Heart Rate Variability in Surgical Patients Experiencing Live Bedside Music; An Explorative Study.

It's known that surgery elicits a stress response involving the autonomic nervous system (ANS) which is important in general recovery but can also have detrimental effects in older patients. Music seems to positively effect postoperative recovery, although the mechanism requires further unravelling. Our objective was to explore the response of the ANS to live bedside music in older surgical patients, by using heart rate variability (HRV) as a proxy. This explorative prospective non-randomized controlled cohort study included 101 older non-cardiac surgical patients, with a median age of 70 (range 60-88 years). HRV was measured in a cohort receiving live bedside music provided by professional musicians and in a control group that did not receive music. HRV was measured pre-intervention, during the intervention, 30 min after the intervention, and again after three hours. Mixed linear modelling was used to assess the effect of the intervention compared to the control group over time. A significant change in both the low and high frequency bands (p = 0.041) and (p = 0.041) respectively, was found over time in the music group compared to the control group indicating relaxation and increased parasympathetic activity in the music group. Other measures revealed a trend but no significant effect was shown. These results provide a first glance and contribute to a better understanding of the effect of music on the recovery of older surgical patients.

Health care professionals' perceptions of unprofessional behaviour in the clinical workplace.

BACKGROUND: Unprofessional behaviour undermines organizational trust and negatively affects patient safety, the clinical learning environment, and clinician well-being. Improving professionalism in healthcare organizations requires insight into the frequency, types, sources, and targets of unprofessional behaviour in order to refine organizational programs and strategies to prevent and address unprofessional behaviours. OBJECTIVE: To investigate the types and frequency of perceived unprofessional behaviours among health care professionals and to identify the sources and targets of these behaviours. METHODS: Data was collected from 2017-2019 based on a convenience sample survey administered to all participants at the start of a mandatory professionalism course for health care professionals including attending physicians, residents and advanced practice providers (APPs) working at one academic hospital in the United States. RESULTS: Out of the 388 participants in this study, 63% experienced unprofessional behaviour at least once a month, including failing to respond to calls/pages/requests (44.3%), exclusion from decision-making (43.0%) and blaming behaviour (39.9%). Other monthly experienced subtypes ranged from 31.7% for dismissive behaviour to 4.6% for sexual harassment. Residents were more than twice as likely (OR 2.25, p<0.001)) the targets of unprofessional behaviour compared to attending physicians. Female respondents experienced more discriminating behaviours (OR 2.52, p<0.01). Nurses were identified as the most common source of unprofessional behaviours (28.1%), followed by residents from other departments (21%). CONCLUSIONS: Unprofessional behaviour was experienced frequently by all groups, mostly inflicted on these groups by those outside of the own discipline or department. Residents were most frequently identified to be the target and nurses the source of the behaviours. This study highlights that unprofessional behaviour is varied, both regarding types of behaviours as well as targets and sources of such behaviours. This data is instrumental in developing training and remediation initiatives attuned to specific professional roles and specific types of professionalism lapses.

The effect of age on resilience of health-related quality of life among polytrauma patients: a cross-sectional multicenter study.

PURPOSE: The aim of this study was to determine the impact of age on patient-reported health-related quality of life (HRQoL) and the capacity to show resilience-i.e., the ability to adapt to stressful adverse events-after sustaining a polytrauma. METHODS: A cross-sectional multicenter cohort was conducted between 2013 and 2016 that included surviving polytrauma patients (ISS ≥ 16). HRQoL was obtained by the Short Musculoskeletal Function assessment and EuroQol (SMFA and EQ-5D-5L). The effect of age on HRQoL was tested with linear regression analysis. Next, the individual scores were compared with age- and sex-matched normative data to determine whether they showed resilience. Multivariate binary logistic regression was used to assess the effect of age on reaching the normative threshold of the surveys, correcting for several confounders. RESULTS: A total of 363 patients responded (57%). Overall, patients had a mean EQ-5D-5L score of 0.73. With higher age, scores on the SMFA subscales "upper extremity dysfunction," "lower extremity dysfunction" and "daily activities" significantly dropped. Only 42% of patients were classified as being resilient, based on the EQ-5D-5L score. Patients aged 60-69 showed the highest resilience (56%), and those aged 80 + showed the lowest resilience (0%). CONCLUSION: Sustaining a polytrauma leads to a serious decline in HRQoL. Aging is associated with a decline in the physical components of HRQoL. No clear relationship with age was seen on the non-physical components of quality of life. Octogenarians, and to a lesser extent septuagenarians and tricenarians, showed to be very vulnerable groups, with low rates of resilience after surviving a polytrauma.

Electronic health record implementation and healthcare workers' work characteristics and autonomous motivation-a before-and-after study.

BACKGROUND: Technological innovation in healthcare is often assumed to contribute to the quality of care. However, the question how technology implementation impacts healthcare workers has received little empirical attention. This study investigates the consequences of Electronic Health Record (EHR) implementation for healthcare workers' autonomous work motivation. These effects are further hypothesized to be mediated by changes in perceived work characteristics (job autonomy and interdependence). Additionally, a moderating effect of profession on the relationship between EHR implementation and work characteristics is explored. METHODS: A quantitative uncontrolled before-and-after study was performed among employees from a large university medical centre in the Netherlands. Data were analysed following the component approach for testing a first stage moderated mediation model, using Generalized Estimating Equations (GEE). RESULTS: A total of 456 healthcare workers (75 physicians, 154 nurses, 145 allied healthcare professionals, and 82 administrative workers) finished both the baseline and the follow-up survey. After EHR implementation, perceived job autonomy decreased, whereas interdependence increased. In line with our hypothesis, job autonomy was positively associated with autonomous motivation. In contrast to our expectations, interdependence also showed a positive association with autonomous motivation. Autonomous motivation was stable over the course of EHR implementation. This study did not provide support for a moderating effect of profession: no differences were observed between the various professions regarding the changes in their experienced job autonomy and interdependence after EHR implementation. CONCLUSIONS: Our study showed that healthcare professionals' perceptions of their work characteristics, but not their autonomous motivation, were changed after EHR implementation, and that these experiences were relatively similar for physicians, nurses, and allied healthcare professionals. The stability of healthcare workers' autonomous motivation may be explained by the opposite effects of decreased job autonomy and increased interdependence, and by the EHR being in line with healthcare workers' values. The changes in job autonomy and interdependence may have consequences beyond motivation, for example by affecting clinical decision-making, proactive behaviour, and the quality of teamwork. These potential consequences of EHR implementation warrant further research.

The effects of pelvic ring injuries on quality of life, physical, and mental health: results of a 2-year prospective cohort study.

PURPOSE: Pelvic ring injuries are known to affect the patients' daily life in terms of physical functioning and quality of life (QoL). Still, prospective studies on the patient's perception over the first 2 years of rehabilitation are lacking. Therefore, patients cannot be properly informed about whether or when they will return to their pre-existing level of physical functioning and QoL. METHODS: A prospective longitudinal cohort study was performed over a 4-year period including all consecutive patients above 18 years who sustained a pelvic ring injury in a level 1 trauma center. Validated patient-reported outcome measures (PROMs) were used to assess physical functioning (SMFA) and QoL (EQ-5D) at baseline (recalled pre-injury score), 6 weeks, 3 months, 6 months, 1 year and 2 years after the injury. It was assessed whether patients had fully recovered by comparing follow-up scores to baseline PROMs. Binary logistic regression analysis was used to identify independent predictors for patients who did not fully recover. Most experienced difficulties at 3 months and 1 year were identified by analyzing the highest reported scores on individual items of the SMFA. RESULTS: A total of 297 patients with a pelvic ring injury were identified of which 189 were eligible for follow-up and 154 (82%) responded. Median SMFA function score at 3 months, 1 and 2 years was 70, 78 and 88, respectively, compared to 96 out of 100 before the injury. Median SMFA bother score was 67, 79 and 88, respectively. Median EQ-5D score at 3 months, 1 and 2 years was 0.61, 0.81 and 0.85, respectively, compared to 1 (maximum achievable) before the injury. After 1 and 2 years of follow-up, 61% and 75% of the patients fully "recovered" in physical functioning and 52% and 71% fully recovered in terms of QoL. Female gender and high-energy trauma were independent predictors for not fully recovering after 1 year. After 3 months of follow-up, 54% of patients reported severe difficulties with recreational activities, whereas after 1 year, most experienced difficulties (31% of patients) concerned heavy house or yard work. Moreover, after 3 months and 1 year, 44% and 27% of patients reported feeling physically disabled. CONCLUSION: Pelvic ring injuries have a large impact on the patients' daily life in the first 2 years of rehabilitation. Directly after the injury, physical functioning and QoL decrease strongly but then gradually improve over a 2-year period with about 75% of patients fully recovering. Female gender and high-energy trauma are shown to be independent predictors for not fully recovering. After 3 months, patients experience difficulties with both the physical and mental effects of the injury which continue to be present after 1 year.

Health care professionals' motivation, their behaviors, and the quality of hospital care: A mixed-methods systematic review.

BACKGROUND: Health care professionals' work motivation is assumed to be crucial for the quality of hospital care, but it is unclear which type of motivation ought to be stimulated to improve quality. Motivation and similar concepts are aligned along a motivational continuum that ranges from (intrinsic) autonomous motivation to (extrinsic) controlled motivation to provide a framework for this mixed-methods systematic review. PURPOSE: This mixed-methods systematic review aims to link various types of health care professionals' motivation directly and through their work-related behaviors to quality of care. METHODS: Six databases were searched from January 1990 to August 2016. Qualitative and quantitative studies were included if they reported on work motivation in relationship to work behavior and/or quality, and study participants were health care professionals working in hospitals in high-income countries. Study bias was evaluated using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields. The review protocol was registered in the PROSPERO database (CRD42016043284). RESULTS: A total of 84 out of 6,525 unique records met the inclusion criteria. Results show that health care professionals' autonomous motivation improves their quality perceptions and work-related behaviors. Controlled motivation inhibits voicing behavior, but when balanced with autonomous motivation, it stimulates core task and proactive behavior. Proactivity is associated with increased quality of care perceptions. PRACTICE IMPLICATIONS: To improve quality of care, policy makers and managers need to support health care professionals' autonomous motivation and recognize and facilitate proactivity as an essential part of health care professionals' jobs. Incentive-based quality improvements need to be complemented with aspects that stimulate autonomous motivation.

Are Sarcopenia and Myosteatosis in Elderly Patients with Pelvic Ring Injury Related to Mortality, Physical Functioning and Quality of Life?

The purpose of this study was to evaluate the prevalence of sarcopenia and/or myosteatosis in elderly patients with pelvic ring injuries and their influence on mortality, patient-perceived physical functioning and quality of life (QoL). A multicenter retrospective cohort study was conducted including elderly patients aged ≥ 65 treated for a pelvic ring injury. Cross-sectional computed tomography (CT) muscle measurements were obtained to determine the presence of sarcopenia and/or myosteatosis. Kaplan-Meier analysis was used for survival analysis, and Cox proportional hazards regression analysis was used to determine risk factors for mortality. Patient-reported outcome measures for physical functioning (SMFA) and QoL (EQ-5D) were used. Multivariable linear regression analyses were used to determine the effect of sarcopenia and myosteatosis on patient-perceived physical functioning and QoL. Data to determine sarcopenia and myosteatosis were available for 199 patients, with a mean follow-up of 2.4 ± 2.2 years: 66 patients (33%) were diagnosed with sarcopenia and 65 (32%) with myosteatosis, while 30 of them (15%) had both. Mortality rates in patients at 1 and 3 years without sarcopenia and myosteatosis were 13% and 21%, compared to 11% and 36% in patients with sarcopenia, 17% and 31% in patients with myosteatosis and 27% and 43% in patients with both. Higher age at the time of injury and a higher Charlson Comorbidity Index (CCI) were independent risk factors for mortality. Patient-reported mental and emotional problems were significantly increased in patients with sarcopenia.

Compromised intestinal integrity in older adults during daily activities: a pilot study.

BACKGROUND: Malnutrition is a common and significant problem in older adults. Insight into factors underlying malnutrition is needed to develop strategies that can improve the nutritional status. Compromised intestinal integrity caused by gut wall hypoperfusion due to atherosclerosis of the mesenteric arteries in the aging gastrointestinal tract may adversely affect nutrient uptake. The presence of compromised intestinal integrity in older adults is not known. The aim of this study is to provide a proof-of-concept that intestinal integrity is compromised in older adults during daily activities. METHODS: Adults aged ≥75 years living independently without previous gastrointestinal disease or abdominal surgery were asked to complete a standardized walking test and to consume a standardized meal directly afterwards to challenge the mesenteric blood flow. Intestinal fatty acid-binding protein (I-FABP) was measured as a plasma marker of intestinal integrity, in blood samples collected before (baseline) and after the walking test, directly after the meal, and every 15 min thereafter to 75 min postprandially. RESULTS: Thirty-four participants (median age 81 years; 56% female) were included. Of the participants, 18% were malnourished (PG-SGA score ≥ 4), and 32% were at risk of malnutrition (PG-SGA score, 2 or 3). An I-FABP increase of ≥50% from baseline was considered a meaningful loss of intestinal integrity and was observed in 12 participants (35%; 8 females; median age 80 years). No significant differences were observed in either baseline characteristics, walking test scores, or calorie/macronutrient intake between the groups with and without a ≥ 50% I-FABP peak. CONCLUSION: This study is first to indicate that intestinal integrity is compromised during daily activities in a considerable part of older adults living independently.

Does 3D-Assisted Operative Treatment of Pelvic Ring Injuries Improve Patient Outcome?-A Systematic Review of the Literature.

Background: There has been an exponential growth in the use of advanced technologies for three-dimensional (3D) virtual pre- and intra-operative planning of pelvic ring injury surgery but potential benefits remain unclear. The purpose of this study was to evaluate differences in intra- and post-operative results between 3D and conventional (2D) surgery. Methods: A systematic review was performed including published studies between 1 January 2010 and 22 May 2020 on all available 3D techniques in pelvic ring injury surgery. Studies were assessed for their methodological quality according to the Modified McMaster Critical Review form. Differences in operation time, blood loss, fluoroscopy time, screw malposition rate, fracture reduction and functional outcome between 3D-assisted and conventional (2D) pelvic injury treatment were evaluated and a best-evidence synthesis was performed. Results: Eighteen studies fulfilled the inclusion criteria, evaluating a total of 988 patients. Overall quality was moderate. Regarding intra-operative results of 3D-assisted versus conventional surgery: The weighted mean operation time per screw was 43 min versus 52 min; for overall operation time 126 min versus 141 min; blood loss 275 ± 197 mL versus 549 ± 404 mL; fluoroscopy time 74 s versus 125 s and fluoroscopy frequency 29 ± 4 versus 63 ± 3. In terms of post-operative outcomes of 3D-assisted versus conventional surgery: weighted mean screw malposition rate was 8% versus 18%; quality of fracture reduction measured by the total excellent/good rate by Matta was 86% versus 82% and Majeed excellent/good rate 88% versus 83%. Conclusion: The 3D-assisted surgery technologies seem to have a positive effect on operation time, blood loss, fluoroscopy dose, time and frequency as well as accuracy of screw placement. No improvement in clinical outcome in terms of fracture reduction and functional outcome has been established so far. Due to a wide range of methodological quality and heterogeneity between the included studies, results should be interpreted with caution.

Live bedside music in daily clinical practice of a surgical hospital ward among older patients: A controlled study design of an innovative practice.

OBJECTIVE: There is an increasing interest in the role of the arts, particularly music, in healthcare. Music seems an attractive non-pharmacological intervention for older patients to improve postoperative outcomes. Although live music elicits more meaningful responses from an audience than recorded music, the use of live music is still rare on hospital wards. In view of the positive effects of recorded music on older surgical patients, we designed, in collaboration with a conservatoire, an innovative practice named Meaningful Music in Health Care (MiMiC). The aim is to determine whether live bedside music implements into daily practice and allows improves patient outcomes. METHOD: This manuscript provides an overview of a trial evaluating if live bedside music can improve postoperative outcomes in older patients. The MiMiC initiative is a non randomized controlled trial study among older surgical patients on three hospital wards. Live bedside music is performed by professional musicians, once a day for six or seven consecutive days. The primary outcome is experienced pain; secondary outcomes are anxiety, relaxation and physical parameters (heart rate, heart rate variability, blood pressure, respiratory rate and oxygenation). Measurements of these variables are collected before the intervention, 30 min afterwards and again after three hours. Daily evaluations determine whether this innovative practice can be implemented in daily practice. CONCLUSION: This manuscript describes a new practice, live bedside music by professional musicians, on surgical hospital wards aiming to improve patient outcomes. It offers a new field of interprofessional collaboration for the benefit of patients. Further research must be conducted focussing on patient outcomes, including cost-effectiveness and the experiences of patients and healthcare professionals.

Patient-reported physical functioning and quality of life after pelvic ring injury: A systematic review of the literature.

BACKGROUND: Pelvic ring injuries are one of the most serious traumatic injuries with large consequences for the patients' daily life. During recent years, the importance of the patients' perception of their functioning and quality of life following injury has increasingly received attention. This systematic review reports on self-reported physical functioning and quality of life after all types of pelvic ring injuries. METHODS: The online databases MEDLINE-PubMed and Ovid-EMBASE were searched for studies published between 2008 and 2019 to identify published evidence of patient-reported physical functioning and quality of life after which they were assessed for their methodological quality. RESULTS: Of the 2577 articles, 46 were reviewed in full-text, including 3049 patients. Most studies were heterogeneous, with small cohorts of patients, a variety of injury types, treatment methods and use of different, often non-validated, outcome measures. The overall methodological quality was moderate to poor. Nine different PROMs were used, of which the Majeed Pelvic Score (MPS), SF-36 and EQ-5D were the most widely used. Mean scores respectively ranged from 75-95 (MPS), 53-69 (SF-36, physical functioning) and 0.63-0.80 (EQ-5D). CONCLUSIONS: Physical functioning and quality of life following pelvic ring injuries seem fair and tend to improve during follow-up. However, differences in patient numbers, injury definition, treatment strategy, follow-up duration and type of PROMs used between studies hampers to elucidate the actual effects of pelvic ring injuries on a patient's life. IMPLICATIONS OF KEY FINDINGS: Physicians and researchers should use valid and reliable patient-reported outcome instruments on large cohorts of patients with properly defined injuries to truly evaluate physical functioning and quality of life after pelvic ring injuries. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO International prospective register of systematic reviews; registration number CRD42019129176.

Reducing the negative appendectomy rate with the laparoscopic appendicitis score; a multicenter prospective cohort and validation study.

BACKGROUND: Approximately nine percent of all acute appendectomies are unintentionally performed on a normal appendix. Failure of treatment (negative appendectomy or missed appendicitis) is associated with higher morbidity and mortality when compared to appendectomy for uncomplicated appendicitis. The Laparoscopic APPendicitis (LAPP) score was developed in order to systematically evaluate the appendix for the presence of inflammation. This study aims to determine whether the LAPP score reduces the negative appendectomy rate without missing appendicitis. METHODS: From September 2013 through May 2016, 322 adult patients presenting with a clinical suspicion of acute appendicitis and an indication for diagnostic laparoscopy were included and analyzed in this multicenter prospective validation study. Depending on the LAPP score, the appendix was either removed (n = 300) or left in situ (n = 22). These patients were compared to a historical control group of 584 patients treated at the same hospitals. The appendix was examined by a pathologist and the negative appendectomy rate was calculated. RESULTS: The negative appendectomy rate was significantly lower when the LAPP score was used (4,7% vs. 8,4%; P = 0,034). None of the patients with a negative LAPP score, in which the appendix remained in situ, developed acute appendicitis within three months. There were no significant differences in operation time, complications, or readmissions. Using the LAPP score was associated with significantly higher rates of preoperative radiological imaging (98% vs. 70%; P < 0,001). After adjusting for covariables, including radiological imaging, use of the LAPP score led to fewer treatment failures when compared to not using the LAPP score (OR: 0,48, 95% C.I. 0,251 to 0,914; P = 0,025). CONCLUSION: The LAPP score is a safe and simple tool to reduce the negative appendectomy rate during laparoscopic surgery without missing cases of acute appendicitis.

The Surgical Hazardous Attitudes Reflection Profile (SHARP) Instrument - A Prototype Study.

OBJECTIVE: There is growing recognition that surgeons' non-technical skills are crucial in guaranteeing optimal quality and safety of patient care. However, insight in relevant attitudes underlying these behavioral skills is lacking. Hazardous attitudes potentially cause risky behavior, which can result in medical errors and adverse events. A questionnaire offering surgeons insight in their attitudinal profile is still missing and would be instrumental in risk reduction. Therefore, the aim of this study is to develop a prototype of a reliable and valid instrument to measure hazardous attitudes among surgeons. DESIGN: To measure hazardous attitudes, a prototype of the Surgical Hazardous Attitudes Reflection Profile (SHARP) tool was designed using a mixed methods approach, consisting of (1) 2 focus group discussions, (2) a modified Delphi analysis, and (3) a survey followed by (4) statistical analysis of the psychometric properties. Statistical analysis included exploratory factor analysis with varimax rotation, calculation of internal consistency reliability coefficients, and interscale correlations. SETTING: Fourteen hospitals across the Netherlands were recruited to guarantee demographic variety and the inclusion of academic, tertiary, and general hospitals. PARTICIPANTS: Nineteen experts participated in the 2 focus groups, and 19 in the modified Delphi study. In total, 302 surgeons (54.1%) completed the SHARP. RESULTS: In total, 302 surgeons (54.1%) completed the SHARP. Exploratory factor analysis resulted in 6 subscales measuring attitude towards (1) authority (α = 0.78), (2) self-performance (α = 0.69), (3) performance feedback (α = 0.61), (4) own fitness to perform (α = 0.54), (5) uncertainty (α = 0.51), and (6) planned procedures (α = 0.48). CONCLUSIONS: This study resulted in a prototype instrument identifying 6 potential hazardous attitudes in surgeons. Attitudes towards "authority" and "self-performance" can now be validly and reliably measured. Further research is required to optimize the prototype version of the instrument and could usefully explore the plausible relations between hazardous attitudes and clinical outcomes.

Older polytrauma: Mortality and complications.

INTRODUCTION: Older adults enduring a polytrauma have an increased mortality risk. Apart from age, the role of other predisposing factors on mortality are mainly described for the total polytrauma population. This study aimed to describe the mortality pattern of older polytrauma patients, its associated risk factors, and the role and etiology of in-hospital complications. METHODS: An eight-year retrospective cohort was constructed from 380 polytrauma patients aged ≥65 in a Dutch level 1 trauma center and linked to the national trauma database (DTR). Demographics, injury characteristics, comorbidity, clinical characteristics, in-hospital mortality, mortality etiology and complications scored according to the Clavien-Dindo classification were analyzed. Primary outcome was the identification of risk factors associated with in-hospital mortality, followed by identification of in-hospital complications and their nature. RESULTS: Overall in-hospital mortality was 36.3%, rising significantly with age. For patients aged ≥85 in-hospital mortality was 60.8%. Polytrauma patients aged ≥75 showed a peak of late-onset deaths one week following trauma. Age, a Glasgow coma score ≤8, coagulopathy, acidosis, injury severity score and the presence of a large subdural hematoma were significant risk factors influencing in-hospital mortality. Respiratory failure was the most prevalent severe and fatal complication. The proportion of fatal complications grew significantly with age (p < 0.01). CONCLUSIONS: Age is strongly associated with in-hospital mortality in polytraumatized elderly. Coagulopathy, acidosis, a low Glasgow coma score, presence of a large subdural hematoma and injury severity score were independently of age associated with an increased mortality. Patients older than 75 years showed a unique trimodal distribution of mortality with a late onset one week following the initial trauma. Elderly were more susceptible for fatal complications. Respiratory failure was the most prevalent severe and fatal complication. Aggressive monitoring and treatment of the pulmonary status is therefore of utmost importance.

Pelvic ring injury in the elderly: Fragile patients with substantial mortality rates and long-term physical impairment.

BACKGROUND: Pelvic ring injuries in the elderly often occur after low-energy accidents. They may result in prolonged immobilization, complications and an intense rehabilitation process. The aim of this study was to assess mortality, physical functioning and quality of life (QoL) in elderly patients with pelvic ring injuries. METHODS: A cross-sectional study was performed including all elderly patients (≥ 65 years) admitted for a pelvic ring injury between 2007-2016. Mortality and survival were evaluated and patient reported outcome measures (PROMs) were used to assess physical functioning (SMFA) and QoL (EQ-5D). These were compared to age-matched normative data from the general Dutch population. RESULTS: A total of 153 patients, with a mean age of 79 years (SD 8) at the time of injury, were included in this study. The mortality rate was 20% at 30 days, 27% at 1 year and 41% at 3 years of follow-up. All six patients with a type C fracture died within 30 days. Analyses of the 153 patients showed that increasing age, fracture type C and Injury Severity Score (ISS) were all independent risk factors for mortality. Eventually, after excluding patients that died (N = 78) or were unable to contact (N = 2), 73 patients were eligible for follow-up, of which 53 patients (73%) responded. Mean Short Musculoskeletal Function Assessment (SMFA) scores were respectively 67.4 (function index), 65.2 (bother index), 66.5 (lower extremity), 60.4 (activities of daily living) and 68.2 (emotion). Mean EuroQuol-5D (EQ-5D) score was 0.72. Overall, physical functioning and quality of life were significantly decreased in comparison with normative data from the general population. CONCLUSION: Elderly people who sustain a pelvic ring injury should be considered as a fragile population with substantial mortality rates. The patients who survived demonstrated a substantially lower level of physical functioning and quality of life in comparison with their age-matched peers from the general population. LEVEL OF EVIDENCE: IV, therapeutic study.

The development and internal validation of a model to predict functional recovery after trauma.

OBJECTIVE: To develop and internally validate the PROgnosis of functional recovery after Trauma (PRO-Trauma) prediction model. DESIGN: A prospective single-center longitudinal cohort study. Patients were assessed at 6 weeks and 12 months post-injury. METHODS: Patients that presented at the emergency department with an acute traumatic injury, were prompted for participation. Patients that completed the assessments at 6 weeks and 12 months post injury were included. Exclusion criteria: age < 18, age > 65, pathologic fractures, injuries that resulted in severe neurologic deficits. The predicted outcome, functional recovery, was defined as a Short Musculoskeletal Function Assessment (SMFA-NL) Problems with Daily Activities (PDA) subscale ≤ 12.2 points at 12 months post-injury (Dutch population norm). Predictors were: gender, age, living with partner, number of chronic health conditions, SMFA-NL PDA score 6 weeks post-injury, ICU admission, length of stay in hospital, injury severity score, occurrence of complications and treatment type. All predictors were obtained before 6 weeks post-injury. Missing data were multiply imputed. Predictor variables were selected using backward stepwise multivariable logistic regression. Hosmer-Lemeshow tests were used to evaluate calibration. Bootstrap resampling was used to internally validate the final model. RESULTS: A total of 246 patients were included, of which 104 (44%) showed functional recovery. The predictors in the final PRO-Trauma model were: living with partner, the number of chronic health conditions, SMFA-NL PDA subscale score at 6 weeks post-injury and length of stay in hospital. The apparent R2 was 0.33 [0.33;0.34], the c-statistic was 0.79 [0.79;0.80]. Hosmer-Lemeshow test indicated good calibration (p = 0.92). Optimism-corrected R2 was 0.28 [0.27;0.29] and the optimism-corrected Area Under the Curve was 0.77 [0.77;0.77]. CONCLUSION: The PRO-Trauma prediction model can be used to obtain valid predictions of attaining functional recovery after trauma at 12 months post-injury. The PRO-Trauma prediction model showed acceptable calibration and discrimination.

The Short Musculoskeletal Function Assessment: a study of the reliability, construct validity and responsiveness in patients sustaining trauma.

OBJECTIVE: To assess test-retest reliability, construct validity and responsiveness of the Dutch Short Musculoskeletal Function Assessment (SMFA-NL) in patients who sustained acute physical trauma. DESIGN: A longitudinal cohort study. SETTING: A level 1 trauma center in The Netherlands. SUBJECTS: Patients who required hospital admission after sustaining an acute physical trauma. INTERVENTION: Patients completed the SMFA-NL at six weeks, eight weeks and six months post-injury. MAIN MEASURE: The measures used were The Dutch Short Musculoskeletal Function Assessment. Test-retest reliability (between six and eight weeks post-injury) using intraclass correlation coefficients, the smallest detectable change and Bland and Altman plots. Construct validity (six weeks post-injury) and responsiveness (between six weeks and six months post-injury) were evaluated using the hypothesis testing method. RESULTS: A total of 248 patients (mean age: 46.5, SD: 13.4) participated, 145 patients completed the retest questionnaires (eight weeks) and 160 patients completed the responsiveness questionnaires (six months). The intraclass correlation coefficients indicated good to excellent reliability on all subscales (0.80 to 0.98). The smallest detectable change was 17.4 for the Upper Extremity Dysfunction subscale, 11.0 for the Lower Extremity Dysfunction subscales, 13.9 for the Problems with Daily Activities subscale and 16.5 for the Mental and Emotional Problems subscale. At group level, the smallest detectable change ranged from 1.48 to 1.96. A total of 86% of the construct validity hypotheses and 79% of the responsiveness hypotheses were confirmed. CONCLUSION: This study showed that the SMFA-NL has good to excellent reliability, sufficient construct validity and is able to detect change in physical function over time.

Pre-injury health status of injured patients: a prospective comparison with the Dutch population.

PURPOSE: The aim of this study was to assess whether injured patients have a different pre-injury health status compared to the Dutch population. METHODS: A broad range of injured patients (age ≥ 18 and ≤ 75 years) completed the condition-specific Short Musculoskeletal Function Assessment (SMFA-NL) and generic health-related quality of life questionnaire EuroQol-5D (EQ-5D), within 2 weeks after patients sustained an injury. Patients reported their health status of the week before their injury. Scores were compared to the Dutch normative data of the questionnaires. Gender, age, educational level, relationship status, and comorbidity adjusted differences were calculated for the SMFA-NL. RESULTS: A total of 596 injured patients completed the questionnaires (response rate: 43%). Unadjusted pre-injury SMFA-NL scores of injured patients were significantly better compared to the Dutch normative data (ranging from + 2.4 to + 8.6 points, p < 0.001 for all subscales and indices). The unadjusted EQ-5D difference score was 0.05 points (p < 0.001) higher in the group of injured patients. Adjusted pre-injury scores were higher than the SMFA-NL normative data. Function index: + 3.6, p < 0.001, bother index: + 3.0, p < 0.001 upper extremity dysfunction: + 0.8, p = 0.2, lower extremity dysfunction: + 3.7, p < 0.001. Problems with daily activities: + 2.8, p = 0.001. Mental and emotional problems: + 6.8, p < 0.001. CONCLUSIONS: Injured patients reported a better pre-injury health status compared to the Dutch population. Patient characteristics explained an important part of the difference in health status between injured patients and the Dutch population.

Structural Validity of the Short Musculoskeletal Function Assessment in Patients With Injuries.

Background: The Short Musculoskeletal Function Assessment (SMFA) is a widely used patient-reported outcome measure, originally having 2 elements of outcome: the function index and the bother index. In multiple studies, it has been argued that the SMFA should be scored using 3, 4, or 6 subscales instead. Therefore, there is inconsistency with the number of underlying dimensions of the SMFA. Objective: The aim of this study was to evaluate the structural validity of the various proposed subscale configurations of the SMFA in a broad range of Dutch patients with injuries. Design: This study used a prospective cohort design. Methods: Participants with injuries were asked to complete the Dutch SMFA (SMFA-NL) at 5 to 8 weeks postinjury. The structural validity of the 6 different factor structures that have been proposed in other studies was evaluated using confirmatory factor analyses. Internal consistency was analyzed using Cronbach alpha. Results: A total of 491 patients participated (response rate = 74%). A 4-factor structure showed an acceptable fit (root-mean-square error of approximation [RMSEA] = 0.070, comparative fit index = 0.973, Tucker-Lewis index = 0.971). Other models, including the original 2-index structure, showed insufficient structural validity in Dutch patients with injuries. The 4-factor structure showed sufficient discriminant validity and good internal consistency (Cronbach alpha ≥ 0.83). Limitations: It is unclear whether conclusions are generalizable across different countries, people who are elderly, and people without injuries. Conclusion: In a broad range of patients with injuries, the SMFA-NL may be best scored and interpreted using a 4-factor structure. Other factor structures showed insufficient structural validity.

Efforts, rewards and professional autonomy determine residents' experienced well-being.

The well-being of residents, our future medical specialists, is not only beneficial to the individual physician but also conditional for delivering high-quality patient care. Therefore, the authors further explored how residents experience their own well-being in relation to their professional and personal life. The authors conducted a qualitative study based on a phenomenological approach. From June to October 2013, 13 in-depth interviews were conducted with residents in various training programs using a semi-structured interview guide to explore participants' experience of their well-being in relation to their professional life. The data were collected and analyzed through an iterative process using the thematic network approach. Effort-reward balance and perceived autonomy were dominant overarching experiences in influencing residents' well-being. Experiencing sufficient autonomy was important in residents' roles as caregivers, as learners and in their personal lives. The experienced effort-reward balance could both positively and negatively influence well-being. We found two categories of ways that influence residents' experience of well-being; (1) professional lives: delivering patient care, participating in teamwork, learning at the workplace and dealing with the organization and (2) personal lives: dealing with personal characteristics and balancing work-life. In residents' well-being experiences, the effort-reward balance and perceived autonomy are crucial. Additionally, ways that influence residents' well-being are identified in both their professional and personal lives. These dominant experiences and ways that influence well-being could be key factors for interventions and residency training adaptations for enhancing residents' well-being.