Are the non-weight bearing guidelines for the after treatment of calcaneal fractures still decisive? A Dutch survey among orthopaedic and trauma surgeons.

PURPOSE: The current rehabilitation for patients with surgically treated displaced intra-articular calcaneal fractures (DIACFs) consists of non-weightbearing for 8-12 weeks. The purpose of the present survey was to investigate the current pre-, peri- and post-operative practices among Dutch foot and ankle surgeons. Moreover, it aims to analyze whether surgeons comply to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) guidelines and which decision criteria were used in the determination of the start of weightbearing. METHODS: A survey was distributed among Dutch trauma and orthopaedic surgeons to determine the most common practices in postoperative weightbearing in patients with DIACFs. RESULTS: 75 surgeons responded to the survey. 33% of the respondents adhered to the AO guidelines. 4% of the respondents strictly followed non-weightbearing guidelines, while 96% interpret the AO guidelines or their local protocol freely, in any frequency. When respondents tended to deviate from the AO guidelines or local protocol, a good patients' compliance to therapy was expected. 83% of the respondents started weightbearing on the fracture, based on reported patient complaints. 87% of the respondents did not see any relation between early weightbearing and the occurrence of complications, including loosening of osteosynthesis materials. CONCLUSION: This study demonstrates that there is limited consensus on the rehabilitation for DIACFs. Moreover, it shows that most surgeons are inclined to interpret the current (AO) guideline or their own local protocol freely. New guidelines, supported with well-founded literature, could help surgeons in a more appropriate daily practice in weightbearing for the rehabilitation of calcaneal fractures.

The Detrimental Impact of the COVID-19 Pandemic on Major Trauma Outcomes in the Netherlands: A Comprehensive Nationwide Study.

OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on the outcome of major trauma patients in the Netherlands. SUMMARY BACKGROUND DATA: Major trauma patients highly rely on immediate access to specialized services, including ICUs, shortages caused by the impact of the COVID-19 pandemic may influence their outcome. METHODS: A multi-center observational cohort study, based on the Dutch National Trauma Registry was performed. Characteristics, resource usage, and outcome of major trauma patients (injury severity score ≥16) treated at all trauma-receiving hospitals during the first COVID-19 peak (March 23 through May 10) were compared with those treated from the same period in 2018 and 2019 (reference period). RESULTS: During the peak period, 520 major trauma patients were admitted, versus 570 on average in the pre-COVID-19 years. Significantly fewer patients were admitted to ICU facilities during the peak than during the reference period (49.6% vs 55.8%; P=0.016). Patients with less severe traumatic brain injuries in particular were less often admitted to the ICU during the peak (40.5% vs 52.5%; P=0.005). Moreover, this subgroup showed an increased mortality compared to the reference period (13.5% vs 7.7%; P=0.044). These results were confirmed using multivariable logistic regression analyses. In addition, a significant increase in observed versus predicted mortality was recorded for patients who had a priori predicted mortality of 50% to 75% (P=0.012). CONCLUSIONS: The COVID-19 peak had an adverse effect on trauma care as major trauma patients were less often admitted to ICU and specifically those with minor through moderate brain injury had higher mortality rates.

Modification of the TRISS: simple and practical mortality prediction after trauma in an all-inclusive registry.

PURPOSE: Numerous studies have modified the Trauma Injury and Severity Score (TRISS) to improve its predictive accuracy for specific trauma populations. The aim of this study was to develop and validate a simple and practical prediction model that accurately predicts mortality for all acute trauma admissions. METHODS: This retrospective study used Dutch National Trauma Registry data recorded between 2015 and 2018. New models were developed based on nonlinear transformations of TRISS variables (age, systolic blood pressure (SBP), Glasgow Coma Score (GCS) and Injury Severity Score (ISS)), the New Injury Severity Score (NISS), the sex-age interaction, the best motor response (BMR) and the American Society of Anesthesiologists (ASA) physical status classification. The models were validated in 2018 data and for specific patient subgroups. The models' performance was assessed based on discrimination (areas under the curve (AUCs)) and by calibration plots. Multiple imputation was applied to account for missing values. RESULTS: The mortality rates in the development and validation datasets were 2.3% (5709/245363) and 2.5% (1959/77343), respectively. A model with sex, ASA class, and nonlinear transformations of age, SBP, the ISS and the BMR showed significantly better discrimination than the TRISS (AUC 0.915 vs. 0.861). This model was well calibrated and demonstrated good discrimination in different subsets of patients, including isolated hip fractures patients (AUC: 0.796), elderly (AUC: 0.835), less severely injured (ISS16) (AUC: 878), severely injured (ISS ≥ 16) (AUC: 0.889), traumatic brain injury (AUC: 0.910). Moreover, discrimination for patients admitted to the intensive care (AUC: s0.846), and for both non-major and major trauma center patients was excellent, with AUCs of 0.940 and 0.895, respectively. CONCLUSION: This study presents a simple and practical mortality prediction model that performed well for important subgroups of patients as well as for the heterogeneous population of all acute trauma admissions in the Netherlands. Because this model includes widely available predictors, it can also be used for international evaluations of trauma care within institutions and trauma systems.

Impact of the SARS-CoV-2 pandemic on trauma care: a nationwide observational study.

PURPOSE: The SARS-CoV-2 pandemic severely disrupted society and the health care system. In addition to epidemiological changes, little is known about the pandemic's effects on the trauma care chain. Therefore, in addition to epidemiology and aetiology, this study aims to describe the impact of the SARS-CoV-2 pandemic on prehospital times, resource use and outcome. METHODS: A multicentre observational cohort study based on the Dutch Nationwide Trauma Registry was performed. Characteristics, resource usage, and outcomes of trauma patients treated at all trauma-receiving hospitals during the first (W1, March 12 through May 11) and second waves (W2, May 12 through September 23), as well as the interbellum period in between (INT, September 23 through December 31), were compared with those treated from the same periods in 2018 and 2019. RESULTS: The trauma caseload was reduced by 20% during the W1 period and 11% during the W2 period. The median length of stay was significantly shortened for hip fracture and major trauma patients (ISS ≥ 16). A 33% and 66% increase in the prevalence of minor self-harm-related injuries was recorded during the W1 and W2 periods, respectively, and a 36% increase in violence-related injuries was recorded during the INT. Mortality was significantly higher in the W1 (2.9% vs. 2.2%) and W2 (3.2% vs. 2.7%) periods. CONCLUSION: The imposed restrictions in response to the SARS-CoV-2 pandemic led to diminished numbers of acute trauma admissions in the Netherlands. The long-lasting pressing demand for resources, including ICU services, has negatively affected trauma care. Further caution is warranted regarding the increased incidence of injuries related to violence and self-harm.

Severe isolated injuries have a high impact on resource use and mortality: a Dutch nationwide observational study.

PURPOSE: The Berlin poly-trauma definition (BPD) has proven to be a valuable way of identifying patients with at least a 20% risk of mortality, by combining anatomical injury characteristics with the presence of physiological risk factors (PRFs). Severe isolated injuries (SII) are excluded from the BPD. This study describes the characteristics, resource use and outcomes of patients with SII according to their injured body region, and compares them with those included in the BPD. METHODS: Data were extracted from the Dutch National Trauma Registry between 2015 and 2019. SII patients were defined as those with an injury with an Abbreviated Injury Scale (AIS) score ≥ 4 in one body region, with at most minor additional injuries (AIS ≤ 2). We performed an SII subgroup analysis per AIS region of injury. Multivariable linear and logistic regression models were used to calculate odds ratios (ORs) for SII subgroup patient outcomes, and resource needs. RESULTS: A total of 10.344 SII patients were included; 47.8% were ICU admitted, and the overall mortality was 19.5%. The adjusted risk of death was highest for external (2.5, CI 1.9-3.2) and for head SII (2.0, CI 1.7-2.2). Patients with SII to the abdomen (2.3, CI 1.9-2.8) and thorax (1.8, CI 1.6-2.0) had a significantly higher risk of ICU admission. The highest adjusted risk of disability was recorded for spine injuries (10.3, CI 8.3-12.8). The presence of ≥ 1 PRFs was associated with higher mortality rates compared to their poly-trauma counterparts, displaying rates of at least 15% for thoracic, 17% for spine, 22% for head and 49% for external SII. CONCLUSION: A severe isolated injury is a high-risk entity and should be recognized and treated as such. The addition of PRFs to the isolated anatomical injury criteria contributes to the identification of patients with SII at risk of worse outcomes.

Dutch trauma system performance: Are injured patients treated at the right place?

BACKGROUND: The goal of trauma systems is to match patient care needs to the capabilities of the receiving centre. Severely injured patients have shown better outcomes if treated in a major trauma centre (MTC). We aimed to evaluate patient distribution in the Dutch trauma system. Furthermore, we sought to identify factors associated with the undertriage and transport of severely injured patients (Injury Severity Score (ISS) >15) to the MTC by emergency medical services (EMS). METHODS: Data on all acute trauma admissions in the Netherlands (2015-2016) were extracted from the Dutch national trauma registry. An ambulance driving time model was applied to calculate MTC transport times and transport times of ISS >15 patients to the closest MTC and non-MTC. A multivariable logistic regression analysis was performed to identify factors associated with ISS >15 patients' EMS undertriage to an MTC. RESULTS: Of the annual average of 78,123 acute trauma admissions, 4.9% had an ISS >15. The nonseverely injured patients were predominantly treated at non-MTCs (79.2%), and 65.4% of patients with an ISS >15 received primary MTC care. This rate varied across the eleven Dutch trauma networks (36.8%-88.4%) and was correlated with the transport times to an MTC (Pearson correlation -0.753, p=0.007). The trauma networks also differed in the rates of secondary transfers of ISS >15 patients to MTC hospitals (7.8% - 59.3%) and definitive MTC care (43.6% - 93.2%). Factors associated with EMS undertriage of ISS >15 patients to the MTC were female sex, older age, severe thoracic and abdominal injury, and longer additional EMS transport times. CONCLUSIONS: Approximately one-third of all severely injured patients in the Netherlands are not initially treated at an MTC. Special attention needs to be directed to identifying patient groups with a high risk of undertriage. Furthermore, resources to overcome longer transport times to an MTC, including the availability of ambulance and helicopter services, may improve direct MTC care and result in a decrease in the variation of the undertriage of severely injured patients to MTCs among the Dutch trauma networks. Furthermore, attention needs to be directed to improving primary triage guidelines and instituting uniform interfacility transfer agreements.

Evaluation of the Berlin polytrauma definition: A Dutch nationwide observational study.

BACKGROUND: The Berlin polytrauma definition (BPD) was established to identify multiple injury patients with a high risk of mortality. The definition includes injuries with an Abbreviated Injury Scale score of ≥3 in ≥2 body regions (2AIS ≥3) combined with the presence of ≥1 physiological risk factors (PRFs). The PRFs are based on age, Glasgow Coma Scale, hypotension, acidosis, and coagulopathy at specific cutoff values. This study evaluates and compares the BPD with two other multiple injury definitions used to identify patients with high resource utilization and mortality risk, using data from the Dutch National Trauma Register (DNTR). METHODS: The evaluation was performed based on 2015 to 2018 DNTR data. First, patient characteristics for 2AIS ≥3, Injury Severity Score (ISS) of ≥16, and BPD patients were compared. Second, the PRFs prevalence and odds ratios of mortality for 2AIS ≥3 patients were compared with those from the Deutsche Gesellschaft für Unfallchirurgie Trauma Register. Subsequently, the association between PRF and mortality was assessed for 2AIS ≥3-DNTR patients and compared with those with an ISS of ≥16. RESULTS: The DNTR recorded 300,649 acute trauma admissions. A total of 15,711 patients sustained an ISS of ≥16, and 6,263 patients had suffered a 2AIS ≥3 injury. All individual PRFs were associated with a mortality of >30% in 2AIS ≥3-DNTR patients. The increase in PRFs was associated with a significant increase in mortality for both 2AIS ≥3 and ISS ≥16 patients. A total of 4,264 patients met the BPDs criteria. Overall mortality (27.2%), intensive care unit admission (71.2%), and length of stay were the highest for the BPD group. CONCLUSION: This study confirms that the BPD identifies high-risk patients in a population-based registry. The addition of PRFs to the anatomical injury scores improves the identification of severely injured patients with a high risk of mortality. Compared with the ISS ≥16 and 2AIS ≥3 multiple injury definitions, the BPD showed to improve the accuracy of capturing patients with a high medical resource need and mortality rate. LEVEL OF EVIDENCE: Epidemiological study, level III.

Adenovirus 7a: a community-acquired outbreak in a children's hospital.

BACKGROUND: Adenoviruses produce many illnesses in children, particularly respiratory and gastrointestinal disease. The most common adenoviral respiratory infections in children are caused by types 1, 2, 3 and 5. Adenoviruses spread rapidly in closed environments often causing epidemic disease. Serotype 7a has been responsible for outbreaks of respiratory disease in children living in close proximity with one another. This report describes a large community-acquired adenovirus 7a epidemic in hospitalized children. METHODS: Evaluation of all patients with cultures positive for adenovirus from a children's hospital-based virology laboratory during a recognized adenovirus outbreak. All such adenovirus isolates were typed, and patients with adenovirus 7a are described by review of medical records. RESULTS: Between March 1 and July 26, 1997, 47 children admitted to the hospital were identified as infected with adenovirus. Of these 47 patients 26 (55%) were infected with adenovirus 7a. Twenty-four (92%) infections were community-acquired. The age range was 11 days to 10 years with a median of 9.5 months. Twenty-two patients (84%) had respiratory symptoms, and 21 (8%) had fever, making these the most common symptoms. The mean durations of fever and hospitalization were 5.5 and 7 days, respectively. One of 26 patients died. CONCLUSIONS: Adenovirus 7a can cause large community epidemics affecting children. The disease produced by adenovirus 7a in children is almost exclusively of the respiratory tract, and in some individuals it may be very severe and possibly fatal.

Retarded Wallerian degeneration following peripheral nerve transection in C57BL/6/Ola mice is associated with delayed down-regulation of the P0 gene.

Wallerian degeneration is markedly retarded in C57BL/6/Ola mice, the majority of axons remaining intact for up to 10 days after sciatic transections. By 5 days after axotomy in normal mice P0 mRNA is markedly down-regulated, whereas high expression is present in the mutant mice at 7 days and is not reduced by a second distal axotomy. However, dissociated Schwann cells cultured without neurons down-regulate P0 in the normal manner. The data suggest that the continued expression of P0 mRNA is probably dependent on a relatively stable axonal signal with a low turnover that does not require continuous fast anterograde or retrograde transport. This may indicate an intrinsic axolemmal molecule(s) is involved in the neuronal signal.

Avoiding laparotomy in nonsurgical pneumoperitoneum.

Patients with free intraperitoneal air collections usually undergo emergency surgery, and the majority will have a gastrointestinal tract perforation. However, there is a subset of patients in whom no identifiable perforation is found at surgery. This entity of noniatrogenic, nonsurgical spontaneous pneumoperitoneum is being diagnosed more frequently at present and is commonly associated with other disease processes that, together, may suggest a benign process. Therefore, a diagnostic algorithm that would preclude operative intervention in this cohort of patients would be of paramount clinical importance. In this report, we present representative cases of the most common types of nonsurgical pneumoperitoneum, review the pathogenesis of this disorder, and discuss its relationship with pneumatosis cystoides intestinalis, pulmonary disorders, scleroderma, and gynecologic processes. Finally, we outline a diagnostic algorithm that may identify patients who can safely be observed, thereby reducing the incidence of negative laparotomies and, secondarily, the aggregate cost of health care.

Temporal relationships between induced changes in c-myc mRNA abundance, proliferation, and differentiation in HL60 cells.

Changes in the relative abundances of c-myc mRNA have been related to changes in other parameters of differentiation (histochemical, clonogenic) during the course of the differentiation of HL60 cells to monocytes/macrophages or to granulocytes. Induction of differentiation to monocytes/macrophages was marked by a rapid rate of appearance of committed cells (80 to 90% in 24 hours) and a concomitant rapid loss of c-myc mRNA. Induction of granulocytic differentiation resulted in a much slower rate of appearance of committed cells (50% in 48 hours), and a much faster rate of loss of c-myc mRNA (tenfold in 1 hour). These data are consistent with there being a direct link between down-regulation of the expression of c-myc and the onset of proliferation arrest and monocytic differentiation, but show there is no such association of c-myc mRNA abundance and proliferation or differentiation during the maturation of HL60 granulocytes.

Loss of axonal contact causes down-regulation of the PLP gene in oligodendrocytes: evidence from partial lesions of the optic nerve.

We have examined the influence that axons may have on the expression of proteolipid protein (PLP), the major myelin protein of the CNS. Partial transections were made of the optic nerve of adult rats to produce approximately a 50% loss of axons. Twenty-eight days after lesioning, sections of the distal nerves were immunostained for GFAP and neurofilament protein and hybridized for PLP mRNA. The area of astrocytosis, as defined by GFAP immunostaining, usually exceeded the extent of axonal loss. PLP mRNA expression in oligodendrocytes in the denervated area of the lesioned nerve was reduced compared to the innervated zones of the lesioned nerve and the contralateral intact nerve. This down-regulation correlated with the axonal loss rather than the area of astrocytosis. The data support the contention that axons are necessary for oligodendrocytes to maintain full expression of their major myelin protein genes.

Effect of optic nerve transection upon myelin protein gene expression by oligodendrocytes: evidence for axonal influences on gene expression.

The effect of optic nerve transection on myelin protein gene expression was studied in rats following axotomy at two ages: during active myelination (17 days of age) and after peak expression of the genes (35 days of age). mRNA levels for proteolipid protein, myelin basic protein and myelin-associated glycoprotein were assessed by northern and dot blotting and by in situ hybridization using tissue sections and cultured individual oligodendrocytes. Transection at 17 days caused down-regulation of mRNAs for proteolipid protein, myelin basic protein and myelin-associated glycoprotein by 5 days after axotomy with an increase in GFAP mRNA. A more protracted change followed axotomy at 35 days of age. The abundance of mRNAs for proteolipid protein and myelin basic protein was significantly reduced by 28 days after transection in the affected nerve. Quantification of proteolipid protein mRNA expression in individual oligodendrocytes confirmed the down-regulation. However, in contrast to the effects on the major myelin proteins, the abundance of myelin-associated glycoprotein mRNA increased in the affected nerve for at least the initial month after lesioning at 35 days. The results show that optic nerve transection has significant effects on myelin protein mRNA expression in oligodendrocytes of optic nerve. However, the changes in myelin protein gene activity are relatively small and more protracted than those seen in Schwann cells after peripheral nerve section. Because axotomy also causes marked changes in the glial population of the optic nerve it is not possible unequivocally to ascribe the alteration in gene expression to loss of axons. However, the data may provide evidence that axons do influence myelin protein genes in oligodendrocytes and are necessary for them to develop their full expression.

Expression of myelin protein gene transcripts by Schwann cells of regenerating nerve.

The expression of many myelin-specific molecules in Schwann cells is profoundly decreased following denervation. This study examines the early reexpression of myelin protein genes associated with reinnervation. Following sciatic nerve crush, the distal, regenerated nerve was divided into appropriate (2.5 or 5 mm) consecutive lengths in which gene expression was monitored using Northern blotting, in situ hybridization, and immunostaining. The spatial separation of the distal axon tip and the more proximally located Schwann cells showing initial upregulation of P0 mRNA was constant over the period of 5-13 days after crush at approximately 3-4 mm in fixed, processed material. Axons associated with Schwann cells showing the initial upregulation were completely or partially enveloped in Schwann cell cytoplasm, with very few having any degree of ensheathment. It is probable that only a limited axon-Schwann cell contact is required for induction of the myelin protein genes. Myelin-associated glycoprotein mRNA was upregulated prior to those for P0 and myelin basic protein which had similar time courses. Reexpression of galactocerebroside also preceded that for P0 mRNA. Signal abundance for all myelin proteins decreased in a proximal to distal direction from the crush site, and with time the "wave" of upregulation moved distally down the nerve. In the more proximal, remyelinating zones, the signal intensity exceeded that of the contralateral normal nerve. Signal intensity also varied considerably between adjacent, expressing Schwann cells. The data provide further evidence of the strong temporospatial relationship between axons and the regulation of myelin protein genes in Schwann cells.

Intracranial ultrasound diagnosis of neonatal periventricular leukomalacia.

Periventricular leukomalacia (PVL) is characterized by focal areas of white matter necrosis adjacent to the external angles of the lateral ventricles. The diagnosis of PVL has hitherto been limited to autopsy findings. The authors discuss pertinent literature and report in vivo diagnosis of nonhemorrhagic PVL by real-time intracranial ultrasonography. They recommend further study of ultrasound as a diagnostic method for evaluating infants at risk for PVL.

Effect of cooling on the responsiveness of canine tracheal muscle.

Airway cooling causes bronchoconstriction in many persons who have asthma. To determine the direct effect of cooling on the response of tracheal muscle to parasympathetic and muscarinic stimuli in situ, the temperature of a segment of canine cervical trachea was adjusted to 37 degrees, 30 degrees, or 25 degrees C by superfusing temperature-controlled saline over its epithelial surface. The contractile response of the tracheal muscle to electrical stimulation of the vagus nerves and to intra-arterial acetylcholine was then determined. Cooling the segment to 25 degrees C decreased the contraction induced by parasympathetic stimulation. However, cooling did not alter the contraction induced by intra-arterial acetylcholine. Parallel studies were conducted in vitro using nine excised tracheal muscle strips taken from the same section of trachea in three additional dogs. Cooling the tracheal muscle to 25 degrees C in vitro increased the maximal contraction induced by both electrical field stimulation and by acetylcholine. Thus, cooling in situ does not alter the response of tracheal muscle to muscarinic stimuli and inhibits the response to parasympathetic stimuli. These data indicate that augmentation of the tracheal muscle response elicited by cooling in vitro does not reflect the response in situ. They suggest that a direct effect of cooling on airway smooth muscle response to parasympathetic and muscarinic stimuli does not account for cooling-induced bronchoconstriction in vivo.

Expression of myelin protein genes in Schwann cells.

The expression of myelin protein genes in Schwann cells has been studied in situ hybridization. 35S-UTP-labelled, antisense and sense RNA probes to the major protein Po, myelin basic protein (MBP), myelin-associated glycoprotein (MAG) and proteolipid protein (PLP) were employed with paraffin-embedded sections, teased fibres and dissociated Schwann cells from sciatic nerves of rats. Teased fibres were also prepared from cervical sympathetic trunks. Po mRNA was strongly expressed in the mid-internodal perinuclear area of Schwann cell cytoplasm. The degree of signal appeared to be related to fibre size. MBP mRNA showed a diffuse pattern along the Schwann cell internode with a marked increase in grains at the paranodal cytoplasm, particularly in larger fibres. This distribution suggests that the paranodal area is a major site of insertion of MBP into myelin membrane. The expression of MAG and PLP mRNA was markedly lower than Po and MBP. Both mRNAs were localized in the perinuclear cytoplasm and showed a dependence on fibre size. No significant signal was present in Schwann cells associated with unmyelinated axons. In addition to providing data on the cellular expression of myelin protein genes, these studies have shown that teased fibres are invaluable in allowing the localization of low abundance mRNAs.

P0 gene expression in cultured Schwann cells.

This study examines the expression of the major myelin protein gene P0 in cultured Schwann cells, grown on their own or in association with neurons. Many freshly dissociated Schwann cells from actively myelinating nerves express Po mRNA in high abundance. If neurons are not present, signal intensity falls markedly with time so that by 7 days in culture only a basal expression is evident which is negligible compared to the level in vivo. Dorsal root ganglia from embryo day 16 (E16) rats contain no significant levels of Po mRNA but when grown in full myelinating medium (containing serum and embryo extract) increasing expression is seen from 4 to 5 days onward even though myelination does not occur until after the second week. In this intervening period the intensity of P0 mRNA expression is lower than that found in the actively myelinating cell. Neurons from sympathetic ganglia are also capable of inducing P0 mRNA expression. Schwann cells in dorsal root ganglia explants grown in serum-free defined medium do not assemble a basal lamina and will not wrap or myelinate axons. Nevertheless P0 mRNA, but not protein, is expressed in levels similar to those found in full myelinating medium prior to myelination. Such Schwann cells also exhibit galactocerebroside and the sulphatide recognised by the 04 antibody. It appears that in defined medium or in myelinating medium prior to myelination axonal signals can induce P0 mRNA expression to a certain degree. However, full up-regulation is usually associated with the rapid membrane expansion accompanying myelination. Whether this augmented up-regulation is due to further axonal signalling or events in the Schwann cell is unknown, but the results suggest that P0 expression can be regulated at several stages of synthesis.