Geriatric patients often present to the hospital in acute surgical settings. In these settings, shared decision-making as equal partners can be challenging. Surgeons should recognize that geriatric... Show moreGeriatric patients often present to the hospital in acute surgical settings. In these settings, shared decision-making as equal partners can be challenging. Surgeons should recognize that geriatric patients, and frail patients in particular, may sometimes benefit from de-escalation of care in a palliative setting rather than curative treatment. To provide more person-centred care, better strategies for improved shared decision-making need to be developed and implemented in clinical practice. A shift in thinking from a disease-oriented paradigm to a patient-goal-oriented paradigm is required to provide better person-centred care for older patients. We may greatly improve the collaboration with patients if we move parts of the decision-making process to the pre-acute phase. In the pre-acute phase appointing legal representatives, having goals of care conversations, and advance care planning can help give physicians an idea of what is important to the patient in acute settings.When making decisions as equal partners is not possible, a greater degree of physician responsibility may be appropriate. Physicians should tailor the "sharedness" of the decision-making process to the needs of the patient and their family. Show less
The affinity between photography and memory is rather axiomatic: We take photos to preserve our memories. This formulation considers photographs as aide-mémoire and photography as a mnemotechnique.... Show moreThe affinity between photography and memory is rather axiomatic: We take photos to preserve our memories. This formulation considers photographs as aide-mémoire and photography as a mnemotechnique. Such a basic analogy, however, falls short in explaining the spatiotemporality and materiality of photography and overlooks the mediated aspects of memory in narrating the past. The difficulty with describing the conjunction of memory and photography lies in the fact that neither of them has a static essence: Both remembering and photography are inherently dynamic processes. While for some the photograph simply is a representational image that embodies past events, for others the photograph’s materiality and social uses are equally crucial in the way it continually reshapes our memories. In addition, debates on “prosthetic memory,” “postmemory,” and trauma have already shown how photography plays a role in the disembodied, transgenerational, and retroactive operations of memory work. To classify diverse approaches toward memory and photography without ignoring the dynamic aspects of either of them, this entry is divided into two parts: “conceiving photography through memory” and “perceiving memory through photography.” While the first section explains how the medium of photography has been historically defined via its approaches to memory and remembrance, the second section shows how some salient views on memory are largely founded on photographic lexicons and metaphors. Among others, the first part draws on the work of thinkers such as Siegfried Kracauer, Roland Barthes, and Elizabeth Edwards, and the second part discusses the work of Sigmund Freud, Marianne Hirsch, and Ulrich Baer. Show less
Isaksson, J.; Isaksson, M.; Stickley, A.; Vermeiren, R.; Koposov, R.; Schwab-Stone, M.; Ruchkin, V. 2023
Community violence exposure (CVE) is one of the most common adverse childhood experiences worldwide. Despite this, its potential effect on disordered eating in adolescents from different cultures... Show moreCommunity violence exposure (CVE) is one of the most common adverse childhood experiences worldwide. Despite this, its potential effect on disordered eating in adolescents from different cultures is underexplored. In the present cross-sectional study, self-reported data were collected from 9751 students (Mean age = 14.27) from Belgium, Russia and the US on CVE (witnessing violence and violence victimization), eating disorder (ED) symptoms (ED thoughts with associated compensatory behaviors), and comorbid symptoms of posttraumatic stress, depression and anxiety. Increased CVE (from no exposure to witnessing to victimization) was associated with more ED symptoms, and the associations remained significant after adjusting for comorbid conditions. The associations were similar for adolescents across the three countries. No gender differences were observed in the association between CVE and ED symptoms, even though girls in general reported more ED symptoms than boys. We conclude that CVE appears to be associated with ED symptoms in three culturally different samples of adolescents. Show less
Isaksson, J.; Isaksson, M.; Stickley, A.; Vermeiren, R.; Koposov, R.; Schwab-Stone, M.; Ruchkin, V. 2023
Community violence exposure (CVE) is one of the most common adverse childhood experiences worldwide. Despite this, its potential effect on disordered eating in adolescents from different cultures... Show moreCommunity violence exposure (CVE) is one of the most common adverse childhood experiences worldwide. Despite this, its potential effect on disordered eating in adolescents from different cultures is underexplored. In the present cross-sectional study, self-reported data were collected from 9751 students (Mean age = 14.27) from Belgium, Russia and the US on CVE (witnessing violence and violence victimization), eating disorder (ED) symptoms (ED thoughts with associated compensatory behaviors), and comorbid symptoms of posttraumatic stress, depression and anxiety. Increased CVE (from no exposure to witnessing to victimization) was associated with more ED symptoms, and the associations remained significant after adjusting for comorbid conditions. The associations were similar for adolescents across the three countries. No gender differences were observed in the association between CVE and ED symptoms, even though girls in general reported more ED symptoms than boys. We conclude that CVE appears to be associated with ED symptoms in three culturally different samples of adolescents. Show less
PurposeThe present study aims to assess whether CT-derived muscle mass, muscle density, and visceral fat mass are associated with in-hospital complications and clinical outcome in level-1 trauma... Show morePurposeThe present study aims to assess whether CT-derived muscle mass, muscle density, and visceral fat mass are associated with in-hospital complications and clinical outcome in level-1 trauma patients.MethodsA retrospective cohort study was conducted on adult patients admitted to the University Medical Center Utrecht following a trauma between January 1 and December 31, 2017. Trauma patients aged 16 years or older without severe neurological injuries, who underwent a CT that included the abdomen within 7 days of admission, were included. An artificial intelligence (AI) algorithm was used to retrieve muscle areas to calculate the psoas muscle index and to retrieve psoas muscle radiation attenuation and visceral fat (VF) area from axial CT images. Multivariable logistic and linear regression analyses were performed to assess associations between body composition parameters and outcomes.ResultsA total of 404 patients were included for analysis. The median age was 49 years (interquartile range [IQR] 30-64), and 66.6% were male. Severe comorbidities (ASA 3-4) were seen in 10.9%, and the median ISS was 9 (IQR 5-14). Psoas muscle index was not independently associated with complications, but it was associated with ICU admission (odds ratio [OR] 0.79, 95% confidence interval [CI] 0.65-0.95), and an unfavorable Glasgow Outcome Scale (GOS) score at discharge (OR 0.62, 95% CI 0.45-0.85). Psoas muscle radiation attenuation was independently associated with the development of any complication (OR 0.60, 95% CI 0.42-0.85), pneumonia (OR 0.63, 95% CI 0.41-0.96), and delirium (OR 0.49, 95% CI 0.28-0.87). VF was associated with developing a delirium (OR 1.95, 95% CI 1.12-3.41).ConclusionIn level-1 trauma patients without severe neurological injuries, automatically derived body composition parameters are able to independently predict an increased risk of specific complications and other poor outcomes. Show less
Ngongo, C.J.; Raassen, T.J.I.P.; Mahendeka, M.; Lombard, L.; Roosmalen, J. van; Temmerman, M. 2022
BackgroundMost genital fistulas result from prolonged, obstructed labor or surgical complications. Other causes include trauma (from accidents, traditional healers, or sexual violence), radiation,... Show moreBackgroundMost genital fistulas result from prolonged, obstructed labor or surgical complications. Other causes include trauma (from accidents, traditional healers, or sexual violence), radiation, carcinoma, infection, unsafe abortion, and congenital malformation. MethodsThis retrospective records review focuses on rare fistula causes among 6,787 women who developed fistula after 1980 and sought treatment between 1994 and 2017 in Tanzania, Uganda, Kenya, Malawi, Zambia, Rwanda, Ethiopia, Somalia, and South Sudan. We compare fistula etiologies across countries and assess associations between rare causes and type of incontinence (urine, feces, or both). ResultsRare fistula accounted for 1.12% (76/6,787) of all fistulas, including traumatic accidents (19/6,787, 0.28%), traumatic sexual violence (15/6,787, 0.22%), traumatic injuries caused by traditional healers (13/6,787, 0.19%), unsafe abortion (10/6,791, 0.15%), radiation (8/6,787, 0.12%), complications of HIV infection (6/6,787, 0.09%), and congenital abnormality (5/6,787, 0.07%). Trauma caused by traditional healers was a particular problem among Somali women. ConclusionFistulas attributable to rare causes illuminate a variety of risks confronting women. Fistula repair training materials should distinguish trauma caused by traditional healers as a distinct fistula etiology. Diverse causes of fistula call for multi-pronged strategies to reduce fistula incidence. Show less
Rijnhout, T.W.H.; Noorman, F.; Horst, R.A. van der; Tan, E.C.T.H.; Viersen, V.V.A.; Waes, O.J.F. van; ... ; Hoencamp, R. 2022
Background The Netherlands Armed Forces have been successfully using deep-frozen (- 80 degrees C) thrombocyte concentrate (DTC) for the treatment of (massive) bleeding trauma patients in austere... Show moreBackground The Netherlands Armed Forces have been successfully using deep-frozen (- 80 degrees C) thrombocyte concentrate (DTC) for the treatment of (massive) bleeding trauma patients in austere environments since 2001. However, high-quality evidence for the effectiveness and safety of DTCs is currently lacking. Therefore, the MAssive transfusion of Frozen bloOD (MAFOD) trial is designed to compare the haemostatic effect of DTCs versus room temperature-stored platelets (RSP) in the treatment of surgical bleeding. Methods The MAFOD trial is a single-blinded, randomized controlled non-inferiority trial and will be conducted in three level 1 trauma centres in The Netherlands. Patients 12 years or older, alive at hospital presentation, requiring a massive transfusion including platelets and with signed (deferred) consent will be included. The primary outcome is the percentage of patients that have achieved haemostasis within 6 h and show signs of life. Haemostasis is defined as the time in minutes from arrival to the time of the last blood component transfusion (plasma/platelets or red blood cells), followed by a 2-h transfusion-free period. This is the first randomized controlled study investigating DTCs in trauma and vascular surgical bleeding. Discussion The hypothesis is that the percentage of patients that will achieve haemostasis in the DTC group is at least equal to the RSP group (85%). With a power of 80%, a significance level of 5% and a non-inferiority limit of 15%, a total of 71 patients in each arm are required, thus resulting in a total of 158 patients, including a 10% refusal rate. The data collected during the study could help improve the use of platelets during resuscitation management. If proven non-inferior in civilian settings, frozen platelets may be used in the future to optimize logistics and improve platelet availability in rural or remote areas for the treatment of (massive) bleeding trauma patients in civilian settings. Show less
In Babylon (1997) by the Dutch author Marcel Möring seems to be highly self-reflexive, just in line with the non-committed way most postmodern novels have been characterized. What tends to be... Show moreIn Babylon (1997) by the Dutch author Marcel Möring seems to be highly self-reflexive, just in line with the non-committed way most postmodern novels have been characterized. What tends to be overlooked in this characterization however is that a very real historic event lies at the basis of the novel’s foundation, namely the Shoah and its aftermath. This event permeates the whole structure of the novel. As argued in this article, this foundation is implied, amongst other things, by the presence of ghosts. Read in conjunction with Van Dijk’s and Whitehead’s analyses of trauma in contemporary novels, and with a focus on haunting and intertextuality, this article demonstrates both the presence of and the struggle of the text with the notion of loss. Show less
Background: Patients with hip fractures (HF) have an increased risk of venous thromboembolism (VTE). In elective orthopedic surgery direct oral anticoagulants (DOACs) have proven to be similarly or... Show moreBackground: Patients with hip fractures (HF) have an increased risk of venous thromboembolism (VTE). In elective orthopedic surgery direct oral anticoagulants (DOACs) have proven to be similarly or more effective compared to low molecular weight heparin (LMWH), but DOACs are not yet approved for thromboprophylaxis in trauma patients with HF. The aim of this study was to systematically review the literature comparing the effectiveness of DOACs and LMWH for thromboprophylaxis in trauma patients with surgically treated HF.Materials and Methods: We searched PubMed, the Cochrane Library, Web of Science, and Embase. The primary outcome was the incidence of VTE (symptomatic and asymptomatic combined). Secondary outcomes were symptomatic VTE; a symptomatic VTE, symptomatic deep venous thrombosis (DVT); symptomatic pulmonary embolism (PE); major, clinically relevant non-major (CRNM), and minor bleeding. Meta-analysis was performed to compare the odds of VTE and secondary outcomes between DOACs and LMWH.Results: The search resulted in 738 titles. Five studies matched inclusion criteria. In total, 4748 hip fracture patients were analyzed (DOACs: 2276 patients, LMWH: 2472 patients). The pooled odds ratio for the risk of VTE for DOAC use was 0.52 (95% confidence interval 0.25-1.11, p = 0.09) compared to LMWH. No statistically significant differences between DOAC and LMWH were found for asymptomatic VTE, symptomatic DVT, PE, major or CRNM bleeding, and minor bleeding.Conclusions: Meta-analysis of the literature suggests that DOACs are associated with equivalent effectiveness and safety compared to LMWH. (C) 2021 The Authors. Published by Elsevier Ltd. Show less
Driessen, M.L.S.; Ditshuizen, J.C. van; Waalwijk, J.F.; Bunt, G. van den; IJpma, F.F.A.; Reininga, I.H.F.; ... ; Jongh, M.A.C. de 2022
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.... Show morePurpose 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. Show less
‘Resilience’ is trending in development theory and practice, where it is often measured using countable socio-economic outcomes. This paper draws on ethnographic research with South Sudanese Zande... Show more‘Resilience’ is trending in development theory and practice, where it is often measured using countable socio-economic outcomes. This paper draws on ethnographic research with South Sudanese Zande refugees in Kiryandongo Refugee Settlement, Uganda, to show a different and often overlooked perspective; that of elderly refugee women. Having lived through decades of war and displacement, these women have developed a rich body of knowledge about suffering, coping, and resilience. Mixing idioms, folktales, and anecdotes, they teach youth not to focus on outcomes or ‘big dreams’, but on a stoic acceptance of loss and perpetual precarity. They advise actions like farming, childcare, and faith. Even so, suffering and coping are socially conditioned and policed, and the intimate circle harbours both protection and dangers, like witchcraft. The women’s accounts contrast bleakly with up-beat neoliberal developmentalism which sees cash-infused ‘resilience’ as the key to refugees’ self-reliant futures. Show less
Traumatic avulsion of the right main bronchus in children is usually caused by blunt trauma or traffic accidents. Primary repair by suturing is the preferred treatment. Lesions are life threatening... Show moreTraumatic avulsion of the right main bronchus in children is usually caused by blunt trauma or traffic accidents. Primary repair by suturing is the preferred treatment. Lesions are life threatening and urgent or emergency surgical repair is indicated. We report our experience with 2 cases of traumatic avulsion of right bronchus in children successfully suture repaired with the use of extracorporeal membrane oxygenation. Show less
Background: Trauma patients are at a significant risk of venous thromboembolism (VTE), with lower extremity fractures (LEF) being independent risk factors. Use of direct oral anticoagusants (DOACs)... Show moreBackground: Trauma patients are at a significant risk of venous thromboembolism (VTE), with lower extremity fractures (LEF) being independent risk factors. Use of direct oral anticoagusants (DOACs) for VTE prophylaxis is effective in elective orthopedic surgery, but currently not approved for trauma patients. The primary objective of this study was to compare the effectiveness and safety of thromboprophylaxis of DOACs with lowmolecular-weight heparin (LMWH) in trauma patients sustaining LEF.Materials and methods: We included adult trauma patients admitted to trauma quality improvement program participating trauma centers (between 2013 and 2016), who sustained LEF and were started on DOACs or LMWH for thromboprophylaxis after admission. Propensity score matching was performed to compare symptomatic VTE and bleeding control interventions between the groups.Results: Of 1,009,922 patients in trauma quality improvement program, 167,640 met inclusion criteria (165,009 received LMWH and 2631 received DOACs). After propensity score matching, 2280 predominantly elderly (median age: 67 y) isolated femur fracture patients (median ISS: 10) were included in each group (4560 patients in total). Symptomatic VTE occurred in 1.4% of patients in both matched groups (P = 0.992). Bleeding control interventions occurred less often in the DOAC group, albeit statistically insignificant (5.8% versus 6.0%, P = 0.772).Conclusions: This study found similar rates of VTE and bleeding control measures for thromboprophylaxis with DOACs or LMWH in matched trauma patients with LEF. Further prospective research is warranted to consolidate the safety of DOAC thromboprophylaxis in trauma patients with LEF. Favorable oral administration and likely increased adherence could benefit this high-risk population. (C) 2020 The Authors. Published by Elsevier Inc. Show less
Hoeboer, C.; Roos, C. de; Son, G.E. van; Spinhoven, P.; Elzinga, B. 2021
Background: Maltreatment by a primary caregiver is an important risk factor for the development of PTSD symptoms. Whereas meta-analyses indicate that parental emotional abuse is one of the most... Show moreBackground: Maltreatment by a primary caregiver is an important risk factor for the development of PTSD symptoms. Whereas meta-analyses indicate that parental emotional abuse is one of the most common forms of maltreatment, the impact of emotional abuse on PTSD symptoms and treatment effectiveness is still unclear, especially in children.Objective: We aimed to investigate the impact of parental emotional abuse on PTSD symptom severity and effectiveness of trauma treatment in children and adolescents.Method: In an outpatient sample (N = 287, mean age = 15.5 years), emotional abuse, index traumatic event, and PTSD symptoms were assessed at baseline. Thereafter, patients received evidence-based treatment for trauma-related symptoms embedded in a broader (systemic) treatment package. In a subsample (n = 130, mean age = 15.3 years) PTSD symptoms were assessed again 6 and 12 months after baseline.Results: Emotional abuse (rather than any other type of maltreatment) was associated with more severe PTSD symptoms in all symptom clusters. This was independent of whether emotional abuse was reported as index traumatic event or not. Moreover, PTSD symptoms were significantly reduced 6 months after the start of trauma-focused treatment, and emotional abuse was associated with more severe PTSD symptoms over the course of treatment.Conclusions: These findings underline the detrimental nature of emotional maltreatment in the context of PTSD symptomatology and treatment effectiveness. This calls for routine assessment of parental emotional abuse in the diagnostic phase, even when this is not the reason of referral. Show less
Sijp, M.P.L. van der; Moonen, L.; Schipper, I.B.; Krijnen, P.; Pre, K.J. du; Niggebrugge, A.H.P. 2020
Introduction: Hip fractures are the most common fractures amongst frail older patients. Earlier studies have indicated an impaired hip flexion strength in patients with fractures that include... Show moreIntroduction: Hip fractures are the most common fractures amongst frail older patients. Earlier studies have indicated an impaired hip flexion strength in patients with fractures that include detachment of the lesser trochanter. These patients may experience protracted functional impairment and longer recovery time, causing prolonged rehabilitation journeys. This study aimed to evaluate the effects of a detached lesser trochanter in trochanteric fractures on the recovery of hip function.Method: A prospective observational cohort study was performed between 2016 and 2019. Community dwelling patients aged 70 years or older with AO 31A1-A3 trochanteric fractures were included. Patients followed routine care and were treated with a DHS or PFNA. The groups with and without involvement of the lesser trochanter were analysed. The primary outcome was hip function assessed at 6 weeks, 3 months and 1 year after surgery with the Harris Hip Score. Secondary outcomes included the Ludloff's test, complications, rehabilitation time, and pain-, independence-, and quality of life scores. A propensity score was used to adjust for any baseline differences between the two groups.Results: A total of 114 patients were included, 51 (44.7%) with involvement of the lesser trochanter and 63 (55.3%) without. Minor differences were observed in the baseline characteristics. No significant difference was observed for the Harris Hip Score (coefficient estimate: 3.31; 95% CI, -5.09-11.72; P = 0.43). The flexion function of the iliopsoas muscle was more often normal with the Ludloff's test in patients without involvement of the lesser trochanter (OR, 2.33; 95% CI, 1.241-4.387; P = 0.009). However, no differences were observed for any of the other secondary outcomes.Conclusion: Although no differences in overall hip function were found, more hip fracture patients with involvement of the lesser trochanter showed prolonged impaired flexion of the hip. The absence of longterm, clinically relevant disadvantages however, proves fixing the lesser trochanter to be redundant. (C) 2020 Elsevier Ltd. All rights reserved. Show less
Introduction: Twenty years ago the Dutch trauma care system was reformed by the designating 11 level one Regional trauma centres (RTCs) to organise trauma care. The RTCs set up the Dutch National... Show moreIntroduction: Twenty years ago the Dutch trauma care system was reformed by the designating 11 level one Regional trauma centres (RTCs) to organise trauma care. The RTCs set up the Dutch National Trauma Registry (DNTR) to evaluate epidemiology, patient distribution, resource use and quality of care. In this study we describe the DNTR, the incidence and main characteristics of Dutch acutely admitted trauma patients, and evaluate the value of including all acute trauma admissions compared to more stringent criteria applied by the national trauma registries of the United Kingdom and Germany.Methods: The DNTR includes all injured patients treated at the ED within 48 hours after trauma and consecutively followed by direct admission, transfers to another hospital or death at the ED. DNTR data on admission years 2007-2018 were extracted to describe the maturation of the registry. Data from 2018 was used to describe the incidence rate and patient characteristics. Inclusion criteria of the Trauma Audit and Research (TARN) and the Deutsche Gesellschaft fur Unfallchirurgie (DGU) were applied on 2018 DNTR data.Results: Since its start in 2007 a total of 865,460 trauma cases have been registered in the DNTR. Hospital participation increased from 64% to 98%. In 2018, a total of 77,529 patients were included, the median age was 64 years, 50% males. Severely injured patients with an ISS=16, accounted for 6% of all admissions, of which 70% was treated at designated RTCs. Patients with an ISS= 15were treated at non-RTCs in 80% of cases.Application of DGU or TARN inclusion criteria, resulted in inclusion of respectively 5% and 32% of the DNTR patients. Particularly children, elderly and patients admitted at non-RTCs are left out. Moreover, 50% of ISS >= 16 and 68% of the fatal cases did not meet DGU inclusion criteriaConclusion: The DNTR has evolved into a comprehensive well-structured nationwide population-based trauma register. With 80,0 00 inclusions annually, the DNTR has become one of the largest trauma databases in Europe The registries strength lies in the broad inclusion criteria which enables studies on the burden of injury and the quality and efficiency of the entire trauma care system, encompassing all trauma-receiving hospitals. (C) 2020 Elsevier Ltd. All rights reserved. Show less
Purpose In hospitalized patients, malnutrition is associated with adverse outcomes. However, the consequences of malnutrition in trauma patients are still poorly understood. This study aims to... Show morePurpose In hospitalized patients, malnutrition is associated with adverse outcomes. However, the consequences of malnutrition in trauma patients are still poorly understood. This study aims to review the current knowledge about the pathophysiology, prevalence, and effects of malnutrition in severely injured patients. Methods A systematic literature review in PubMed and Embase was conducted according to PRISMA-guidelines. Results Nine review articles discussed the hypermetabolic state in severely injured patients in relation to malnutrition. In these patients, malnutrition negatively influenced the metabolic response, and vice versa, thereby rendering them susceptible to adverse outcomes and further deterioration of nutritional status. Thirteen cohort studies reported on prevalences of malnutrition in severely injured patients; ten reported clinical outcomes. In severely injured patients, the prevalence of malnutrition ranged from 7 to 76%, depending upon setting, population, and nutritional assessment tool used. In the geriatric trauma population, 7-62.5% were malnourished at admission and 35.6-60% were at risk for malnutrition. Malnutrition was an independent risk factor for complications, mortality, prolonged hospital length of stay, and declined quality of life. Conclusions Despite widespread belief about the importance of nutrition in severely injured patients, the quantity and quality of available evidence is surprisingly sparse, frequently of low-quality, and outdated. Based on the malnutrition-associated adverse outcomes, the nutritional status of trauma patients should be routinely and carefully monitored. Trials are required to better define the optimal nutritional treatment of trauma patients, but a standardized data dictionary and reasonable outcome measures are required for meaningful interpretation and application of results. Show less
Background: Patients with lower-limb trauma requiring immobilization have an increased risk of venous thromboembolism (VTE). While thromboprophylaxis for all patients seems not effective, targeted... Show moreBackground: Patients with lower-limb trauma requiring immobilization have an increased risk of venous thromboembolism (VTE). While thromboprophylaxis for all patients seems not effective, targeted thromboprophylaxis in high risk patients may be an appropriate alternative. Therefore, we aimed to develop and validate a risk assessment model for VTE risk: the TRiP(cast) score (Thrombosis Risk Prediction following cast immobilization).Methods: In this prediction model study, for development, data were used from the MEGA study (case-control study into the etiology of VTE) and for validation, data from the POT-CAST trial (randomized trial on the effectiveness of thromboprophylaxis following cast immobilization) were used. Model discrimination was calculated by estimating the Area Under the Curve (AUC). For model calibration, observed and predicted risks were assessed.Findings: The TRiP( cast) score includes 14 items; one item for trauma severity (or type), one for type of immobilization and 12 items related to patients' characteristics. Validation analyses showed an AUC of 0.74 (95%CI 0.61-0.87) in the complete dataset (n = 1250) and 0.72 (95%CI 0.60-0.84) in the imputed data set (n = 1435). The calibration plot shows the degree of agreement between the observed and predicted risks (intercept 0.0016 and slope 0.933). Using a cut-off score of 7 points in the POT-CAST trial (incidence 1.6%), the sensitivity, specificity, positive and negative predictive values were 76.1%, 51.2%, 2.5%, and 99.2%, respectively.Interpretation: The TRiP(cast) score provides a helpful tool in daily clinical practice to accurately stratify patients in high versus low-risk categories in order to guide thromboprophylaxis prescribing. To accommodate implementation in clinical practice a mobile phone application has been developed. (C) 2020 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license. (http://creativecommon.org/licenses/by-nc-nd/4.0/) Show less
Background Epigenetic mechanisms have been suggested to play a role in the development of post-traumatic stress disorder (PTSD). Here, blood-derived DNA methylation data (HumanMethylation450... Show moreBackground Epigenetic mechanisms have been suggested to play a role in the development of post-traumatic stress disorder (PTSD). Here, blood-derived DNA methylation data (HumanMethylation450 BeadChip) collected prior to and following combat exposure in three cohorts of male military members were analyzed to assess whether DNA methylation profiles are associated with the development of PTSD. A total of 123 PTSD cases and 143 trauma-exposed controls were included in the analyses. The Psychiatric Genomics Consortium (PGC) PTSD EWAS QC pipeline was used on all cohorts, and results were combined using a sample size weighted meta-analysis in a two-stage design. In stage one, we jointly analyzed data of two new cohorts (N = 126 and 78) for gene discovery, and sought to replicate significant findings in a third, previously published cohort (N = 62) to assess the robustness of our results. In stage 2, we aimed at maximizing power for gene discovery by combining all three cohorts in a meta-analysis. Results Stage 1 analyses identified four CpG sites in which, conditional on pre-deployment DNA methylation, post-deployment DNA methylation was significantly associated with PTSD status after epigenome-wide adjustment for multiple comparisons. The most significant (intergenic) CpG cg05656210 (p = 1.0 x 10(-08)) was located on 5q31 and significantly replicated in the third cohort. In addition, 19 differentially methylated regions (DMRs) were identified, but failed replication. Stage 2 analyses identified three epigenome-wide significant CpGs, the intergenic CpG cg05656210 and two additional CpGs located in MAD1L1 (cg12169700) and HEXDC (cg20756026). Interestingly, cg12169700 had an underlying single nucleotide polymorphism (SNP) which was located within the same LD block as a recently identified PTSD-associated SNP in MAD1L1. Stage 2 analyses further identified 12 significant differential methylated regions (DMRs), 1 of which was located in MAD1L1 and 4 were situated in the human leukocyte antigen (HLA) region. Conclusions This study suggests that the development of combat-related PTSD is associated with distinct methylation patterns in several genomic positions and regions. Our most prominent findings suggest the involvement of the immune system through the HLA region and HEXDC, and MAD1L1 which was previously associated with PTSD. Show less
