Identifying the severely injured benefitting from a specific level of trauma care in an inclusive network: A multicentre retrospective study.

INTRODUCTION: Defining major trauma (MT) with an Injury Severity Score (ISS) > 15 has limitations. This threshold is used for concentrating MT care in networks with multiple levels of trauma care. OBJECTIVE: This study aims to identify subgroups of severely injured patients benefiting on in-hospital mortality and non-fatal clinical outcome measures in an optimal level of trauma care. METHODS: A multicentre retrospective cohort study on data of the Dutch National Trauma Registry, region South West, from January 1, 2015 until December 31, 2019 was conducted. Patients ≥ 16 years admitted within 48 h after trauma transported with (H)EMS to a level I trauma centre (TC) or a non-level I trauma facility with a Maximum Abbreviated Injury Scale (MAIS) ≥ 3 were included. Patients with burns or patients of ≥ 65 years with an isolated hip fracture were excluded. Logistic regression models were used for comparing level I with non-level I. Subgroup analysis were done for MT patients (ISS > 15) and non-MT patients (ISS 9-14). RESULTS: A total of 7,493 records were included. In-hospital mortality of patients admitted to a non-level I trauma facility did not differ significantly from patients admitted to the level I TC (adjusted Odds Ratio (OR): 0.94; 95% confidence interval (CI) 0.68-1.30). This was also applicable for MT patients (OR: 1.06; 95% CI 0.73-1.53) and non-MT patients (OR: 1.30; 95% CI (0.56-3.03). Hospital and ICU LOS were significantly shorter for patients admitted to a non-level I trauma facilities, and patients admitted to a non-level I trauma facility were more likely to be discharged home. Findings were confirmed for MT and non-MT patients, per injured body region. CONCLUSION: All levels of trauma care performed equally on in-hospital mortality among severely injured patients (MAIS ≥ 3), although patients admitted to the level I TC were more severely injured. Subgroups of patients by body region or ISS, with a survival benefit or more favorable clinical outcome measures were not identified. Subgroups analysis on clinical outcome measures across different levels of trauma care in an inclusive trauma network is too simplistic if subgroups are based on injuries in specific body region or ISS only.

Comparing health status after major trauma across different levels of trauma care.

INTRODUCTION: Mortality due to trauma has reduced the past decades. Trauma network implementations have been an important contributor to this achievement. Besides mortality, patient reported outcome parameters should be included in evaluation of trauma care. While concentrating major trauma care, hospitals are designated with a certain level of trauma care following specific criteria. OBJECTIVE: Comparing health status of major trauma patients after two years across different levels of trauma care in trauma networks. METHODS: Multicentre observational study comprising a secondary longitudinal multilevel analysis on prospective cohorts from two neighbouring trauma regions in the Netherlands. INCLUSION CRITERIA: patient aged ≥ 18 with an ISS > 15 surviving their injuries at least one year after trauma. Health status was measured one and two years after trauma by EQ-5D-5 L, added with a sixth health dimension on cognition. Level I trauma centres were considered as reference in uni- and multivariate analysis. RESULTS: Respondents admitted to a level I trauma centre scored less favourable EQ-US and EQ-VAS in both years (0.81-0.81, 71-75) than respondents admitted to a level II (0.88-0.87, 78-85) or level III (0.89-0.88, 75-80) facility. Level II facilities scored significantly higher EQ-US and EQ-VAS in time for univariate analysis (ß 0.095, 95% CI 0.038-0.153, p = 0.001, and ß 7.887, 95% CI 3.035-12.740, p = 0.002), not in multivariate analysis (ß 0.052, 95% CI -0.010-0.115, p = 0.102, and ß 3.714, 95% CI -1.893-9.321, p = 0.193). Fewer limitations in mobility (OR 0.344, 95% CI 0.156-0.760), self-care (OR 0.219, 95% CI 0.077-0.618), and pain and discomfort (OR 0.421, 95% CI 0.214-0.831) remained significant for level II facilities in multivariate analysis, whereas significant differences with level III facilities disappeared. CONCLUSION: Major trauma patients admitted to level I trauma centres reported a less favourable general health status and more limitations compared to level II and III facilities scoring populations norms one to two years after trauma. Differences on general health status and limitations in specific health domains disappeared in adjusted analysis. Well-coordinated trauma networks offer homogeneous results for all major trauma patients when they are distributed in different centres according to their need of care.

Fatigue-related changes in motor-unit synchronization of quadriceps muscles within and across legs.

Two experiments were conducted to examine effects of muscle fatigue on motor-unit synchronization of quadriceps muscles (rectus femoris, vastus medialis, vastus lateralis) within and between legs. We expected muscle fatigue to result in an increased common drive to different motor units of synergists within a leg and, hence, to increased synchronization, i.e., an increased coherence between corresponding surface EMGs. We further expected fatigue-related motor overflow to cause motor-unit synchronization of homologous muscles of both legs, although to a lesser extent than for synergists within a leg. In the first experiment, different levels of fatigue were induced by varying posture (knee angle), whereas in the second experiment fatigue was induced in a fixed posture by instructing participants to produce different force levels. EMG coherence was found in two distinct frequency bands (6-11 and 13-18 Hz) and was higher within a leg than between legs. The fatigue-related increase of 6-11 Hz inter-limb synchronization resembled the increased motor overflow during unimanual contractions and thus hinted at an increase in bilateral coupling. Synchronization at 13-18 Hz was clearly different and appeared to be related to posture.