Missing patient registrations in the Dutch National Trauma Registry of Southwest Netherlands: Prevalence and epidemiology.

INTRODUCTION: Health care patient records have been digitalised the past twenty years, and registries have been automated. Missing registrations are common, and can result in selection bias. OBJECTIVE: To assess the prevalence and characteristics of missed registrations in a Dutch regional trauma registry. METHODS: An automatically generated trauma registry export was done for ten out of eleven hospitals in trauma region Southwest Netherlands, between June 1 and August 31, 2020. Second, lists were checked for being falsely flagged as 'non-trauma'. Finally, a list was generated with trauma tick box flagged as 'trauma' but were not automatically in the export due to administrative errors. Automated and missed registration datasets were compared on patient characteristics and logistic regression models were run with random intercepts and missed registration as outcome variable on the complete dataset. RESULTS: A total of 2,230 automated registrations and 175 (7.3 %) missed registrations were included for the Dutch National Trauma Registry, ranging from 1 to 14 % between participating hospitals. Patients of the missed registration dataset had characteristics of a higher level of care, compared with patients of automated registrations. Level of trauma care (level II OR 0.464 95 % CI 0.328-0.666, p < 0.001; level III OR 0.179 95 % CI 0.092-0.325, p < 0.001), major trauma (OR 2.928 95 % CI 1.792-4.65, p < 0.001), ICU admission (OR 2.337 95 % CI 1.792-4.650, p < 0.001), and surgery (OR 1.871 95 % CI 1.371-2.570, p < 0.001) were potential predictors for missed registrations in multivariate logistic regression analysis. CONCLUSION: Missed registrations occur frequently and the rate of missed registrations differs greatly between hospitals. Automated and missed registration datasets display differences related to patients requiring more intensive care, which held for the major trauma subset. Checking for missed registrations is time consuming, automated registration lists need a human touch for validation and to be complete.

Extramedullary versus intramedullary fixation of unstable trochanteric femoral fractures (AO type 31-A2): a systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review was to compare extramedullary fixation and intramedullary fixation for AO type 31-A2 trochanteric fractures in the elderly, with regard to functional outcomes, complications, surgical outcomes, and costs. METHODS: Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results are presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). RESULTS: Fourteen RCTs (2039 patients) and 13 observational studies (22,123 patients) were included. Statistically superior results in favor of intramedullary fixation were found for Harris Hip Score (MD 4.09, 95% CI 0.91-7.26, p = 0.04), Parker mobility score (MD - 0.67 95% CI - 1.2 to - 0.17, p = 0.009), lower extremity measure (MD - 4.07 95% CI - 7.4 to - 0.8, p = 0.02), time to full weight bearing (MD 1.14 weeks CI 0.92-1.35, p < 0.001), superficial infection (RR 2.06, 95% CI 1.18-3.58, p = 0.01), nonunion (RR 3.67, 95% CI 1.03-13.10, p = 0.05), fixation failure (RR 2.26, 95% CI 1.16-4.44, p = 0.02), leg shortening (MD 2.23 mm, 95% CI 0.81-3.65, p = 0.002), time to radiological bone healing (MD 2.19 months, 95% CI 0.56-3.83, p = 0.009), surgery duration (MD 11.63 min, 95% CI 2.63-20.62, p = 0.01), operative blood loss (MD 134.5 mL, 95% CI 51-218, p = 0.002), and tip-apex distance > 25 mm (RR 1.73, 95% CI 1.10-2.74, p = 0.02). No comparable cost/costs-effectiveness data were available. CONCLUSION: Current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed in a detailed cost-effectiveness analysis.

European river typologies fail to capture diatom, fish, and macrophyte community composition.

Typology systems are frequently used in applied and fundamental ecology and are relevant for environmental monitoring and conservation. They aggregate ecosystems into discrete types based on biotic and abiotic variables, assuming that ecosystems of the same type are more alike than ecosystems of different types with regard to a specific property of interest. We evaluated whether this assumption is met by the Broad River Types (BRT), a recently proposed European river typology system, that classifies river segments based on abiotic variables, when it is used to group biological communities. We compiled data on the community composition of diatoms, fishes, and aquatic macrophytes throughout Europe and evaluated whether the composition is more similar in site groups with the same river type than in site groups of different river types using analysis of similarities, classification strength, typical species analysis, and the area under zeta diversity decline curves. We compared the performance of the BRT with those of four region-based typology systems, namely, Illies Freshwater Ecoregions, the Biogeographic Regions, the Freshwater Ecoregions of the World, and the Environmental Zones, as well as spatial autocorrelation (SA) classifications. All typology systems received low scores from most evaluation methods, relative to predefined thresholds and the SA classifications. The BRT often scored lowest of all typology systems. Within each typology system, community composition overlapped considerably between site groups defined by the types of the systems. The overlap tended to be the lowest for fishes and between Illies Freshwater Ecoregions. In conclusion, we found that existing broad-scale river typology systems fail to delineate site groups with distinct and compositionally homogeneous communities of diatoms, fishes, and macrophytes. A way to improve the fit between typology systems and biological communities might be to combine segment-based and region-based typology systems to simultaneously account for local environmental variation and historical distribution patterns, thus potentially improving the utility of broad-scale typology systems for freshwater biota.

Evaluating associations between level of trauma care and outcomes of patients with specific severe injuries: A systematic review and meta-analysis.

BACKGROUND: Trauma networks have multiple designated levels of trauma care. This classification parallels concentration of major trauma care, creating innovations and improving outcome measures. OBJECTIVES: The objective of this study is to assess associations of level of trauma care with patient outcomes for populations with specific severe injuries. METHODS: A systematic literature search was conducted using six electronic databases up to April 19, 2022 (PROSPERO CRD42022327576). Studies comparing fatal, nonfatal clinical, or functional outcomes across different levels of trauma care for trauma populations with specific severe injuries or injured body region (Abbreviated Injury Scale score ≥3) were included. Two independent reviewers included studies, extracted data, and assessed quality. Unadjusted and adjusted pooled effect sizes were calculated with random-effects meta-analysis comparing Level I and Level II trauma centers. RESULTS: Thirty-five studies (1,100,888 patients) were included, of which 25 studies (n = 443,095) used for meta-analysis, suggesting a survival benefit for the severely injured admitted to a Level I trauma center compared with a Level II trauma center (adjusted odds ratio [OR], 1.15; 95% confidence interval [CI], 1.06-1.25). Adjusted subgroup analysis on in-hospital mortality was done for patients with traumatic brain injuries (OR, 1.23; 95% CI, 1.01-1.50) and hemodynamically unstable patients (OR, 1.09; 95% CI, 0.98-1.22). Hospital and intensive care unit length of stay resulted in an unadjusted mean difference of -1.63 (95% CI, -2.89 to -0.36) and -0.21 (95% CI, -1.04 to 0.61), respectively, discharged home resulted in an unadjusted OR of 0.92 (95% CI, 0.78-1.09). CONCLUSION: Severely injured patients admitted to a Level I trauma center have a survival benefit. Nonfatal outcomes were indicative for a longer stay, more intensive care, and more frequently posthospital recovery trajectories after being admitted to top levels of trauma care. Trauma networks with designated levels of trauma care are beneficial to the multidisciplinary character of trauma care. LEVEL OF EVIDENCE: Systematic review and meta-analysis; Level III.

Applicability of devices available for the measurement of intracompartmental pressures: a cadaver study.

PURPOSE: The indication for surgical treatment of the chronic exertional compartment syndrome is evaluated by measuring intracompartmental pressures. The validity of these invasive intracompartmental pressure measurements are increasingly questioned in the absence of a standardized test protocol and uniform cut-off values. The aim of the current study was to test compartment pressure monitors and needles for uniformity, thereby supporting the physician's choice in the selection of appropriate test materials. METHODS: A compartment syndrome was simulated in embalmed above-knee cadaveric leg specimen. Four different terminal devices (Compass manometer, Stryker device, Meritrans transduce, and arterial line) were tested with 22 different needle types. Legs were pressurized after introduction of the four terminal devices in the anterior compartment, using the same needle type. Pressure was recorded at a 30-second interval for 11 minutes in total. Before and after pressurization, the intravenous bag of saline was weighed. RESULTS: The simulation of a compartment syndrome resulted in intracompartmental pressure values exceeding 100 mmHg in 17 of the 22 legs (77%). In the other five legs, a smaller built-up of pressure was seen, although maximum intracompartmental pressure was in between 70 and 100 mmHg. The intraclass correlation coefficient was above 0.700 for all possible needle types. Excellent to good resemblance was seen in 16 out of 22 instrumental setups (73%). The mean volume of saline infusion required in runs that exceeded 100 mmHg (309 ± 116 ml) was significantly lower compared to the legs in which 100 mmHg was not achieved (451 ± 148 ml; p = 0.04). CONCLUSION: The intracompartmental pressure recordings of the four terminal devices were comparable, when tested with a standardized pressurization model in a human cadaver model. None of the included terminal devices or needle types were found to be superior. The results provide evidence for more diverse material selection when logistic choices for intracompartmental pressure measurement devices are warranted. LEVEL OF EVIDENCE: Level IV.

Primary admission and secondary transfer of trauma patients to Dutch level I and level II trauma centers: predictors and outcomes.

PURPOSE: The importance and impact of determining which trauma patients need to be transferred between hospitals, especially considering prehospital triage systems, is evident. The objective of this study was to investigate the association between mortality and primary admission and secondary transfer of patients to level I and II trauma centers, and to identify predictors of primary and secondary admission to a designated level I trauma center. METHODS: Data from the Dutch Trauma Registry South West (DTR SW) was obtained. Patients ≥ 18 years who were admitted to a level I or level II trauma center were included. Patients with isolated burn injuries were excluded. In-hospital mortality was compared between patients that were primarily admitted to a level I trauma center, patients that were transferred to a level I trauma center, and patients that were primarily admitted to level II trauma centers. Logistic regression models were used to adjust for potential confounders. A subgroup analysis was done including major trauma (MT) patients (ISS > 15). Predictors determining whether patients were primarily admitted to level I or level II trauma centers or transferred to a level I trauma center were identified using logistic regression models. RESULTS: A total of 17,035 patients were included. Patients admitted primarily to a level I center, did not differ significantly in mortality from patients admitted primarily to level II trauma centers (Odds Ratio (OR): 0.73; 95% confidence interval (CI) 0.51-1.06) and patients transferred to level I centers (OR: 0.99; 95%CI 0.57-1.71). Subgroup analyses confirmed these findings for MT patients. Adjusted logistic regression analyses showed that age (OR: 0.96; 95%CI 0.94-0.97), GCS (OR: 0.81; 95%CI 0.77-0.86), AIS head (OR: 2.30; 95%CI 2.07-2.55), AIS neck (OR: 1.74; 95%CI 1.27-2.45) and AIS spine (OR: 3.22; 95%CI 2.87-3.61) are associated with increased odds of transfers to a level I trauma center. CONCLUSIONS: This retrospective study showed no differences in in-hospital mortality between general trauma patients admitted primarily and secondarily to level I trauma centers. The most prominent predictors regarding transfer of trauma patients were age and neurotrauma. These findings could have practical implications regarding the triage protocols currently used.

Health-related quality of life and return to work 1 year after major trauma from a network perspective.

INTRODUCTION: Major trauma often results in long-term disabilities. The aim of this study was to assess health-related quality of life, cognition, and return to work 1 year after major trauma from a trauma network perspective. METHODS: All major trauma patients in 2016 (Injury Severity Score > 15, n = 536) were selected from trauma region Southwest Netherlands. Eligible patients (n = 365) were sent questionnaires with the EQ-5D-5L and questions on cognition, level of education, comorbidities, and resumption of paid work 1 year after trauma. RESULTS: A 50% (n = 182) response rate was obtained. EQ-US and EQ-VAS scored a median (IQR) of 0.81 (0.62-0.89) and 70 (60-80), respectively. Limitations were prevalent in all health dimensions of the EQ-5D-5L; 90 (50%) responders reported problems with mobility, 36 (20%) responders reported problems with self-care, 108 (61%) responders reported problems during daily activities, 129 (73%) responders reported pain or discomfort, 70 (39%) responders reported problems with anxiety or depression, and 102 (61%) of the patients reported problems with cognition. Return to work rate was 68% (37% full, 31% partial). A median (IQR) EQ-US of 0.89 (0.82-1.00) and EQ-VAS of 80 (70-90) were scored for fully working responders; 0.77 (0.66-0.85, p < 0.001) and 70 (62-80, p = 0.001) for partial working respondents; and 0.49 (0.23-0.69, p < 0.001) and 55 (40-72, p < 0.001) for unemployed respondents. CONCLUSION: The majority experience problems in all health domains of the EQ-5D-5L and cognition. Return to work status was associated with all health domains of the EQ-5D-5L and cognition.

Posterior tibial plateau fracture treatment with the new WAVE posterior proximal tibia plate: feasibility and first results.

INTRODUCTION: Operative management of posterior tibial plateau fractures (PTPF) remains challenging. The treatment goal is to restore the alignment and articular congruence, and providing sufficient stability which allows early mobilization. The purpose of this study was to assess the feasibility and safety of the newly developed WAVE posterior proximal tibia plate. METHODS: Between Oct 2017 and Jun 2020, 30 adult patients with a tibial plateau fracture and posterior involvement were selected for treatment with a WAVE posterior proximal tibia plate. Patient reported outcome was assessed using the Knee injury and Osteoarthritis Outcome Score (KOOS) at time of injury (pre-injury) and at 1-year follow-up. Radiological outcome was evaluated with CT-imaging. RESULTS: Twenty-eight patients were eligible for treatment with the new implant (3 'one-column', 10 'two column' and 15 'three-column' fractures), whereas in 2 patients anatomical fit was insufficient. KOOS results showed fair outcome scores at 1 year, with a large negative impact compared to pre-injury levels; however, a trend towards better results compared to a previous PTPF reference cohort. Radiological follow-up showed insufficient posterolateral buttress in two cases and residual articular step-off (> 2 mm) in seven patients, of which five were classified as three column fractures. CONCLUSION: Management of PTPF using the WAVE posterior proximal tibia plate is feasible and safe with satisfactory clinical and radiological results after 1 year. Nevertheless, there is a learning curve regarding optimal implant positioning to achieve the maximum benefit of the implant.

The feasibility and reliability of frailty assessment tools applicable in acute in-hospital trauma patients: A systematic review.

BACKGROUND: Assessing frailty in patients with an acute trauma can be challenging. To provide trustworthy results, tools should be feasible and reliable. This systematic review evaluated existing evidence on the feasibility and reliability of frailty assessment tools applied in acute in-hospital trauma patients. METHODS: A systematic search was conducted in relevant databases until February 2020. Studies evaluating the feasibility and/or reliability of a multidimensional frailty assessment tool used to identify frail trauma patients were identified. The feasibility and reliability results and the risk of bias of included studies were assessed. This study was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and registered in Prospective Register of Systematic Reviews (ID: CRD42020175003). RESULTS: Nineteen studies evaluating 12 frailty assessment tools were included. The risk of bias of the included studies was fair to good. The most frequently evaluated tool was the Clinical Frailty Scale (CFS) (n = 5). All studies evaluated feasibility in terms of the percentage of patients for whom frailty could be assessed; feasibility was high (median, 97%; range, 49-100%). Other feasibility aspects, including time needed for completion, tool availability and costs, availability of instructions, and necessity of training for users, were hardly reported. Reliability was only assessed in three studies, all evaluating the CFS. The interrater reliability varied between 42% and >90% agreement, with a Krippendorff α of 0.27 to 0.41. CONCLUSION: Feasibility of most instruments was generally high. Other aspects were hardly reported. Reliability was only evaluated for the CFS with results varying from poor to good. The reliability of frailty assessment tools for acute trauma patients needs further critical evaluation to conclude whether assessment leads to trustworthy results that are useful in clinical practice. LEVEL OF EVIDENCE: Systematic review, Level II.

The definition of major trauma using different revisions of the abbreviated injury scale.

BACKGROUND: A threshold Injury Severity Score (ISS) ≥ 16 is common in classifying major trauma (MT), although the Abbreviated Injury Scale (AIS) has been extensively revised over time. The aim of this study was to determine effects of different AIS revisions (1998, 2008 and 2015) on clinical outcome measures. METHODS: A retrospective observational cohort study including all primary admitted trauma patients was performed (in 2013-2014 AIS98 was used, in 2015-2016 AIS08, AIS08 mapped to AIS15). Different ISS thresholds for MT and their corresponding observed mortality and intensive care (ICU) admission rates were compared between AIS98, AIS08, and AIS15 with Chi-square tests and logistic regression models. RESULTS: Thirty-nine thousand three hundred seventeen patients were included. Thresholds ISS08 ≥ 11 and ISS15 ≥ 12 were similar to a threshold ISS98 ≥ 16 for in-hospital mortality (12.9, 12.9, 13.1% respectively) and ICU admission (46.7, 46.2, 46.8% respectively). AIS98 and AIS08 differed significantly for in-hospital mortality in ISS 4-8 (χ2 = 9.926, p = 0.007), ISS 9-11 (χ2 = 13.541, p = 0.001), ISS 25-40 (χ2 = 13.905, p = 0.001) and ISS 41-75 (χ2 = 7.217, p = 0.027). Mortality risks did not differ significantly between AIS08 and AIS15. CONCLUSION: ISS08 ≥ 11 and ISS15 ≥ 12 perform similarly to a threshold ISS98 ≥ 16 for in-hospital mortality and ICU admission. This confirms studies evaluating mapped datasets, and is the first to present an evaluation of implementation of AIS15 on registry datasets. Defining MT using appropriate ISS thresholds is important for quality indicators, comparing datasets and adjusting for injury severity. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.

Poor sporting abilities after tibial plateau fractures involving the posterior column: how can we do better?

PURPOSE: Tibial plateau fractures with the involvement of the posterior column are an important prognostic factor towards poor functional outcome. We aimed to assess the sporting abilities postoperatively with special emphasis on the type of sports and sport-specific movements, as well as time needed to resume sports, restricting factors in sports engagement, and patient satisfaction. We aimed to provide prognostic information on return to sports. METHODS: Demographic, clinical and radiological variables were retrospectively collected from 82 multicentric patients between 2014 and 2016. Prospectively, sporting abilities before and after surgery were determined using questionnaires at a mean follow-up of 33 months postoperatively. RESULTS: Involvement in sports significantly decreased, with only 68.4% of patients resuming sports (p < 0.001). The mean time needed to partially or fully resume sports was 6-9 and 9-12 months, respectively. The ability to resume at the pre-injury level of effort and performance was 22% and 12%, respectively. Restricting factors were pain (66%), fear of re-injury (37%), limited range of motion (26%), and instability (21%). The majority (59%) of patients were unsatisfied with their physical abilities. Significantly worse outcomes were observed in patients playing high-impact sports, experiencing knee pain during physical activity, suffering from extension/valgus or flexion/varus trauma. CONCLUSIONS: Tibial plateau fractures with the involvement of the posterior column significantly hamper the patients' sporting abilities, leaving the majority of patients unsatisfied. Preoperative counseling about prognosis, setting realistic expectations, optimizing rehabilitation and pain management postoperatively, and advising low-impact sports might improve engagement in physical activities and emotional impact on patients. LEVEL OF EVIDENCE: 3.

The association between level of trauma care and clinical outcome measures: A systematic review and meta-analysis.

BACKGROUND: With implementation of trauma systems, a level of trauma care classification was introduced. Use of such a system has been linked to significant improvements in survival and other outcomes. OBJECTIVES: The aim of this study was assessing the association between level of trauma care and fatal and nonfatal outcome measures for general and major trauma (MT) populations. METHODS: A systematic literature search was conducted using six electronic databases up to December 18, 2019. Studies comparing mortality or nonfatal outcomes between different levels of trauma care in general and MT populations (preferably Injury Severity Score of >15) were included. Two independent reviewers performed selection of relevant studies, data extraction, and a quality assessment of included articles. With a random-effects meta-analysis, adjusted and unadjusted pooled effect sizes were calculated for level I versus non-level I trauma centers. RESULTS: Twenty-two studies were included. Quality of the included studies was good; however, adjustment for comorbidity (32%) and interhospital transfer (38%) was performed less frequently. Nine (60%) of the 15 studies analyzing in-hospital mortality in general trauma populations reported a survival benefit for level I trauma centers. Level I trauma centers were not associated with higher mortality than non-level I trauma centers (adjusted odd ratio, 0.97; 95% confidence interval, 0.61-1.52). Of the 11 studies reporting in-hospital mortality in MT populations, 10 (91%) reported a survival benefit for level I trauma centers. Level I trauma centers were associated with lower mortality than non-level I trauma centers (adjusted odd ratio, 0.77; 95% confidence interval, 0.69-0.87). CONCLUSION: The association between level of trauma care and in-hospital mortality is evident for MT populations; however, this does not hold for general trauma populations. Level I trauma centers produce improved survival in MT populations. This association could not be proven for nonfatal outcomes in general and MT populations because of inconsistencies in the body of evidence. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level III.

The effect of early broad-spectrum versus delayed narrow-spectrum antibiotic therapy on the primary cure rate of acute infection after osteosynthesis.

PURPOSE: Infection near metal implants is a problem that presents challenging treatment dilemmas for physicians. The aim of this study was to analyse the efficacy of two treatment protocols for acute fracture-related infections. METHODS: Seventy-one patients in two level-1 trauma centres in the Netherlands were retrospectively included in this study. These trauma centres had different standardised protocols for acute infection after osteosynthesis: 39 patients were selected from protocol A and 32 from protocol B. Both protocols involve immediate surgical debridement and soft tissue coverage, but differ in antibiotic approach: (A) immediate empirical combination antibiotic therapy with rifampicin, or (B) postponed (1-5 days) targeted antibiotic therapy. The primary outcome of these protocols was success, defined as a fracture healing in the absence of infection. The secondary outcome was antibiotic resistance patterns. Logistic regression was conducted on patients and treatment-related factors in association with primary success. RESULTS: Primary success was achieved in 72% of protocol A patients, in 47% of those in protocol B (P = 0.033), and with prolongation of treatment success was achieved in 90% and 78% of patients, respectively. Protocol A exhibited a better primary success rate (adjusted OR 3.45, CI 1.13-10.52) when adjusted for age and soft tissue injury. There was no significant difference in antibiotic resistance between the two protocols. CONCLUSION: Both protocols yielded high overall success rates. Immediate empirical antibiotics can be used safely without additional bacterial resistance and may contribute to increased success rates.

Safe approach for fixation of first metacarpal fractures: an anatomical study.

This anatomical study defines a safe zone for percutaneous or minimally invasive fixation of first metacarpal fractures in order to avoid injury of the superficial branch of the radial nerve and the dorsal branch of the radial artery. The courses of the nerve and artery branches were marked in 20 embalmed cadaver specimens. With computer-assisted surgical anatomy mapping, a large diversity in the anatomical patterns for the nerve and a consistent pattern for the artery were found. Based on these findings, we conclude that transfixation of the first and the second metacarpals with K-wires placed in the distal 75% of both the first and second metacarpals is the safest way to avoid damages to the nerve and artery branches during fracture fixation.

The Effect of Perioperative Music on Medication Requirement and Hospital Length of Stay: A Meta-analysis.

OBJECTIVE: To assess and quantify the effect of perioperative music on medication requirement, length of stay and costs in adult surgical patients. SUMMARY BACKGROUND DATA: There is an increasing interest in nonpharmacological interventions to decrease opioid analgesics use, as they have significant adverse effects and opioid prescription rates have reached epidemic proportions. Previous studies have reported beneficial outcomes of perioperative music. METHODS: A systematic literature search of 8 databases was performed from inception date to January 7, 2019. Randomized controlled trials investigating the effect of perioperative music on medication requirement, length of stay or costs in adult surgical patients were eligible. Meta-analysis was performed using random effect models, pooled standardized mean differences (SMD) were calculated with 95% confidence intervals (CI). This study was registered with PROSPERO (CRD42018093140) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. RESULTS: The literature search yielded 2414 articles, 55 studies (N = 4968 patients) were included. Perioperative music significantly reduced postoperative opioid requirement (pooled SMD -0.31 [95% CI -0.45 to -0.16], P < 0.001, I = 44.3, N = 1398). Perioperative music also significantly reduced intraoperative propofol (pooled SMD -0.72 [95% CI -1.01 to -0.43], P < 0.00001, I = 61.1, N = 554) and midazolam requirement (pooled SMD -1.07 [95% CI -1.70 to -0.44], P < 0.001, I = 73.1, N = 184), while achieving the same sedation level. No significant reduction in length of stay (pooled SMD -0.18 [95% CI -0.43 to 0.067], P = 0.15, I = 56.0, N = 600) was observed. CONCLUSIONS: Perioperative music can reduce opioid and sedative medication requirement, potentially improving patient outcome and reducing medical costs as higher opioid dosage is associated with an increased risk of adverse events and chronic opioid abuse.

The FLORIVON flora survey in the Netherlands between 1902 and 1950.

In 1902, the nationwide citizen science project, known as FLORIVON, for mapping the flora of the Netherlands was launched, resulting in the publication of a complete flora atlas in 1980. Until 2004, the atlas dataset of the fieldwork between 1902 and 1950 had only been partly digitised and observations were aggregated and anonymised. Between 2001 and 2018, the dataset has been entirely digitised from the original field forms, including notes on non-native taxa. This paper presents key characteristics and figures of the dataset and provides an overview of the historical survey project, the digitisation process and subsequent validation of the data. The dataset is currently curated in the National Database Flora and Fauna and published in GBIF.

Patterns of injury and outcomes in the elderly patient with rib fractures: a multicenter observational study.

BACKGROUND: High rates of pneumonia and death have been reported among elderly patients with rib fractures. This study aims to identify patterns of injury and risk factors for pneumonia and death in elderly patients with rib fractures. METHODS: A retrospective multicenter observational study was performed using data registered in the national trauma registry between 2008 and 2015 in the South West Netherlands Trauma region. Data regarding demographics, mechanism of injury, pulmonary and cardiovascular history, pattern of extra-thoracic and intrathoracic injuries, ICU admission, length of stay, and morbidity and mortality following admission were collected. RESULTS: Eight hundred eighty-four patients were included. Median age was 76 years (P25-P75 70-83). 235 patients (26.6%) were 81 years or older. Moderate or worse extra-thoracic injuries were present in 456 patients (51.6%), of whom 146 (16.6%) had severe head injuries and 45 (5.1%) severe spinal injuries. Median ISS was 9 (P25-P75 5-18). The rate of pneumonia was 10% (n = 84). Ten percent of patients (n = 88) died. Risk factors for in-hospital mortality included age (OR 3.4; p = 0.003), presence of COPD (OR 1.3; p = 0.01), presence of cardiac disease (OR 2.6; p = 0.003), severe or worse head (OR 3.5; p < 0.001), abdominal (OR 6.8; p = 0.004) and spinal injury (OR 4.6; p = 0.011) by AIS, number of rib fractures (OR 2.6; p = 0.03), and need for chest tube drainage (OR 2.1; p = 0.021). CONCLUSIONS: Pneumonia and death occur in about 10% of elderly patients with rib fractures. Apart from the severity of thoracic injuries, the presence and severity of extra-thoracic injuries and cardiopulmonary comorbidities are associated with poor outcome.

[Firework injuries in the south-western region of the Netherlands around the turn of the year 2017-2018]. / Vuurwerkletsel in Zuidwest-Nederland.

OBJECTIVE: To report the number of patients with firework-related injuries treated in December 2017 and January 2018 in a hospital in the south-west Netherlands trauma region, and to provide details about the types of firework used and the specific injuries. DESIGN: A prospective multicentre cohort study (NTR6793). METHODS: Patients of all ages with firework-related injuries were eligible for inclusion. The injury had to have been sustained between 1 December 2017 and 31 January 2018, and treated at a hospital in the south-west Netherlands trauma region (approximately 2.5 million inhabitants). Data were extracted from patients' medical files and additional information was obtained from patient interviews. RESULTS: Fifty-four patients were included. The majority were male (93%) and the median age was 15 years. Twenty-five (46%) patients were bystanders and 12 (22%) were injured by illegal fireworks. Fifty patients were injured by bangers (n=22) or decorative fireworks (n=28). The patients had a total of 79 injuries, of which 29 (37%) were localised to the upper extremity and 19 (24%) to the eyes. Most upper extremity injuries were burns (69%), primarily partial thickness. Of the eye injuries, 14 were caused by blunt trauma, seven by chemical trauma, and one by penetrating trauma. Three patients sustained indirect firework-related injuries. CONCLUSION: Between 1 December 2017 and 31 January 2018 in the south-west Netherlands trauma region mainly teenage males and bystanders sustained firework-related injuries. Most injuries were upper extremity burns and eye injuries, mainly due to legal fireworks and bangers or decorative fireworks. The extent of the sample indicates that the study findings can be extrapolated to the rest of the Netherlands.

Managing Successional Stage Heterogeneity to Maximize Landscape-Wide Biodiversity of Aquatic Vegetation in Ditch Networks.

The presence of a high diversity of different successional stages in a landscape may help to conserve and promote landscape-wide biodiversity. A strategy to achieve this is using Cyclic Rejuvenation through Management (CRM), an approach employed in a variety of different ecosystems. CRM periodically resets the successional stages in a landscape. For aquatic systems this constitutes vegetation removal and dredging. For this approach to be useful (a) successional stages are required to be different in community composition and (b) these differences need to be caused by true replacement of species between stages. While potentially valid, these assumptions are not generally tested prior to application of CMR. In this study we test these assumptions to explore the usefulness of managing on successional stage heterogeneity for maximizing landscape-wide aquatic plant diversity. We carried out vegetation surveys in the ditch networks of 21 polder landscapes in Netherlands, each containing 24 ditch reaches. Using a clustering approach combined with insight from literature on vegetation succession in these systems we assigned our sampled communities to defined successional stages. After partitioning landscape diversity into its alpha and beta components, we quantified the relative importance of replacement among successional stages. Next, through scenario analyses based on simulations we studied the effects of reducing successional stage heterogeneity on landscape-wide biodiversity. Results showed that differences in community composition among successional stages were a potentially important factor contributing to landscape diversity. Early successional stages were characterized by higher replacement of species compared to late successional stages. In a scenario of gradual decrease of heterogeneity through the systematic loss of the earliest successional stages we found 20% of the species richness in a polder was lost, pointing toward the importance of maintaining early successional stages in a polder. This makes a compelling case for application of CRM within agricultural drainage ditch landscapes to maximize regional aquatic plant diversity. While applied to drainage ditch systems, our data-driven approach is broadly applicable to other systems and may help in providing first indications of the potential of the CRM approach. We argue that CRM may maintain and promote regional biodiversity without compromising the hydrological function of the systems.

Mowing Submerged Macrophytes in Shallow Lakes with Alternative Stable States: Battling the Good Guys?

Submerged macrophytes play an important role in maintaining good water quality in shallow lakes. Yet extensive stands easily interfere with various services provided by these lakes, and harvesting is increasingly applied as a management measure. Because shallow lakes may possess alternative stable states over a wide range of environmental conditions, designing a successful mowing strategy is challenging, given the important role of macrophytes in stabilizing the clear water state. In this study, the integrated ecosystem model PCLake is used to explore the consequences of mowing, in terms of reducing nuisance and ecosystem stability, for a wide range of external nutrient loadings, mowing intensities and timings. Elodea is used as a model species. Additionally, we use PCLake to estimate how much phosphorus is removed with the harvested biomass, and evaluate the long-term effect of harvesting. Our model indicates that mowing can temporarily reduce nuisance caused by submerged plants in the first weeks after cutting, particularly when external nutrient loading is fairly low. The risk of instigating a regime shift can be tempered by mowing halfway the growing season when the resilience of the system is highest, as our model showed. Up to half of the phosphorus entering the system can potentially be removed along with the harvested biomass. As a result, prolonged mowing can prevent an oligo-to mesotrophic lake from becoming eutrophic to a certain extent, as our model shows that the critical nutrient loading, where the lake shifts to the turbid phytoplankton-dominated state, can be slightly increased.