Establishing Outcome Parameters for Helicopter Emergency Medical Services Research in the Netherlands: Results of a Mixed-Methods Delphi Consensus Study.

OBJECTIVES: Physician staffed Helicopter Emergency Medical Services (P-HEMS) care in the Netherlands has transitioned from predominantly trauma management to handling a variety of medical conditions. Relevant outcome parameters for Dutch P-HEMS research have not been previously defined. National consensus was sought to identify relevant long term patient outcome parameters, process outcome parameters and performance outcome parameters for Dutch P-HEMS care. METHODS: This was a mixed methods Delphi consensus study. A list of potentially relevant outcome parameters was identified using a systematic literature review. These parameters were subsequently surveyed in a Delphi consensus study. Helicopter Emergency Medical Services physicians and relevant stakeholders were invited to participate in this Delphi survey, where they were allowed to suggest additional outcome parameters. Descriptive analysis was performed on all data sets. RESULTS: Forty-nine potential outcome parameters for Dutch P-HEMS care were surveyed. Of 71 invited participants, 53 (75%), 40 (56%), and 20 (28%) participated in the first, second, and third round of the Delphi study, respectively. Consensus was reached on 25 (51%) of 49 outcome parameters as being important. These consisted of seven long term patient related outcome parameters, four short term patient related outcome parameters, five process outcome parameters and nine performance outcome parameters. CONCLUSIONS: In conclusion, this study identified 25 outcome parameters relevant for Dutch physician staffed HEMS care. These parameters should be considered when designing future studies and should be routinely collected for each dispatch if possible.

Transanal endoscopic surgery for complications of prior rectal surgery.

BACKGROUND: Long-term complications of previous rectal surgery (e.g., enterovisceral fistula, anastomotic stricture, rectal stenosis) can be challenging problems for which transabdominal or transperineal surgery with or without definitive fecal diversion is often required. Transanal endoscopic surgery (TES) might allow for local treatment of these complications, thereby saving patients from otherwise major surgery. PATIENTS AND METHODS: All patients undergoing TES in the IJsselland Hospital (NL) since 1996 were recorded in a prospective database, of which twenty patients were treated for complications after previous rectal surgery. Data on prior treatment, surgical techniques, outcomes, and need for additional surgery were collected. RESULTS: Twenty patients were identified from the database (rectourinary fistula n = 3, rectovaginal fistula n = 5, anastomotic stricture n = 8, and rectal stenosis n = 4). One of the three (33 %) rectourinary fistulas and two of five (40 %) rectovaginal fistulas were successfully treated with TES. Anastomotic strictures were successfully treated in 5/8 (63 %) patients. Strictures after local excision of rectal tumors were successfully treated in 3/4 (75 %) patients. No minor complication and one major complication occurred (rectovaginal fistula after stenoplasty eventually requiring Hartmann's procedure). CONCLUSIONS: Transanal treatment of anastomotic strictures, rectal stenosis, and fistula after prior rectal surgery is safe and effective in a large proportion of patients. TES should be considered as a first step in all patients presenting with these late complications after rectal surgery.

Sarcopenia impairs survival in patients with potentially curable hepatocellular carcinoma.

BACKGROUND: A reduction in skeletal muscle mass (sarcopenia) independently predicts poor survival in patients with hepatocellular carcinoma (HCC) undergoing treatment with curative intent. Whether this is due to an increased risk of recurrence and disease specific death, or due to an increased risk of postoperative morbidity and mortality is currently unclear. In this study, we investigate the association between sarcopenia and death in a cohort of HCC patients undergoing treatment with curative intent. METHODS: Patients undergoing surgical resection or radiofrequency ablation for lesions ≤ 3 cm between 2002 and 2013 were identified. Clinicopathological characteristics, CT-assessed sarcopenia and outcomes were analyzed. RESULTS: Among 90 patients, 52 (57.8%) were found to be sarcopenic. Sarcopenic patients had a limited overall survival (median: 33 months vs. non-sarcopenic median: 105 months; P = 0.002), but not disease-free survival. Sarcopenia was an independent predictor for overall survival in multivariate Cox-regression analysis (HR 3.756; P = 0.001). Major complications (32.7% vs. 13.2%, P = 0.033) and treatment-related mortality (17.3% vs. 2.6%, P = 0.029) were more frequent in sarcopenic patients. CONCLUSION: Sarcopenia impairs survival in patients with potentially curable hepatocellular carcinoma, mainly due to an increase in treatment-related mortality.

Talus-derived reference coordinate system for 3D calcaneal assessment: A novel approach to improve morphological measurements.

In 3D-analysis of the calcaneus, a consistent coordinate system aligned with the original anatomical directions is crucial for pre- and postoperative analysis. This importance stems from the calcaneus's key role in weight-bearing and biomechanical alignment. However, defining a reliable coordinate system based solely on fractured or surgically reconstructed calcanei presents significant challenges. Given its anatomical prominence and consistent orientation, the talus offers a potential solution to this challenge. Our work explores the feasibility of talus-derived coordinate systems for 3D-modeling of the calcaneus across its various conditions. Four methods were tested on nonfractured, fractured and surgically reconstructed calcanei, utilizing Principal Component Analysis, anatomical landmarks, bounding box, and an atlas-based approach. The methods were compared with a self-defined calcaneus reference coordinate system. Additionally, the impact of deviation of the coordinate system on morphological measurements was investigated. Among methods for constructing nonfractured calcanei coordinate systems, the atlas-based method displayed the lowest Root Mean Square value in comparison with the reference coordinate system. For morphological measures like Böhler's Angle and the Critical angle of Gissane, the atlas talus-based system closely aligned with ground truth, yielding differences of 0.6° and 1.2°, respectively, compared to larger deviations seen in other talus-based coordinate systems. In conclusion, all tested methods were feasible for creating a talus derived coordinate system. A talus derived coordinate system showed potential, offering benefits for morphological measurements and clinical scenarios involving fractured and surgically reconstructed calcanei. Further research is recommended to assess the impact of these coordinate systems on surgical planning and outcomes.

Deferred consent in emergency trauma research: A qualitative study assessing the healthcare professional's opinions.

INTRODUCTION: Severely injured patients are often incapacitated to provide informed consent for clinical studies. Deferred consent could facilitate unbiased enrollment in studies involving these patients. Little is known about how healthcare professionals (HCPs) perceive deferred consent and how this impacts patient enrollment. The aim of this study was to identify factors that could influence HCPs decision-making during recruitment of patients for interventional studies in (pre)hospital emergency trauma research. METHODS: This was a qualitative study in which physicians and nurses working in prehospital or in-hospital care were interviewed using a semi-structured interview guide. Interviews were audio-recorded, transcribed, and analyzed according to thematic analysis as described by Braun and Clarke. RESULTS: Ten semi-structured interviews were conducted with six physicians and four nurses. Eight themes were identified as being relevant consent related factors influencing HCPs' decision-making during patient recruitment in studies using deferred consent: (1) HCPs' lack of knowledge; (2) Patients' and proxies' inability to be informed; (3) Practical (im)possibilities for informed consent; (4) Nature of intervention; (5) HCPs' personal beliefs; (6) Importance of emergency care research; (7) HCPs' trust in legal base; and (8) Communication and collaboration. CONCLUSIONS: Eight consent-related factors influencing HCPs' decision making were identified. Insufficient knowledge about consent procedures among HCPs leads to significant negative attitudes towards deferred consent.

Non-compressible truncal and junctional hemorrhage: A retrospective analysis quantifying potential indications for advanced bleeding control in Dutch trauma centers.

BACKGROUND: Truncal and junctional hemorrhage is the leading cause of potentially preventable deaths in trauma patients. To reduce this mortality, the application of advanced bleeding control techniques, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), junctional tourniquets, Foley catheters, or hemostatic agents should be optimized. This study aimed to identify trauma patients with non-compressible truncal and junctional hemorrhage (NCTJH) who might benefit from advanced bleeding control techniques during initial trauma care. We hypothesized that there is a substantial cohort of Dutch trauma patients that can possibly benefit from advanced bleeding control techniques. METHODS: Adult trauma patients with an Abbreviated Injury Scale ≥3 in the torso, neck, axilla, or groin region, who were presented between January 1st, 2014 and December 31st, 2018 to two Dutch level-1 trauma centers, were identified from the Dutch Trauma Registry. Potential indications for advanced bleeding control in patients with NCTJH were assessed by an expert panel of three trauma surgeons based on injury characteristics, vital signs, response to resuscitation, and received treatment. RESULTS: In total, 1719 patients were identified of whom 249 (14.5 %) suffered from NCTJH. In 153 patients (60.6 %), hemorrhagic shock could have been mitigated or prevented with advanced bleeding control techniques. This group was younger and more heavily injured: median age of 40 versus 48 years and median ISS 33 versus 22 as compared to the entire cohort. The mortality rate in these patients was 31.8 %. On average, each of the included level-1 trauma centers treated an NCTJH patient every 24 days in whom a form of advanced bleeding control could have been beneficial. CONCLUSIONS: More than half of included Dutch trauma patients with NCTJH may benefit from in-hospital application of advanced bleeding control techniques, such as REBOA, during initial trauma care. Widespread implementation of these techniques in the Dutch trauma system may contribute to reduction of mortality and morbidity from non-compressible truncal and junctional hemorrhage.

Patients' Preferences for Bone-Anchored Prostheses After Lower-Extremity Amputation: A 2-Center Discrete Choice Experiment in The Netherlands (PREFER-BAP-1).

BACKGROUND: The rising popularity and use of a bone-anchored prosthesis (BAP) involving an osseointegrated implant for patients with lower-limb amputations experiencing socket-related issues have led to increased interest in the measurement of clinical and functional outcomes. However, the value of BAP treatment characteristics from the patient perspective has not yet been investigated. This study aimed to determine the relative importance of specific BAP characteristics, and the effect of complications in quality-of-life (QoL) points and monetary utility decrement (loss [€]), using a 2-center discrete choice experiment (DCE) conducted in The Netherlands. METHODS: A DCE was developed that included the most salient characteristics of BAP treatment based on a review of the literature and qualitative and quantitative methods. The following characteristics were selected: QoL change, short- and long-term complications, osseointegrated implant survival, and out-of-pocket contributions (costs). Patients aged 18 to 99 years who were eligible for, or had already received, an osseointegrated implant were invited to participate, after informed consent, to elicit BAP treatment preferences. A Bayesian mixed logit model was used. RESULTS: Two hundred and forty-seven completed surveys were collected; 64% of the patients were male, 73% had undergone a transfemoral amputation, and 33% had >36 months of experience with a BAP. Patients considered long-term complications and QoL the most important characteristics. Long-term complications were 3.4 times more important than short-term complications. Opting out was undesirable, and patients valued better and beneficial levels (associated with better outcomes) of BAP characteristics positively. Implant removal was the level with the greatest loss among all complications, at 1.15 (95% credible interval [CI], 0.96 to 1.38) QoL points and €16,940 (95% CI, €14,780 to €19,040) loss. CONCLUSIONS: To our knowledge, this is the first study to use a DCE to elicit patients' preferences regarding BAP treatment, outcomes, and related complications; we found that patients strongly care about long-term complications. The results suggest that osseointegrated implant teams and policy-makers should consider these areas when proposing treatment protocols. Furthermore, policy and clinical guidelines for BAP treatment could be enhanced by our results with respect to patients' perspectives, management of patients' expectations, and associated losses in QoL points and monetary loss secondary to complications. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Emergency reflex action drill for traumatic cardiac arrest in a simulated pre-hospital setting; a one-group pre-post intervention study.

BACKGROUND: Emergency Reflex Action Drills (ERADs) are meant to decrease stress-associated cognitive demand in high urgency situations. The aim of this study was to develop and test an ERAD for witnessed traumatic cardiac arrest (TCA), an event in which potentially reversible causes need to be systematically addressed and treated in a short period of time. We hypothesize that this ERAD (the TCA-Drill) helps ground Emergency Medical Services (EMS) nurses in overcoming performance decline during this specific high-pressure situation. METHODS: This was a prospective, experimental one-group pre-post intervention study. Ground EMS nurses participated in a session of four simulated scenarios, with an in-between educational session to teach the TCA-Drill. Scenarios were video recorded, after which adherence and time differences were analyzed. Self-confidence on clinical practice was measured before and after the scenarios. RESULTS: Twelve ground EMS nurses participated in this study. Overall median time to address reversible causes of TCA decreased significantly using the TCA-Drill (132 vs. 110 s; p = 0.030) compared with the conventional ALS strategy. More specifically, participants adhering to the TCA-Drill showed a significantly lower time needed for hemorrhage control (58 vs. 37 s; p = 0.012). Eight of 12 (67 %) ground EMS nurses performed the ERAD without protocol deviations. Reported self-confidence significantly increased on 11 of the 13 surveyed items. CONCLUSIONS: The use of an ERAD for TCA (the TCA-Drill) significantly reduces the time to address reversible causes for TCA without delaying chest compressions in a simulated environment and can be easily taught to ground EMS nurses and increases self-confidence. IMPLICATIONS FOR CLINICAL PRACTICE: The use of an ERAD for TCA (the TCA-Drill can significantly reduce the time to address reversible causes for TCA without delaying chest compression. This drill can be easily taught to ground EMS nurses and increases their self-confidence in addressing TCA-patients.

A novel method to perform morphological measurements on three-dimensional (3D) models of the calcaneus based on computed tomography (CT)-imaging.

Background: While current preoperative and postoperative assessment of the fractured and surgically reconstructed calcaneus relies on computed tomography (CT)-imaging, there are no established methods to quantify calcaneus morphology on CT-images. This study aims to develop a semi-automated method for morphological measurements of the calcaneus on three-dimensional (3D) models derived from CT-imaging. Methods: Using CT data, 3D models were created from healthy, fractured, and surgically reconstructed calcanei. Böhler's angle (BA) and Critical angle of Gissane (CAG) were measured on conventional lateral radiographs and corresponding 3D CT reconstructions using a novel point-based method with semi-automatic landmark placement by three observers. Intraobserver and interobserver reliability scores were calculated using intra-class correlation coefficient (ICC). In addition, consensus among observers was calculated for a maximal allowable discrepancy of 5 and 10 degrees for both methods. Results: Imaging data from 119 feet were obtained (40 healthy, 39 fractured, 40 reconstructed). Semi-automated measurements on 3D models of BA and CAG showed excellent reliability (ICC: 0.87-1.00). The manual measurements on conventional radiographs had a poor-to-excellent reliability (ICC: 0.22-0.96). In addition, the percentage of consensus among observers was much higher for the 3D method when compared to conventional two-dimensional (2D) measurements. Conclusions: The proposed method enables reliable and reproducible quantification of calcaneus morphology in 3D models of healthy, fractured and reconstructed calcanei.

Opportunities and barriers for prehospital emergency medical services research in the Netherlands; results of a mixed-methods consensus study.

INTRODUCTION: Quality improvement in prehospital emergency medical services (EMS) can only be achieved by high-quality research and critical appraisal of current practices. This study examines current opportunities and barriers in EMS research in the Netherlands. METHODS: This mixed-methods consensus study consisted of three phases. The first phase consisted of semi-structured interviews with relevant stakeholders. Thematic analysis of qualitative data derived from these interviews was used to identify main themes, which were subsequently discussed in several online focus groups in the second phase. Output from these discussions was used to shape statements for an online Delphi consensus study among relevant stakeholders in EMS research. Consensus was met if 80% of respondents agreed or disagreed on a particular statement. RESULTS: Forty-nine stakeholders participated in the study; qualitative thematic analysis of the interviews and focus group discussions identified four main themes: (1) data registration and data sharing, (2) laws and regulations, (3) financial aspects and funding, and (4) organization and culture. Qualitative data from the first two phases of the study were used to construct 33 statements for an online Delphi study. Consensus was reached on 21 (64%) statements. Eleven (52%) of these statements pertained to the storage and use of EMS patient data. CONCLUSION: Barriers for prehospital EMS research in the Netherlands include issues regarding the use of patient data, privacy and legislation, funding and research culture in EMS organizations. Opportunities to increase scientific productivity in EMS research include the development of a national strategy for EMS data and the incorporation of EMS topics in research agendas of national medical professional associations.

Impact of Point-of-Care Ultrasound on Prehospital Decision Making by HEMS Physicians in Critically Ill and Injured Patients: A Prospective Cohort Study.

INTRODUCTION: Several studies have shown the additional benefit of point-of-care ultrasound (POCUS) by prehospital Emergency Medical Services (EMS). Since organization of EMS may vary significantly across countries, the value of POCUS likely depends on the prehospital system in which it is used. In order to be able to optimally implement POCUS and develop a tailored training curriculum, it is important to know how often POCUS is currently used, for which indications it is used, and how it affects decision making. The aims of this study were: (1) to determine the percentage of patients in whom POCUS was used by Dutch Helicopter Emergency Medical Services (HEMS) crews; (2) to determine how often POCUS findings led to changes in on-scene management; and (3) what these changes were. METHODS: Patients who received prehospital care from December 1, 2020 through March 31, 2021 by a single HEMS crew were included in this prospective cohort study. Clinical data and specific data on POCUS examination, findings, and therapeutic consequences were collected and analyzed. RESULTS: During the study period, on-scene HEMS care was provided to 612 patients, of which 211 (34.5%) patients underwent POCUS. Of these, 209 (34.2%) patients with a median age of 45 years were included. There were 131 (62.7%) trauma patients, and 70 (33.7%) of the included patients underwent cardiopulmonary resuscitation (CPR). The median reported time of POCUS examination was three (P25-P75 2-5) minutes. Median prolongation of on-scene time was zero (P25-P75 0-1) minutes. In 85 (40.7%) patients, POCUS examination had therapeutic consequence: POCUS was found to impact treatment decisions in 34 (26.0%) trauma patients and 51 (65.4%) non-trauma patients. In patients with cardiac arrest, POCUS was most often used to aid decision making with regard to terminating or continuing resuscitation (28 patients; 13.4%). CONCLUSION: During the study period, POCUS examination was used in 34.5% of all prehospital HEMS patients and had a therapeutic consequence in 40.7% of patients. In trauma patients, POCUS seems to be most effective for patient triage and evaluation of treatment effectiveness. Moreover, POCUS can be of significant value in patients undergoing CPR. A tailored HEMS POCUS training curriculum should include ultrasound techniques for trauma and cardiac arrest.

3D-printed patient specific instruments for corrective osteotomies of the lower extremity.

3D-printing has become a promising adjunct in orthopedic surgery over the past years. A significant drop in costs and increased availability of the required hardware and software needed for using the technique, have resulted in a relatively fast adaptation of 3D-printing techniques for various indications. In this review, the role of 3D-printing for deformity corrections of the lower extremity is described.

Personalized 3D-printed forearm braces as an alternative for a traditional plaster cast or splint; A systematic review.

Forearm fractures such as distal radius fractures are traditionally treated with a plaster or synthetic cast. Patients commonly report inconvenience of the cast, skin problems, and occasionally radial sensory nerve numbness. A known issue with casting is that the rate of secondary dislocation is high. As an alternative to casts, personalized 3D-printed braces are increasingly used. This review provides an inventory of current developments and experience with 3D-printed forearm braces. Main focus was on the design requirements, materials used, technical requirements, and preclinical and clinical results. Review of 12 studies showed that all printed braces used an open design. Fused Deposition Modelling is most commonly used 3D-printing technique (seven studies) and polylactic acid is the most commonly used material (five studies). Clinical evaluation was done in six studies, mainly involving distal radius fractures, and generally showed a low complication rate and high patient satisfaction with the printed brace. Whether or not the results obtained with 3D-printed braces are superior to results after casting requires further studies.

Comparing restrictive versus liberal oxygen strategies for trauma patients - the TRAUMOX2 trial: protocol for a randomised clinical trial.

INTRODUCTION: Supplemental oxygen is commonly used in trauma patients, although it may lead to hyperoxaemia that has been associated with pulmonary complications and increased mortality. The primary objective of this trial, TRAUMOX2, is to compare a restrictive versus liberal oxygen strategy the first 8 hours following trauma. METHODS AND ANALYSIS: TRAUMOX2 is an investigator-initiated, international, parallel-grouped, superiority, outcome assessor-blinded and analyst-blinded, randomised, controlled, clinical trial.Adult patients with suspected major trauma are randomised to eight hours of a restrictive or liberal oxygen strategy. The restrictive group receives the lowest dosage of oxygen (>21%) that ensures an SpO2 of 94%. The liberal group receives 12-15 L O2/min or FiO2=0.6-1.0.The primary outcome is a composite of 30-day mortality and/or development of major respiratory complications (pneumonia and/or acute respiratory distress syndrome).With 710 participants in each arm, we will be able to detect a 33% risk reduction with a restrictive oxygen strategy if the incidence of our primary outcome is 15% in the liberal group. ETHICS AND DISSEMINATION: TRAUMOX2 is carried out in accordance with the Helsinki II Declaration. It has been approved by the Danish Committee on Health Research Ethics for the Capital Region (H-21018062) and The Danish Medicines Agency, as well as the Dutch Medical Research Ethics Committee Erasmus MS (NL79921.078.21 and MEC-2021-0932). A website (www.traumox2.org) is available for updates and study results will be published in an international peer-reviewed scientific journal. TRIAL REGISTRATION NUMBERS: EudraCT 2021-000556-19; NCT05146700.

Safety and efficacy of radiofrequency ablation for hepatocellular adenoma.

PURPOSE: To investigate the safety and efficacy of radiofrequency (RF) ablation for the treatment of hepatocellular adenoma (HCA). MATERIALS AND METHODS: From 2000 to 2009, 170 patients with HCA were referred to a single tertiary hepatobiliary center. Medical records of 18 patients treated with RF ablation were retrospectively analyzed. RESULTS: All patients were female, and the majority had a history of hormonal contraceptive use. Ten patients (56%) had multiple HCAs, with a median number of two lesions (range, one to 12) per patient. Median size of HCA at the time of RF ablation was 3.0 cm (range, 0.8-7.3 cm). A total of 45 HCAs were ablated in 32 sessions (open, n = 4; percutaneous, n = 28). RF ablation was complete after the first session in 26 HCAs (57.8%), and the majority of patients underwent multiple RF ablation sessions to fully ablate all HCAs. Major complications developed in two patients. CONCLUSIONS: RF ablation can be used effectively in the treatment of HCA. However, multiple sessions are often required, and signs of residual adenoma might persist in some patients despite repetitive treatment. RF ablation might be especially beneficial in cases not amenable to surgery or in patients who would require major hepatic resection otherwise.

Development of hepatic pseudotumors for image-guided interventional and surgical research in a large animal model.

PURPOSE: Real-time image guidance and navigation have become increasingly important in an era of minimally invasive interventional and surgical procedures in the liver. To develop, test, and implement tools for real-time image guidance, the authors sought to create an in vivo tumor mimic with realistic imaging and treatment capabilities. MATERIALS AND METHODS: Hepatic pseudotumors were created by injecting 1-2 mL of alginate (a hydrocolloid) directly into the liver parenchyma in eight live pigs and two dog cadavers. Tumors were imaged by B-mode ultrasound (US), US elasticity imaging, multi-detector row computed tomography (CT), CT fluoroscopy, and magnetic resonance (MR) imaging to assess imaging capabilities. Procedures performed with the alginate pseudotumors included radiofrequency (RF) ablation and robotic needle guidance. RESULTS: Twenty-four hepatic pseudotumors were created, ranging in size from 10 mm to 28 mm at an average depth of 6 mm. Average time of preparation and insertion was 3 minutes. All tumors were palpable under the surface of the liver and were easily visible on B-mode US, US elasticity imaging, CT, and MR imaging. Tumors were successfully "treated" with RF ablation, and gross examination of the liver showed good encompassment of the tumor by the zone of thermal coagulation. In addition, the pseudotumors allowed for easy introduction of various types of needles, including RF ablation probes and experimental steerable needles. CONCLUSIONS: Alginate pseudotumors can easily be imaged and allow for different procedures to be performed. This model can be used for various research purposes.

Sarcopenia negatively impacts short-term outcomes in patients undergoing hepatic resection for colorectal liver metastasis.

BACKGROUND: As indications for liver resection expand, objective measures to assess the risk of peri-operative morbidity are needed. The impact of sarcopenia on patients undergoing liver resection for colorectal liver metastasis (CRLM) was investigated. METHODS: Sarcopenia was assessed in 259 patients undergoing liver resection for CRLM by measuring total psoas area (TPA) on computed tomography (CT). The impact of sarcopenia was assessed after controlling for clinicopathological factors using multivariate modelling. RESULTS: Median patient age was 58 years and most patients (60%) were male. Forty-one (16%) patients had sarcopenia (TPA ≤ 500 mm(2) /m(2) ). Post-operatively, 60 patients had a complication for an overall morbidity of 23%; 26 patients (10%) had a major complication (Clavien grade ≥3). The presence of sarcopenia was strongly associated with an increased risk of major post-operative complications [odds ratio (OR) 3.33; P= 0.008]. Patients with sarcopenia had longer hospital stays (6.6 vs. 5.4 days; P= 0.03) and a higher chance of an extended intensive care unit (ICU) stay (>2 days; P= 0.004). On multivariate analysis, sarcopenia remained independently associated with an increased risk of post-operative complications (OR 3.12; P= 0.02). Sarcopenia was not significantly associated with recurrence-free [hazard ratio (HR) = 1.07] or overall (HR = 1.05) survival (both P > 0.05). CONCLUSIONS: Sarcopenia impacts short-, but not long-term outcomes after resection of CRLM. While patients with sarcopenia are at an increased risk of post-operative morbidity and longer hospital stay, long-term survival is not impacted by the presence of sarcopenia.

Outcomes after Prehospital Traumatic Cardiac Arrest in the Netherlands: a Retrospective Cohort Study.

BACKGROUND: Traumatic cardiac arrest (TCA) is a severe and life-threatening situation that mandates urgent action. Outcomes after on-scene treatment of TCA in the Netherlands are currently unknown. The aim of the current study was to investigate the rate of survival to discharge in patients who suffered from traumatic cardiac arrest and who were subsequently treated on-scene by the Dutch Helicopter Emergency Medical Services (HEMS). METHODS: A retrospective cohort study was performed including patients ≥ 18 years with TCA for which the Dutch HEMS were dispatched between January 1st 2014 and December 31st 2018. Patients with TCA after hanging, submersion, conflagration or electrocution were excluded. The primary outcome measure was survival to discharge after prehospital TCA. Secondary outcome measures were return of spontaneous circulation (ROSC) on-scene and neurological status at hospital discharge. RESULTS: Nine-hundred-fifteen patients with confirmed TCA were included. ROSC was achieved on-scene in 261 patients (28.5%). Thirty-six (3.9%) patients survived to hospital discharge of which 17 (47.2%) had a good neurological outcome. Age < 70 years (0.7% vs. 5.2%; p=0.041) and a shockable rhythm on first ECG (OR 0.65 95%CI 0.02-0.28; p<0.001) were associated with increased odds of survival. CONCLUSION: Neurologic intact survival is possible after prehospital traumatic cardiac arrest. Younger patients and patients with a shockable ECG rhythm have higher survival rates after TCA. LEVEL OF EVIDENCE: prognostic study, level III.

Factors determining the sensitivity of intraoperative ultrasonography in detecting colorectal liver metastases in the modern era.

BACKGROUND: With improved preoperative cross-sectional imaging, the added clinical value of intraoperative ultrasonography (IOUS) in the detection of colorectal liver metastases (CRLM) is unclear. Specifically, the ability of IOUS to detect additional liver metastases during surgery and its relationship between clinical and lesion specific ultrasonographic characteristics remains ill-defined. The purpose of the current study was to determine the association of clinical parameters and tumor echogenicity with the ability of IOUS to detect occult CRLM. MATERIALS AND METHODS: A total of 213 patients undergoing surgical exploration and IOUS for CRLM between 1998 and 2009 were included in the study. All patients underwent preoperative multidetector computed tomography (CT) imaging and lesion detection was compared with those identified by IOUS. In addition, early (<6 months) intrahepatic recurrence was used as a surrogate for residual disease (e.g., metastases that were undetected on initial IOUS). The influence of various characteristics on the rate in which additional metastases were detected and the rate of early intrahepatic recurrence was examined. RESULTS: Overall, IOUS detected additional liver metastases in 10% of patients (n = 22). Detection of additional metastases was significantly higher in patients with multiple (≥4) tumors (P < 0.001) and hypoechoic tumors (P = 0.007). Of 153 patients undergoing resection only, 17 (11%) had an early intrahepatic recurrence. This was more common in patients with isoechoic metastases during IOUS (P = 0.03). CONCLUSIONS: Even with the use of modern cross-sectional preoperative imaging, IOUS detects additional liver metastases in 10% of patients. In addition, the sensitivity of IOUS for detecting occult CRLM is highly dependent on the number and echogenicity of detected tumors.

Safety and efficacy of curative intent surgery for peri-ampullary liver metastasis.

INTRODUCTION: The management of patients with peri-ampullary liver metastasis remains controversial. We sought to assess the safety and efficacy of curative intent surgery for peri-ampullary liver metastasis. METHODS: Between 1993 and 2009, 40 patients underwent curative intent surgery (resection and/or radiofrequency ablation (RFA)) for peri-ampullary liver metastasis. Clinicopathologic and outcome data were collected and analyzed. RESULTS: Location of the primary tumor was pancreas head (n = 20), ampulla of Vater (n = 10), distal bile duct (n = 5), or duodenum (n = 5). Most patients (n = 27) presented with synchronous disease, while 13 patients presented with metachronous disease following a median disease-free interval of 22 months. Most patients (n = 25) presented with hepatic metastasis from pancreaticobiliary origin (pancreatic or distal common bile duct) compared with 15 patients who had metastasis from an intestinal-type primary (ampullary or duodenal). There were no differences in metastatic tumor number or size between these groups (P > 0.05). Post-operative morbidity and mortality was 30% and 5% respectively. Overall 1- and 3-year survival was 55% and 18%. Patients who underwent resection of liver metastasis from intestinal-type tumors experienced a longer survival compared with patients who had pancreaticobiliary lesions (median: 13 months vs. 23 months; P = 0.05). CONCLUSION: Curative intent surgery for peri-ampullary liver metastasis was associated with post-operative morbidity and a 5% mortality rate. Although the overall survival benefit was modest, patients with liver metastasis from intestinal-type tumors experienced improved survival following resection of liver metastasis compared with pancreaticobiliary lesions.