

Methods: A nationwide retrospective cohort study was performed with the use of the Dutch Trauma Registry which covers 99% of the acutely admitted Dutch trauma population. All patients aged 18 years and older admitted to the hospital between January 2015 and December 2017 with one or more rib fractures were included. Incidence rates were calculated using demographic data from the Dutch Population Register. Subgroup analyses were performed for flail chest, polytrauma, primary thoracic trauma, and elderly patients.

Results: A total of 14,850 patients were admitted between 2015 and 2017 with one or more rib fractures, which was 6.0% of all trauma patients. Of these, 573 (3.9%) patients had a flail chest, 4438 (29.9%) were polytrauma patients, 9273 (63.4%) were patients with primary thoracic trauma, and 6663 (44.9%) were elderly patients. The incidence rate of patients with rib fractures for the entire cohort was 29 per 100.000 person-years. The overall 30-day mortality was 6.9% (n = 1208) with higher rates observed in flail chest (11.9%), polytrauma (14.8%), and elderly patients (11.7%). The median hospital length of stay was 6 days (IQR, 3-11) and 37.3% were admitted to the intensive care unit (ICU).

Conclusions: Rib fractures are a relevant and frequently occurring problem among the trauma population. Subgroup analyses showed that there is a substantial heterogeneity among patients with rib fractures with considerable differences regarding the epidemiology, in-hospital outcomes, and 30-day mortality.
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http://dx.doi.org/10.1007/s00068-020-01412-2DOI Listing
June 2020

Complications and outcome after rib fracture fixation: A systematic review.

J Trauma Acute Care Surg 2020 08;89(2):411-418

From the Department of Surgery (J.P.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Orthopaedic Surgery (J.P.), Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery, University Medical Center Utrecht (R.B.B., F.H.), Utrecht, The Netherlands; Department of Orthopaedic Surgery (M.H.), Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, Massachusetts; Department of Surgery (M.B.D.J.), University Medical Center Utrecht, Utrecht, The Netherlands; Department of Orthopedic and Trauma Surgery (F.J.P.B.), Cantonal Hospital Lucerne, Lucerne, Switzerland; Department of Surgery (L.P.H.L.), University Medical Center Utrecht, Utrecht; Department of Clinical Epidemiology (R.H.H.G.), Leiden University Medical Center, Leiden; and Department of Surgery (R.M.H.), University Medical Center Utrecht, Utrecht, The Netherlands.

Background: In recent years, there has been a growing interest in operative treatment for multiple rib fractures and flail chest. However, to date, there is no comprehensive study that extensively focused on the incidence of complications associated with rib fracture fixation. Furthermore, there is insufficient knowledge about the short- and long-term outcomes after rib fracture fixation.

Methods: This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The MEDLINE, EMBASE, and Cochrane databases were searched to identify studies reporting on complications and/or outcome of surgical treatment after rib fractures. Complications were subdivided into (1) surgery- and implant-related complications, (2) bone-healing complications, (3) pulmonary complications, and (4) mortality.

Results: Forty-eight studies were included, with information about 1,952 patients who received rib fracture fixation because of flail chest or multiple rib fractures. The overall risk of surgery- and implant-related complications was 10.3%, with wound infection in 2.2% and fracture-related infection in 1.3% of patients. Symptomatic nonunion was a relatively uncommon complication after rib fixation (1.3%). Pulmonary complications were found in 30.9% of patients, and the overall mortality was 2.9%, of which one third appeared to be the result of the thoracic injuries and none directly related to the surgical procedure. The most frequently used questionnaire to assess patient quality of life was the EuroQol-5D (EQ-5D) (n = 4). Four studies reporting on the EQ-5D had a weighted mean EQ-5D index of 0.80 indicating good quality of life after rib fracture fixation.

Conclusion: Surgical fixation can be considered as a safe procedure with a considerably low complication risk and satisfactory long-term outcomes, with surgery- and implant-related complications in approximately 10% of the patients. However, the clinically most relevant complications such as infections occur infrequently, and the number of complications requiring immediate (surgical) treatment is low.

Level Of Evidence: Systematic Review, level III.
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http://dx.doi.org/10.1097/TA.0000000000002716DOI Listing
August 2020

The evolution of trauma care in the Netherlands over 20 years.

Eur J Trauma Emerg Surg 2020 Apr 23;46(2):329-335. Epub 2019 Nov 23.

Department of Surgery, University Medical Centre Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.

Introduction: In 1999 an inclusive trauma system was initiated in the Netherlands and a nationwide trauma registry, including all admitted trauma patients to every hospital, was started. The Dutch trauma system is run by trauma surgeons who treat both the truncal (visceral) and extremity injuries (fractures).

Materials And Methods: In this comprehensive review based on previous published studies, data over the past 20 years from the central region of the Netherlands (Utrecht) was evaluated.

Results: It is demonstrated that the initiation of the trauma systems and the governance by the trauma surgeons led to a region-wide mortality reduction of 50% and a mortality reduction for the most severely injured of 75% in the level 1 trauma centre. Furthermore, major improvements were found in terms of efficiency, demonstrating the quality of the current system and its constructs such as the type of surgeon. Due to the major reduction in mortality over the past few years, the emphasis of trauma care evaluation shifts towards functional outcome of severely injured patients. For the upcoming years, centralisation of severely injured patients should also aim at the balance between skills in primary resuscitation and surgical stabilization versus longitudinal surgical involvement.

Conclusion: Further centralisation to a limited number of level 1 trauma centres in the Netherlands is necessary to consolidate experience and knowledge for the trauma surgeon. The future trauma surgeon, as specialist for injured patients, should be able to provide the vast majority of trauma care in this system. For the remaining part, intramural, regional and national collaboration is essential.
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http://dx.doi.org/10.1007/s00068-019-01273-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7113214PMC
April 2020

[Penetrating neck injury caused by stabbing: a rare but complex problem in the Netherlands].

Ned Tijdschr Geneeskd 2019 08 9;163. Epub 2019 Aug 9.

Universitair Medisch Centrum Utrecht, afd. Heelkunde, Utrecht.

Penetrating neck injuries (PNIs) as a result of stabbing or deliberate self-harm are complex and potentially life-threatening. Nowadays, selective non-operative management of PNI has become common practice. Diagnostic and treatment algorithms originating from high-volume trauma centres in South-Africa and North-America are used in Dutch clinical practice. Three patients that sustained a PNI are discussed. Two patients, aged 61 and 37, only had mild signs on physical examination that justified additional diagnostic investigations. In the first patient, a penetrating oesophageal injury was found and repaired. The latter had a partial Horner syndrome as a result of PNI, no underlying injuries were found. One patient, aged 57, was haemodynamically unstable and therefore received immediate surgical exploration of the neck. A penetrating injury of the jugular vein was discovered and repaired. A summary of literature and guidelines is presented for the benefit of Dutch physicians that may be confronted with these complex injuries.
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August 2019

Ned Tijdschr Geneeskd 2019 08 9;163. Epub 2019 Aug 9.

Universitair Medisch Centrum Utrecht, afd. Heelkunde, Utrecht.

Penetrating neck injuries (PNIs) as a result of stabbing or deliberate self-harm are complex and potentially life-threatening. Nowadays, selective non-operative management of PNI has become common practice. Diagnostic and treatment algorithms originating from high-volume trauma centres in South-Africa and North-America are used in Dutch clinical practice. Three patients that sustained a PNI are discussed. Two patients, aged 61 and 37, only had mild signs on physical examination that justified additional diagnostic investigations. In the first patient, a penetrating oesophageal injury was found and repaired. The latter had a partial Horner syndrome as a result of PNI, no underlying injuries were found. One patient, aged 57, was haemodynamically unstable and therefore received immediate surgical exploration of the neck. A penetrating injury of the jugular vein was discovered and repaired. A summary of literature and guidelines is presented for the benefit of Dutch physicians that may be confronted with these complex injuries.
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August 2019

Development and validation of a novel prediction model to identify patients in need of specialized trauma care during field triage: design and rationale of the GOAT study.

Diagn Progn Res 2019 20;3:12. Epub 2019 Jun 20.

2Department of Traumatology, University Medical Center Utrecht, Utrecht, The Netherlands.

Background: Adequate field triage of trauma patients is crucial to transport patients to the right hospital. Mistriage and subsequent interhospital transfers should be minimized to reduce avoidable mortality, life-long disabilities, and costs. Availability of a prehospital triage tool may help to identify patients in need of specialized trauma care and to determine the optimal transportation destination.

Methods: The GOAT (Gradient Boosted Trauma Triage) study is a prospective, multi-site, cross-sectional diagnostic study. Patients transported by at least five ground Emergency Medical Services to any receiving hospital within the Netherlands are eligible for inclusion. The reference standards for the need of specialized trauma care are an Injury Severity Score ≥ 16 and early critical resource use, which will both be assessed by trauma registrars after the final diagnosis is made. Variable selection will be based on ease of use in practice and clinical expertise. A gradient boosting decision tree algorithm will be used to develop the prediction model. Model accuracy will be assessed in terms of discrimination (c-statistic) and calibration (intercept, slope, and plot) on individual participant's data from each participating cluster (i.e., Emergency Medical Service) through internal-external cross-validation. A reference model will be externally validated on each cluster as well. The resulting model statistics will be investigated, compared, and summarized through an individual participant's data meta-analysis.

Discussion: The GOAT study protocol describes the development of a new prediction model for identifying patients in need of specialized trauma care. The aim is to attain acceptable undertriage rates and to minimize mortality rates and life-long disabilities.
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http://dx.doi.org/10.1186/s41512-019-0058-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6584978PMC
June 2019

Epidural Analgesia for Severe Chest Trauma: An Analysis of Current Practice on the Efficacy and Safety.

Crit Care Res Pract 2019 19;2019:4837591. Epub 2019 Mar 19.

Department of Surgery, University Medical Center Utrecht, Utrecht, Netherlands.

Background: Adequate pain control is essential in the treatment of patients with traumatic rib fractures. Although epidural analgesia is recommended in international guidelines, the use remains debatable and is not undisputed. The aim of this study was to describe the efficacy and safety of epidural analgesia in patients with multiple traumatic rib fractures.

Methods: A retrospective cohort study was performed. Patients with ≥3 rib fractures following blunt chest trauma who received epidural analgesia between January 2015 and January 2018 were included. The main outcome parameters were the success rate of epidural analgesia and the incidence of medication-related side effects and catheter-related complications.

Results: A total of 76 patients were included. Epidural analgesia was successful in a total of 45 patients (59%), including 22 patients without and in 23 patients with an additional analgesic intervention. In 14 patients (18%), epidural analgesia was terminated early without intervention due to insufficient sensory blockade (=4), medication-related side effects (=4), and catheter-related complications (=6). In 17 patients (22%), the epidural catheter was removed after one or multiple additional interventions due to insufficient pain control. Minor epidural-related complications or side effects were encountered in 36 patients (47%). One patient had a major complication (opioid intoxication).

Conclusion: Epidural analgesia was successful in 59% of patients; however, 30% needed additional analgesic interventions. As about half of the patients had epidural-related complications, it remains debatable whether epidural analgesia is a sufficient treatment modality in patients with multiple rib fractures.
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http://dx.doi.org/10.1155/2019/4837591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6444241PMC
March 2019

Injuries related to bicycle accidents: an epidemiological study in The Netherlands.

Eur J Trauma Emerg Surg 2020 Apr 15;46(2):413-418. Epub 2018 Oct 15.

Departement of Orthopaedics, Diakonessenhuis Utrecht/Zeist, Utrecht/Zeist, The Netherlands.

Background: This study aims to analyze the incidence and outcomes of bicycle-related injuries in hospitalized patients in The Netherlands.

Methods: Bicycle accidents resulting in hospitalization in a level-I trauma center in The Netherlands between 2007 and 2017 were retrospectively identified. We subcategorized data of patients involved in a regular bicycle, race bike, off-road bike or e-bike accident. The primary outcomes were mortality rate and incidence of multitrauma. Secondary outcomes were differences between bicycle subcategories. Independent risk factors were identified using multivariable logistic regression. All variables with a p value < 0.20 in univariable analysis were entered in multivariable analysis.

Results: We identified 1986 patients. The mortality rate after emergency room admission was 5.7%, and 41.0% were multitraumas. A higher age, multitrauma and cerebral haemorrhages were independent risk factors for in hospital mortality. Independent risk factors found for multitrauma were a higher age, two-sided trauma, e-bike accidents and cerebral haemorrhage.

Conclusion: Bicycle accidents resulting in hospitalization have a high mortality rate. Furthermore, a high incidence of multitrauma, fractures and cerebral haemorrhages were found. Considering the increasing incidence of bicycle accident victims needing hospital admission, new and more efficient prevention strategies are essential.
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http://dx.doi.org/10.1007/s00068-018-1033-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7113215PMC
April 2020

Feasibility of using head and neck CT imaging to assess skeletal muscle mass in head and neck cancer patients.

Oral Oncol 2016 11 3;62:28-33. Epub 2016 Oct 3.

Department of Otorhinolaryngology - Head and Neck Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; Brain Center Rudolf Magnus, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. Electronic address:

Objectives: Patients with head and neck cancer (HNC) have a higher risk of malnutrition and sarcopenia, which is associated with adverse clinical outcome. As abdominal CT-imaging is often used to detect sarcopenia, such scans are rarely available in HNC patients, possibly explaining why no studies investigate the effect of sarcopenia in this population. We correlated skeletal muscle mass assessed on head and neck CT-scans with abdominal CT-imaging.

Methods: Head and neck, and abdominal CT-scans of trauma (n=51) and HNC-patients (n=52) were retrospectively analyzed. On the head and neck CT-scans, the paravertebral and sternocleidomastoid muscles were delineated. On the abdominal CT-scans, all muscles were delineated. Cross-sectional area (CSA) of the muscles at the level of the C3 vertebra was compared to CSA at the L3 level using linear regression. A multivariate linear regression model was established.

Results: HNC-patients had significantly lower muscle CSA than trauma patients (37.9 vs. 45.1cm, p<0.001, corrected for sex and age). C3 muscle CSA strongly predicted L3 muscle CSA (r=0.785, p<0.001). This correlation was stronger in a multivariate model including sex, age and weight (r=0.891, p<0.001).

Discussion: Assessment of skeletal muscle mass on head and neck CT-scans is feasible and may be an alternative to abdominal CT-imaging. This method allows assessment of sarcopenia using routinely performed scans without additional imaging or additional patient burden. Identifying sarcopenic patients may help in treatment selection, or to select HNC patients for physiotherapeutic or nutritional interventions to improve their outcome.
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http://dx.doi.org/10.1016/j.oraloncology.2016.09.006DOI Listing
November 2016

Introducing the Surgical Therapeutic Index in trauma surgery: an assessment tool for the benefits and risks of operative fracture treatment strategies.

J Shoulder Elbow Surg 2016 Dec 8;25(12):2005-2010. Epub 2016 Aug 8.

Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands. Electronic address:

Background: The Surgical Therapeutic Index (STI) has been described as an indicator of the benefits and risks of surgical treatment. The index is calculated by dividing the cure rate of an operative treatment by the complication rate. This study introduces the STI in trauma surgery by comparing the indices for surgical plate fixation (PF) and intramedullary fixation (IMF) of displaced midshaft clavicular fractures.

Methods: In a previously reported, randomized controlled fashion, 120 patients were assigned to PF or IMF. Cure was defined by a Disabilities of the Arm, Shoulder and Hand score of 8 or less. Complications were noted as present or not present for each follow-up assessment, and a panel of experts provided weights to the severity of complications. STIs were reported along with their 95% confidence intervals. The higher a procedure's STI, the higher the benefit/risk balance of that procedure.

Results: The nonweighted STI after 6 weeks was significantly higher in the PF group. During further follow- up, the differences leveled out and became nonsignificant. When weighting the STI for severity, the indices decrease but are significantly in favor of the PF group at 6 weeks and 6 months after surgery. At 1 year postoperatively, differences are not significant.

Conclusion: The STI may be a reliable tool to assess the benefits and risks of operative fracture treatment. Further studies with consistent results of this new scoring system are needed before conclusions can be generalized. When determining the indices of PF and IMF, a significant difference in favor of PF was observed during the early phase of recovery.
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http://dx.doi.org/10.1016/j.jse.2016.05.009DOI Listing
December 2016

Observation Versus Embolization in Patients with Blunt Splenic Injury After Trauma: A Propensity Score Analysis.

World J Surg 2016 May;40(5):1264-71

Trauma Unit Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.

Background: Non-operative management (NOM) is the standard of care in hemodynamically stable patients with blunt splenic injury after trauma. Splenic artery embolization (SAE) is reported to increase observation success rate. Studies demonstrating improved splenic salvage rates with SAE primarily compared SAE with historical controls. The aim of this study was to investigate whether SAE improves success rate compared to observation alone in contemporaneous patients with blunt splenic injury.

Methods: We included adult patients with blunt splenic injury admitted to five Level 1 Trauma Centers between January 2009 and December 2012 and selected for NOM. Successful treatment was defined as splenic salvage and no splenic re-intervention. We calculated propensity scores, expressing the probability of undergoing SAE, using multivariable logistic regression and created five strata based on the quintiles of the propensity score distribution. A weighted relative risk (RR) was calculated across strata to express the chances of success with SAE.

Results: Two hundred and six patients were included in the study. Treatment was successful in 180 patients: 134/146 (92 %) patients treated with observation and 48/57 (84 %) patients treated with SAE. The weighted RR for success with SAE was 1.17 (0.94-1.45); for complications, the weighted RR was 0.71 (0.41-1.22). The mean number of transfused blood products was 4.4 (SD 9.9) in the observation group versus 9.1 (SD 17.2) in the SAE group.

Conclusions: After correction for confounders with propensity score stratification technique, there was no significant difference between embolization and observation alone with regard to successful treatment in patients with blunt splenic injury after trauma.
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http://dx.doi.org/10.1007/s00268-015-3387-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4820474PMC
May 2016

[More complications after a fall from height in patients with a mental disorder].

Authors:
Loek P H Leenen

Ned Tijdschr Geneeskd 2015 ;159:A9481

UMC Utrecht, afd. Traumatologie, Utrecht.

In this issue of the Nederlands Tijdschrift voor Geneeskunde researchers from the Amsterdam Medical Centre describe the coincidence of psychiatric comorbidities and complications in patients suffering from a fall from height. Apart from typical somatic issues related to these diseases, such as substance abuse and specific medication, the attitude of healthcare workers toward this category of patients is discussed and critically appraised.
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May 2016

[A new protocol, is the spine still safe?].

Ned Tijdschr Geneeskd 2015 ;159:A8902

Universitair Medisch Centrum Utrecht, Utrecht.

The latest version of the Dutch National Protocol Ambulance Care (Landelijk Protocol Ambulancezorg LPA8), introduced on 1 January 2015, contains too few guarantees of the safety of trauma patients in whom spinal immobilisation has to be performed. A number of strict indications have been removed and too much freedom is also permitted with respect to implementation. Although the previous standard method using a spinal board, collar and blocks did have disadvantages, the new operating method has been insufficiently substantiated and, in addition, is not well matched to the protocols of Accident and Emergency departments. It is vital that the agencies involved collaborate to reach a joint solution.
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August 2015

Variation in treatment of blunt splenic injury in Dutch academic trauma centers.

J Surg Res 2015 Mar 4;194(1):233-8. Epub 2014 Sep 4.

Trauma Unit, Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands. Electronic address:

Background: The incidence of splenectomy after trauma is institutionally dependent and varies from 18% to as much as 40%. This is important because variation in management influences splenic salvage. The aim of this study was to investigate whether differences exist between Dutch level 1 trauma centers with respect to the treatment of these injuries, and if variation in treatment was related to splenic salvage, spleen-related reinterventions, and mortality.

Methods: Consecutive adult patients who were admitted between January 2009 and December 2012 to five academic level 1 trauma centers were identified. Multinomial logistic regression was used to measure the influence of hospital on treatment strategy, controlling for hemodynamic instability on admission, high grade (American Association for the Surgery of Trauma 3-5) splenic injury, and injury severity score. Binary logistic regression was used to quantify differences among hospitals in splenic salvage rate.

Results: A total of 253 patients were included: 149 (59%) were observed, 57 (23%) were treated with splenic artery embolization and 47 (19%) were operated. The observation rate was comparable in all hospitals. Splenic artery embolization and surgery rates varied from 9%-32% and 8%-28%, respectively. After adjustment, the odds of operative management were significantly higher in one hospital compared with the reference hospital (adjusted odds ratio 4.98 [1.02-24.44]). The odds of splenic salvage were significantly lower in another hospital compared with the reference hospital (adjusted odds ratio 0.20 [0.03-1.32]).

Conclusions: Although observation rates were comparable among the academic trauma centers, embolization and surgery rates varied. A nearly 5-fold increase in the odds of operative management was observed in one hospital, and another hospital had significantly lower odds of splenic salvage. The development of a national guideline is recommended to minimalize splenectomy after trauma.
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http://dx.doi.org/10.1016/j.jss.2014.08.063DOI Listing
March 2015

Intubation after noninvasive ventilation failure in chronic obstructive pulmonary disease: associated factors at emergency department presentation.

Eur J Emerg Med 2015 Feb;22(1):49-54

aDepartment of Internal Medicine, Academic Medical Center, Amsterdam bDepartment of Pulmonology, Diakonessenhuis, Utrecht Departments of cEmergency Medicine dSurgery, University Medical Centre, Utrecht, The Netherlands.

Objective: Noninvasive ventilation (NIV) is a common practice in acute hypercapnic respiratory failure (AHRF) because of exacerbation of chronic obstructive pulmonary disease (COPD). However, a recent study has shown that patients who require invasive mechanical ventilation (IMV) after failure of NIV experience high mortality rates (up to 30%). Therefore, the aim of this study is to determine the parameters, specifically for emergency department (ED) presentation, associated with the transition from NIV to IMV because of NIV failure.

Patients And Methods: This is a 4-year retrospective cohort study in the EDs of two Dutch hospitals. International Classification of Disease codes were used to identify 139 COPD patients treated with NIV. Those with AHRF (pH limits: 7.25-7.35), a full resuscitation order, and those without a pneumonia were selected for the study (n=40 with 50 NIV episodes). Parameters in patients treated successfully with NIV were compared with those in patients requiring transition to IMV due to NIV failure. Univariable regression analysis was used and, if P-value less than 0.20, analyses were entered into a multivariable logistic regression analysis model.

Results: NIV was successful in 33 (66%) patients, 10 (20%) required transition to IMV, and seven (14%) died. Age over 65 years and a Glasgow Coma Score less than 15 were associated significantly with the transition from NIV to IMV in multivariable analysis (P<0.05).

Conclusion: Older age and a low Glasgow Coma Score at ED presentation are factors associated with the transition from NIV to IMV in COPD patients with AHRF.
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http://dx.doi.org/10.1097/MEJ.0000000000000141DOI Listing
February 2015

Segmental tibial fractures: an infrequent but demanding injury.

Clin Orthop Relat Res 2013 Sep;471(9):2790-6

Department of Surgery, University Medical Center Utrecht, PO Box 85500, Suite G04.228, 3508 GA, Utrecht, The Netherlands.

Background: Segmental tibial fractures are considered to be a special injury type associated with high complication rates. However, it is unclear whether healing of these fractures truly differs from that of nonsegmental fractures.

Questions/purposes: We therefore asked (1) does the time to union in segmental tibial fractures differ from that of nonsegmental fractures; and (2) does the complication rate of segmental fractures differ from that of nonsegmental fractures?

Methods: We retrospectively studied 30 patients with segmental tibial fractures treated at a Level I trauma center from January 2000 to December 2008 and compared healing and complications with a matched control group of 30 nonsegmental tibial fractures. In followup we determined time to union, delayed and nonunion, and overall complication rates. Patients were followed at least until union was attained. The minimum followup was 5 months (median, 15 months; range, 5-54 months).

Results: Median time to union was 34 weeks (range, 12-122 weeks). Segmental fractures took longer to heal than nonsegmental fractures (median, 34 weeks; range, 12-122 weeks and median, 24 weeks; range, 11-39 weeks, respectively). The overall rate of complications was higher in segmental fractures as was the necessity for reoperation to attain healing.

Conclusions: Healing of segmental tibial fractures is characterized by substantially more complications and longer healing times than nonsegmental fractures and should be considered as a special type of injury. We believe these should be treated in specialized trauma centers.
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http://dx.doi.org/10.1007/s11999-012-2739-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734401PMC
September 2013

Video registration of trauma team performance in the emergency department: the results of a 2-year analysis in a Level 1 trauma center.

J Trauma 2009 Dec;67(6):1412-20

Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.

Background: Trauma teams responsible for the first response to patients with multiple injuries upon arrival in a hospital consist of medical specialists or resident physicians. We hypothesized that 24-hour video registration in the trauma room would allow for precise evaluation of team functioning and deviations from Advanced Trauma Life Support (ATLS) protocols.

Methods: We analyzed all video registrations of trauma patients who visited the emergency room of a Level I trauma center in the Netherlands between September 1, 2000, and September 1, 2002. Analysis was performed with a score list based on ATLS protocols.

Results: From a total of 1,256 trauma room presentations, we found a total of 387 video registrations suitable for analysis. The majority of patients had an injury severity score lower than 17 (264 patients), whereas 123 patients were classified as multiple injuries (injury severity score >or=17). Errors in team organization (omission of prehospital report, no evident leadership, unorganized resuscitation, not working according to protocol, and no continued supervision of the patient) lead to significantly more deviations in the treatment than when team organization was uncomplicated.

Conclusions: Video registration of diagnostic and therapeutic procedures by a multidisciplinary trauma team facilitates an accurate analysis of possible deviations from protocol. In addition to identifying technical errors, the role of the team leader can clearly be analyzed and related to team actions. Registration strongly depends on availability of video tapes, timely started registration, and hardware functioning. The results from this study were used to develop a training program for trauma teams in our hospital that specifically focuses on the team leader's functioning.
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http://dx.doi.org/10.1097/TA.0b013e31818d0e43DOI Listing
December 2009

Pneumocephalus Following Severe Head Trauma.

Eur J Trauma Emerg Surg 2009 Apr 30;35(2):186. Epub 2008 Sep 30.

Department of Surgery, G04-228, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands.

It is important to be alert to the possibility of pneumocephalus in patients with head injury. Pneumocephalus is a potentially lethal complication in patients with craniofacial fractures following severe head trauma. A patient presented with intracranial air after he fell down from a height of 4 m. The patient recovered without any neurological deficits after conservative treatment. A time sequence of cerebral CT scans shows how the pneumocephalus developed and finally resolved without surgical intervention. The etiology, diagnosis, treatment and possible complications of this injury are discussed briefly.
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http://dx.doi.org/10.1007/s00068-008-8027-7DOI Listing
April 2009

Determinants of long-term functional consequences after major trauma.

J Trauma 2007 Apr;62(4):919-27

Department of Rehabilitation, University Medical Center, The Netherlands.

Objective: The purpose of this study was to describe the long-term functional consequences from major trauma and to quantify the effect of sociodemographic, injury-related, and physical determinants of its outcome.

Methods: A prospective cohort study was performed at the University Medical Center Utrecht (Level I trauma center) in the Netherlands during 1999 and 2000. All severely (injury severity score [ISS] >or=16) injured adult (age >or=16) trauma survivors (n = 359) were selected for follow-up. Between 12 and 18 months after trauma, outcome was assessed by means of Glasgow Outcome Scale (GOS), EuroQol (EQ-5D), and cognitive complaints.

Results: Follow-up assessments (overall response rate 93%) were obtained of 335 patients (249 men, 86 women) with a mean age of 38 years (SD = 17) and a mean ISS of 25 (SD = 10.6). The mean visual analog scale score on the EuroQol (EQvas) was 73.5 (SD = 17.8) and the mean utility score (EQus) was 69.1 (SD = 29.9), both below the norm. Patients reported limitations of mobility (48%); self-care (18%); daily activities (55%); pain and discomfort (63%); anxiety or depression (28%); and cognitive complaints (65%). In multivariate analyses, injury localization (spinal cord injury, lower extremity injury, or brain injury) was significantly associated with EQvas, EQus, and other outcome measures. Educational level was significantly associated with EQvas, anxiety/depression, and cognitive complaints. Comorbidity was significantly associated with EQvas, EQus, all dimensions of the EQ-5D (except anxiety/depression), and cognitive complaints.

Conclusion: In addition to the injury localization, educational level and comorbidity were identified as important independent predictors of long-term functional consequences after major trauma. These determinants need further attention in outcome research and clinical practice.
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http://dx.doi.org/10.1097/01.ta.0000224124.47646.62DOI Listing
April 2007

Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury.

Crit Care Med 2005 Oct;33(10):2207-13

Division of Perioperative Care and Emergency Medicine, Department of Neurology, University Medical Center, Utrecht, The Netherlands.

Objective: : Intracranial hypertension after severe head injury is associated with case fatality, but there is no sound evidence that monitoring of intracranial pressure (ICP) and targeted management of cerebral perfusion pressure (CPP) improve outcome, despite widespread recommendation by experts in the field. The purpose was to determine the effect of ICP/CPP-targeted intensive care on functional outcome and therapy intensity levels after severe head injury.

Design: : Retrospective cohort study with prospective assessment of outcome.

Setting: : Two level I trauma centers in The Netherlands from 1996 to 2001.

Patients: : Three hundred thirty-three patients who had survived and remained comatose for >24 hrs, from a total of 685 consecutive severely head-injured adults.

Interventions: : In center A (supportive intensive care), mean arterial pressure was maintained at approximately 90 mm Hg, and therapeutic interventions were based on clinical observations and computed tomography findings. In center B (ICP/CPP-targeted intensive care), management was aimed at maintaining ICP <20 mm Hg and CPP >70 mm Hg. Allocation to either trauma center was solely based on the site of the accident.

Measurements And Main Results: : We measured extended Glasgow Outcome Scale after >/=12 months. Patient characteristics were well balanced between the centers. ICP monitoring was used in zero of 122 (0%) and 142 of 211 (67%) patients in centers A and B, respectively. In-hospital mortality rate was 41 (34%) vs. 69 (33%; p = .87). The odds ratio for a more favorable functional outcome following ICP/CPP-targeted therapy was 0.95 (95% confidence interval, 0.62-1.44). This result remained after adjustment for potential confounders. Sedatives, vasopressors, mannitol, and barbiturates were much more frequently used in center B (all p < .01). The median number of days on ventilator support in survivors was 5 (25th-75th percentile, 2-9) in center A vs. 12 (7-19) in center B (p < .001).

Conclusions: : ICP/CPP-targeted intensive care results in prolonged mechanical ventilation and increased levels of therapy intensity, without evidence for improved outcome in patients who survive beyond 24 hrs following severe head injury.
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http://dx.doi.org/10.1097/01.ccm.0000181300.99078.b5DOI Listing
October 2005

The registration of complications in surgery: a learning curve.

World J Surg 2005 Mar;29(3):402-9

Department of Surgery, St. Elisabeth Hospital, P.O. Box 90052, 5600 PD, Tilburg, The Netherlands.

Registration of complications in surgery is an important method used for quality improvement. Unfortunately many different definitions and classification systems have been used, which influences the interpretation and the outcome of complication registration. Since 1986 complications have been registered on a daily basis in our surgical department. We focus in this article on the influence of changes in interpretation of the definition and registration methods used on the incidence of registered complications. Between 1986 and 1993 complications registered were strictly related to surgical procedures. In the second period, between 1993 and 2001, the interpretation of the definition changed and all adverse events were registered in a patient-centred way, not only related to the surgical procedure. The definition used in both periods did not change. In 1993 we started with the implementation of a fully automated registration system in our surgical department. In the first period 1699 (7%) complications in 24,201 surgical procedures were registered and in the second period 8335 (27%) complications were registered in 31,161 surgical procedures. A dramatic increase in the total number of registered complications was seen with the implementation of a fully automated registration system and a patient-centred way of registering complications. In the context of the evolving discussion of quality of care, a uniform definition and registration system has to be used to assure reliable outcome data in surgery and to form a basis for comparison.
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http://dx.doi.org/10.1007/s00268-004-7358-8DOI Listing
March 2005

Prevalence and determinants of disabilities and return to work after major trauma.

J Trauma 2005 Jan;58(1):126-35

Department of Surgery, St. Elisabeth Hospital, Tilburg, The Netherlands.

Objective: The purpose of this study was to assess the prevalence and determinants of disabilities and return to work after severe injury in a Dutch, Level I trauma center.

Methods: We prospectively included 295 patients with an Injury Severity Score > or = 16 treated between January 1996 and January 1999. All survivors received a mailed questionnaire in 2000, at least 1 year after their initial hospital admission. Health status was measured by the EuroQol-5D instrument, and the Glasgow Outcome Scale. Additional questions were asked about cognitive functioning and return-to-work rates. Regression analyses was conducted to explore the associations between these functional outcome measures and patient characteristics.

Results: Of the 295 patients included, 99 (34%) died in hospital or during follow-up. From the 196 survivors, a response was obtained from 166 (85%). Of the survivors, 33% had to change their work or daily activity as a result of their injuries. Of the 127 patients of working age (18-65 years), 33 (26%) were unable to work and depended on social security. Problems with mobility, self-care, daily activities, pain/discomfort, anxiety/depression, and cognitive ability were found in 34%, 15%, 51%, 58%, 37%, and 57%, respectively. The EuroQol-5D summary score (0.76) was far below that of the general population norms. The number of body areas affected, injury severity (Injury Severity Score > or = 25), and gender (female) were significant independent predictors of worse long-term functional outcome.

Conclusion: Severe trauma has a substantial impact on long-term functioning. Empiric quantitative data, as presented in this study, enable us to estimate the burden of injury and to evaluate the quality of trauma care programs.
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http://dx.doi.org/10.1097/01.ta.0000112342.40296.1fDOI Listing
January 2005

Pre-hospital trauma care: a proposal for more efficient evaluation.

Injury 2004 Aug;35(8):725-33

Department of Surgery, St. Elisabeth Hospital Tilburg, Tilburg, The Netherlands.

Although mortality is an important outcome parameter for pre-hospital trauma care, it is influenced by many factors other than pre-hospital trauma care alone. We therefore studied an alternative method to evaluate pre-hospital trauma care by calculating the change in probability of survival (Ps) according to the TRISS methodology, before and directly after the pre-hospital trauma care. Correlations between patient characteristics and a change in Ps were assessed. Further, required sample sizes were calculated for an 80% power to detect a hypothetical 3% reduction in mortality and the corresponding change in Ps. In 140 of 191 patients with an Injury Severity Score > or =16, the Ps did not change. In 36, the Ps increased and in 15 patients, the Ps decreased. Between these three groups, significant differences were found in Revised Trauma Score and age, but no clear differences in Injury Severity Score or mortality. A 3% difference in mortality would require 6800 patients, in contrast to 3500 when the change in Ps was the primary outcome parameter. A change in Ps is a promising outcome parameter for a more efficient evaluation of pre-hospital trauma care. A good collaboration is, however, required between ambulance services and the trauma center for reliable registration.
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http://dx.doi.org/10.1016/j.injury.2003.09.006DOI Listing
August 2004

Transient adrenocortical insufficiency following traumatic bilateral adrenal hemorrhage.

J Trauma 2004 May;56(5):1135-7

Surgical Intensive Care Unit, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands.

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http://dx.doi.org/10.1097/01.ta.0000044626.18085.0cDOI Listing
May 2004

Consequences of delayed diagnoses in trauma patients: a prospective study.

J Am Coll Surg 2003 Oct;197(4):596-602

St Elisabeth Hospital Department of Surgery, Tilburg, The Netherlands.

Background: The approach to trauma care has improved in recent decades but delayed diagnoses still occur. This study aimed to analyze the prevalence and consequences of delayed diagnoses in a single European trauma center. The effect of a systematic reexamination of the patient (tertiary survey) and reevaluation of x-rays and CT scans was evaluated.

Study Design: We prospectively registered complications among all trauma patients admitted to our hospital from January 1, 1996, to January 1, 2000. All relevant trauma and patient-related data were added by the physician to a hospital-wide trauma database with client server architecture. Complications including delay in diagnosis were subsequently added to this database. Admitted trauma patients underwent a tertiary survey and all x-rays and CT scans were reevaluated within 24 hours after admission.

Results: A total of 3,879 patients were studied and 1,016 complications were registered. Of all complications 55 concerned delayed diagnoses detected in 49 patients (1.3%). In 28 of these patients (57.1%) the tertiary survey (20 of 49; 40.8%) and reevaluation of x-rays and CT scans (8 of 49; 16.3%) resulted in detection of delayed diagnoses within 24 hours. Detection of the remaining 21 delayed diagnoses occurred after more than 24 hours. Delayed diagnoses resulted in delayed treatment in 27 of the 49 patients (55.1%) and surgery was necessary in 12 patients (24.5%). None of the delayed diagnoses resulted in death.

Conclusions: A prospective trauma and complication registration enables evaluation of the delays in diagnosis. In our study population more than half of the delayed diagnoses could be detected by a tertiary survey and reevaluation of x-rays and CT scans. Attempts to decrease the number of delayed diagnoses should prevent delays in treatment and improve the quality of trauma care.
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http://dx.doi.org/10.1016/S1072-7515(03)00601-XDOI Listing
October 2003