Clinical implications of additional posterior fractures in combined anterior-posterior pelvic ring fractures in elderly patients.

OBJECTIVES: Historically, pelvic ring fractures (PRF) are considered to occur predominantly in the anterior ring and therfore to be mechanically stable. Combined anterior and posterior (A + P) PRF are expected to be less mechanically stable and therefore to be associated with higher levels of pain and reduced mobility compared to isolated anterior fractures. The current study investigates the clinical relevance of combined A + P PRF in elderly patients. METHODS: A prospective multicentre cohort study was conducted in patients >70 years of age with anterior PRF after low-energy trauma diagnosed on conventional radiographs. All patients underwent an additional CT-scan. Patients were divided into two groups; isolated anterior or combined A + P fractures. Patients were treated conservatively with adequate analgesia for at least one week. If patients could not be mobilised after conservative treatment, surgical fixation was performed. Numerical Rating Scale (NRS) pain scores, dependence on walking aids and Activities of Daily Living scores (ADL) were measured at 2-4 weeks, and 3, 6 and 12 months after fracture. RESULTS: 102 patients (age 81.1 ± 7.6 years) were included. Isolated anterior fractures were diagnosed in 25 (24.5%) and A + P fractures in 77 (75.5%) patients. Baseline characteristics did not differ between the two groups. Most patients were successfully treated conservatively and 5 (4.9%) underwent percutaneous trans-iliac, trans-sacral screw fixation after failure of conservative treatment. At 2-4 weeks post trauma, patients with A + P fractures had similar median pain scores (3 (range 0-8) vs. 5 (0-10), p = 0.19) and ADL scores (85 (25-100) vs. 78.6 (5-100), p = 0.67), but were more dependent on walking aids (92.8% vs. 72.2%; p = 0.02) compared to patients with isolated anterior fractures. There were no significant differences at 3 months. At one year follow-up the median NRS pain and ADL scores for both fracture groups were 0 and 100, respectively. Mortality was 10.8%, and additional loss to follow-up was 17.6%. CONCLUSIONS: The vast majority of elderly patients with PRF have combined A + P fractures. The clinical implications of additional posterior pelvic ring fractures in elderly patients appears to be limited.

Indications for surgical fixation of low-energy pelvic ring fractures in elderly: a systematic review.

INTRODUCTION: There are no generally accepted criteria for when and how to fixate osteoporotic pelvic ring fractures in elderly. This systemic review aims to summarize the currently available literature regarding the indications and methods for surgical fixation of fragility fractures of the pelvic ring in elderly patients after low-energy trauma. MATERIALS AND METHODS: The Pubmed and Embase databases were searched using the key words pelvic fractures, geriatric, fragility, osteoporosis, and surgical fixation, and their synonyms. Extracted data including the indication, method of operative fixation, and post-operative outcomes (pain levels, mobility, complications and mortality) were analyzed using descriptive statistics. The studies were too heterogeneous to perform a meta-analysis. RESULTS: Eleven cohort studies (3 comparative and 8 noncomparative) were included. The methodological quality was poor to moderate; the studies were heterogeneous regarding study design and reported outcomes. In all included studies operative treatment for all fracture types was preceded by a period of conservative treatment comprising physiotherapy-guided full weight-bearing. Time to surgery differed widely. For posterior ring fixation, the majority of the included studies used minimally invasive surgery with trans-iliosacral screws. Five studies described a form of additional fixation of the anterior pelvic ring but did not report the indications. CONCLUSIONS: Fixation of low-energy pelvic ring fractures in elderly is commonly performed after a period of conservative treatment, with persistent pain as the most frequent indication for fixation. Fracture classification based on stability seems to be of secondary importance. Timing for surgical fixation of the pelvic ring fracture in elderly patients remains diverse. Large well-designed comparative prospective studies and randomized controlled trials are needed to provide clearly substantiated guidelines.

Rates and risk factors of complications associated with operative treatment of pelvic fractures.

PURPOSE: Post-operative complications following fixation of pelvic fractures can lead to mortality and increased morbidity. Available literature regarding complications is heterogeneous and knowledge on risk factors is limited. This study aims to identify the most common post-operative complications and their possible risk factors following pelvic fracture surgery. METHODS: A retrospective cohort study was performed in two level-1 trauma centers in the Netherlands between January 2015 and January 2021. Included patients were all adult patients (≥ 18 years) with an operatively treated pelvic fracture (pelvic ring and/or acetabular fractures). Post-operative complications included surgical site infections (SSI), material-related complications, neurological complications, malunion/non-union and performed reoperations. A forward stepwise multivariable logistic regression analysis was used to identify any risk factors associated with these complications. RESULTS: Complications occurred in 55 (24%) of the 233 included patients. SSI's were most common, occurring in 34 (15%) patients. Duration of surgery (odds ratio 1.01 per minute, 95% confidence interval 1.00-1.01) and obesity (odds ratio 1.10 per BMI point, 95% confidence interval 1.29-7.52) were independent risk factors for development of SSI. Less common post-operative complications were material-related complications (8%) and neurological damage (5%). CONCLUSION: Limiting operation time by using less invasive and less time-consuming surgical approaches may reduce the risk of SSI. More awareness and post-operative screening for early signs of SSI is mandatory, especially in obese patients. Future research should include large prospective patient cohorts to determine risk factors for other post-operative complications associated with pelvic fracture surgery.

Systematic review: periprocedural hydration in the prevention of post-ERCP pancreatitis.

BACKGROUND: With an overall incidence of 3.5%, pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography (ERCP). Periprocedural hydration may prevent post-ERCP pancreatitis by maintaining pancreatic microperfusion, thereby inhibiting the pancreatic inflammatory response. However, the evidence for periprocedural hydration as a preventive measure is unclear. AIM: To conduct a systematic review to assess the evidence regarding periprocedural hydration as a preventive measure for post-ERCP pancreatitis. METHODS: We searched PubMed and EMBASE databases and adhered to the PRISMA guidelines. We included studies addressing periprocedural hydration as a preventive measure to reduce frequency and severity of post-ERCP pancreatitis. Study quality was assessed by using the MINORS and Cochrane Collaboration's tool. RESULTS: Six studies with a total of 1102 patients were included. Two randomised controlled trials reported a decreased incidence of post-ERCP pancreatitis after hydration: 0% vs. 17% (P = 0.016) and 5.3% vs. 22.7% (P = 0.002). A third trial and two case-controls studies did not report significant differences. Two retrospective studies found that patients with mild post-ERCP pancreatitis had received significantly more fluids during (mean 940 mL vs. 810 mL; P = 0.031) or after ERCP (median 2834 mL vs. 2044 mL; P < 0.02) compared to patients with moderate/severe disease. Adverse events of periprocedural hydration were not reported in any of the included studies. The different methodologies of the included studies precluded a formal data synthesis. CONCLUSIONS: There is some evidence to suggest that hydration affords protection against post-ERCP pancreatitis, but study heterogeneity precludes firm conclusions. Adequately powered randomised trials are needed to evaluate the preventive effect of periprocedural hydration.

Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer.

INTRODUCTION: In pancreatic cancer, preoperative biliary drainage (PBD) increases complications compared with surgery without PBD, demonstrated by a recent randomised controlled trial (RCT). This outcome might be related to the plastic endoprosthesis used. Metal stents may reduce the PBD-related complications risk. METHODS: A prospective multicentre cohort study was performed including patients with obstructive jaundice due to pancreatic cancer, scheduled to undergo PBD before surgery. This cohort was added to the earlier RCT (ISRCTN31939699). The RCT protocol was adhered to, except PBD was performed with a fully covered self-expandable metal stent (FCSEMS). This FCSEMS cohort was compared with the RCT's plastic stent cohort. PBD-related complications were the primary outcome. Three-group comparison of overall complications including early surgery patients was performed. RESULTS: 53 patients underwent PBD with FCSEMS compared with 102 patients treated with plastic stents. Patients' characteristics did not differ. PBD-related complication rates were 24% in the FCSEMS group vs 46% in the plastic stent group (relative risk of plastic stent use 1.9, 95% CI 1.1 to 3.2, p=0.011). Stent-related complications (occlusion and exchange) were 6% vs 31%. Surgical complications did not differ, 40% vs 47%. Overall complication rates for the FCSEMS, plastic stent and early surgery groups were 51% vs 74% vs 39%. CONCLUSIONS: For PBD in pancreatic cancer, FCSEMS yield a better outcome compared with plastic stents. Although early surgery without PBD remains the treatment of choice, FCSEMS should be preferred over plastic stents whenever PBD is indicated. TRIAL REGISTRATION NUMBER: Dutch Trial Registry (NTR3142).

Dutch Chronic Pancreatitis Registry (CARE): design and rationale of a nationwide prospective evaluation and follow-up.

BACKGROUND: Chronic pancreatitis is a complex disease with many unanswered questions regarding the natural history and therapy. Prospective longitudinal studies with long-term follow-up are warranted. METHODS: The Dutch Chronic Pancreatitis Registry (CARE) is a nationwide registry aimed at prospective evaluation and follow-up of patients with chronic pancreatitis. All patients with (suspected) chronic or recurrent pancreatitis are eligible for CARE. Patients are followed-up by yearly questionnaires and review of medical records. Study outcomes are pain, disease complications, quality of life, and pancreatic function. The target sample size was set at 500 for the first year and 1000 patients within 3 years. RESULTS: A total of 1218 patients were included from February 2010 until June 2013 by 76 participating surgeons and gastroenterologist from 33 hospitals. Participation rate was 90% of eligible patients. Eight academic centers included 761 (62%) patients, while 25 community hospitals included 457 (38%). Patient centered outcomes were assessed by yearly questionnaires, which had a response rate of 85 and 82% for year 1 and 2, respectively. The median age of patients was 58 years, 814 (67%) were male, and 38% had symptoms for less than 5 years. DISCUSSION: The CARE registry has successfully recruited over 1200 patients with chronic and recurrent pancreatitis in about 3 years. The defined inclusion criteria ensure patients are included at an early disease stage. Participation and compliance rates are high. CARE offers a unique opportunity with sufficient power to investigate many clinical questions regarding natural course, complications, and efficacy and timing of treatment strategies.

Prediction scores or gastroenterologists' Gut Feeling for triaging patients that present with acute upper gastrointestinal bleeding.

INTRODUCTION: Several prediction scores for triaging patients with upper gastrointestinal (GI) bleeding have been developed, yet these scores have never been compared to the current gold standard, which is the clinical evaluation by a gastroenterologist. The aim of this study was to assess the added value of prediction scores to gastroenterologists' Gut Feeling in patients with a suspected upper GI bleeding. METHODS: WE PROSPECTIVELY EVALUATED GUT FEELING OF SENIOR GASTROENTEROLOGISTS AND ASKED THEM TO ESTIMATE: (1) the risk that a clinical intervention is needed; (2) the risk of rebleeding; and (3) the risk of mortality in patients presenting with suspected upper GI bleeding, subdivided into low, medium, or high risk. The predictive value of the gastroenterologists' Gut Feeling was compared to the Blatchford and Rockall scores for various outcomes. RESULTS: We included 974 patients, of which 667 patients (68.8%) underwent a clinical intervention. During the 30-day follow up, 140 patients (14.4%) developed recurrent bleeding and 44 patients (4.5%) died. Gut Feeling was independently associated with all studied outcomes, except for the predicted mortality after endoscopy. Predictive power, based on the AUC of the Blatchford and Rockall prediction scores, was higher than the Gut Feeling of the gastroenterologists. However, combining both the Blatchford and Rockall scores and the Gut Feeling yielded the highest predictive power for the need of an intervention (AUC 0.88), rebleeding (AUC 0.73), and mortality (AUC 0.71 predicted before and 0.77 predicted after endoscopy, respectively). CONCLUSIONS: Gut Feeling is an independent predictor for the need of a clinical intervention, rebleeding, and mortality in patients presenting with upper GI bleeding; however, the Blatchford and Rockall scores are stronger predictors for these outcomes. Combining Gut Feeling with the Blatchford and Rockall scores resulted in the most optimal prediction.

The predictive value of proteinuria in acute pancreatitis.

BACKGROUND/OBJECTIVES: Acute pancreatitis has a highly variable clinical course. Early and reliable predictors for the severity of acute pancreatitis are lacking. Proteinuria appears to be a useful predictor of disease severity and outcome in a variety of clinical conditions. This study aims to investigate the predictive value of proteinuria on admission for the severity of acute pancreatitis compared with other commonly used predictors; the APACHE II score, Modified Glasgow score and C-reactive protein (CRP). METHODS: This is a post-hoc analysis of 64 patients admitted with acute pancreatitis treated in one teaching hospital, who participated in a previous randomized trial. Proteinuria was defined as a Protein/Creatinine (P/C) ratio >23 mg/mmol. The primary endpoint was severe acute pancreatitis. Secondary endpoints included infectious complications, need for invasive intervention, ICU stay and in-hospital mortality. RESULTS: Proteinuria was present in 30/64 patients (47%). Eleven patients (17%) had severe acute pancreatitis. There was no difference in incidence of severe acute pancreatitis between patients with and without proteinuria: 6/30 patients (20%) versus 5/34 patients (15%) respectively (p = 0.58). Likewise, the occurrence of infectious complications, need for intervention and ICU stay and mortality did not differ significantly (p = 0.58, p = 0.99, p = 0.33 and p = 0.60 respectively). The diagnostic performance of the P/C ratio for the prediction of severe pancreatitis was inferior to the Modified Glasgow score (p = 0.04) and CRP (p = 0.03). CONCLUSION: Proteinuria on admission does not seem to be a reliable predictor for disease severity in acute pancreatitis. The diagnostic performance of the P/C ratio is inferior to the Modified Glasgow score and CRP.

Routine colonoscopy is not required in uncomplicated diverticulitis: a systematic review.

BACKGROUND: It is generally accepted that patients following an episode of diverticulitis should have additional colonoscopy screening to rule out a colorectal malignancy. We aimed to investigate the rate of CRC found by colonoscopy after an attack of uncomplicated diverticulitis. METHODS: MEDLINE, Embase, and Cochrane databases were searched systematically for clinical trials or observational studies on colonic evaluation by colonoscopy after the initial diagnosis of acute uncomplicated diverticulitis, followed by hand-searching of reference lists. RESULTS: Nine studies met the inclusion criteria and included a total number of 2,490 patients with uncomplicated diverticulitis. Subsequent colonoscopy after an episode of uncomplicated diverticulitis was performed in 1,468 patients (59%). Seventeen patients were diagnosed with CRC, having a prevalence of 1.16% (95% confidence interval 0.72-1.9% for CRC). Hyperplastic polyps were seen in 156 patients (10.6%), low-grade adenoma in 90 patients (6.1%), and advanced adenoma was reported in 32 patients (2.2%). CONCLUSION: Unless colonoscopy is regarded for screening in individuals aged 50 years and older, routine colonoscopy in the absence of other clinical signs of CRC is not required.

Nurse endoscopists perform colonoscopies according to the international standard and with high patient satisfaction.

BACKGROUND AND STUDY AIMS: Colonoscopy is increasingly performed by nurse endoscopists. We aimed to assess the endoscopic quality and patient experience of these procedures. PATIENTS AND METHODS: This prospective multicenter study analyzed 100 consecutive colonoscopies each for 10 trained nurse endoscopists with respect to endoscopic quality and patient experience. Colonoscopies were performed under the supervision of a gastroenterologist, using the techniques and protocols of the participating hospitals. Patient experience was assessed using a questionnaire. RESULTS: Most nurse endoscopists were female (90 %; median age 43 [range 35 - 49]). Before the start of the study, they had performed a median of 528 colonoscopies (range 208 - 2103). For the 1000 patients, mean age was 56 ± 15 years; 55 % were women; and 96 % were in class I or II according to the American Society of Anesthesiologists' physical status classification system. Colonoscopies were performed for screening or surveillance in 42 %; for symptomatic indications in 58 % of patients. The unassisted cecal intubation rate was 94 %; the mean withdrawal time was 10 ±â€Š5 minutes. The adenoma detection rate was 26.7 %. In 229 of the colonoscopies (23 %), the nurse endoscopists required assistance from the supervising gastroenterologist. The complication rate was 0.2 %: one perforation and one cardiopulmonary complication. The questionnaire was completed by 734 /1000 patients (73 %) and of these 694 /734 (95 %) were satisfied with the endoscopic procedure. Among the respondents 530 /734 (72 %) had no specific preference for a physician or nurse endoscopist, whereas 113 /734 (15 %) preferred a physician endoscopist, and 91 /734 (12 %) preferred a nurse endoscopist. CONCLUSION: The nurse endoscopists performed colonoscopies according to the internationally recognized quality standards and with high patient satisfaction.

[The 'paper-based' preoperative evaluation: non-optimal health care]. / Het preoperatieve 'papieren consult': geen goede zorgverlening.

A nationwide preoperative assessment guideline was introduced in the Netherlands in 1997 at the advice of the Health Council of the Netherlands. The preoperative assessment should entail an appropriate interview, a physical examination, additional tests, risk assessment and informing the patient. Dutch and several international guidelines recommend a complete assessment under the responsibility of the anaesthesiologist. In addition, Dutch law states that patients should be clearly informed about any medical procedure that is to be performed, including the possible risks and alternatives. All of the above is not possible with a paper-based assessment. A complete assessment may reduce health care costs by reducing the number of consultations by other specialists, additional tests, cancellations and length of stay. The assessment also reduces patient anxiety and improves patient satisfaction. In conclusion, a complete preoperative assessment is required by guidelines and law and does offer many advantages.

Vibrational Förster transfer to hydrated protons.

We have studied the influence of excess protons on the vibrational energy relaxation of the O-H and O-D stretching modes in water using femtosecond pump-probe spectroscopy. Without excess protons, we observe exponential decays with time constants of 1.7 and 4.3 ps for the bulk and anion bound O-D stretch vibrations. The addition of protons introduces a new energy relaxation pathway, which leads to an increasingly nonexponential decay of the O-D stretch vibration. This new pathway is attributed to a distance-dependent long range dipole-dipole (Forster) interaction between the O-D stretching vibration and modes associated with dissolved protons. The high efficiency of hydrated protons as receptors of vibrational energy follows from the very large absorption cross section and broad bandwidth of protons in water. For a proton concentration of 1M we find that Forster energy transfer occurs over an average distance of 4.5 A, which corresponds to a separation of about two water molecules.

Vibrational Förster transfer in ice Ih.

We have studied Förster energy transfer between O-H vibrations in H(2)O/D(2)O ice Ih using femtosecond, two-color, mid-infrared pump-probe spectroscopy. We found that as a result of couplings to nearby O-H stretch modes, the vibrational relaxation time decreases from 480 fs for dilute HDO in D(2)O down to 300 fs for pure H(2)O ice. The anisotropy shows an initial 140 fs decay down to a concentration-dependent end level. This end level for low concentrations can be explained from the limited rotational freedom ( approximately 20 degrees ) of a water molecule in the ice lattice over time scales > 15 ps. The decreasing end levels for higher concentrations of H(2)O result from Forster energy transfer to the next-nearest six O-H groups. No Förster transfer beyond these neighbors is observed. Variation of the ice temperature between 200 and 270 K was found to have negligible effect on the dynamics.

Direct observation of proton transfer in ice Ih using femtosecond spectroscopy.

We studied proton transfer in ice samples containing the photoacid 8-hydroxypyrene-1,3,6-trisulfonic acid and the base sodium formate using femtosecond pump-probe spectroscopy. Pump pulses, centered at a wavelength of 400 nm, electronically excited the photoacid molecules which released their protons. These protons subsequently traveled from the photoacid through the ice lattice to the base and were observed as they arrived at the base using the transient absorption of an infrared probe pulse. Both the temperature and concentration dependence of the proton transfer dynamics were modeled using a discrete set of two intrinsic transfer rates, associated with short and long-range proton transfer, respectively. Proton transfer in configurations where the acid and base were separated by up to about two water molecules, was found to occur on a approximately 1 ps time scale for all temperatures (240-270 K). Long range direct proton transfer through water wires of about four water molecules in length was found to occur on a approximately 300 ps time scale at 270 K. This latter process was observed to slow down significantly with decreasing temperature, with an activation energy of approximately 80 kJ/mol.

Speech therapy in patients with excessive supragastric belching--a pilot study.

In patients whose main symptom is excessive belching, supragastric belching appears to be the predominant mechanism. This belch pattern is characterized by a rapid influx of air into the oesophagus, immediately followed by rapid air expulsion. The rate at which supragastric belching occurs is influenced by attention and distraction, suggesting a behavioural disorder and speech therapy may be of benefit to these patients. In 17 consecutive patients with excessive belching, concurrent impedance monitoring and high-resolution manometry were performed to ascertain the mechanism of belching. Patients with supragastric belches were referred to a speech therapist, who was familiar with the concept of supragastric belching. Before and after treatment by the speech therapist, patients filled out a VAS scale regarding the severity of their symptoms. In all patients, supragastric belches were identified with impedance monitoring. Eleven patients were referred to a speech therapist, six patients were not able or willing to undergo repetitive treatments. Eleven patients completed treatment by the speech therapist consisting of 10 (8-10) sessions. Overall, the VAS scales showed a significant improvement of the severity of symptoms (P < 0.05). Six of the 11 patients reported a large decrease (>30%) in their symptoms and four patients reported a modest decrease (<30%). In one patient, the VAS scores indicated an increase in symptoms. Speech therapy performed by a well-informed speech pathologist leads to a significant symptom reduction in patients with excessive supragastric belching. This is the first study indicating benefit of a treatment for excessive belching.

Structure dynamics of the proton in liquid water probed with terahertz time-domain spectroscopy.

We study the hydration of protons in liquid water using terahertz time-domain spectroscopy and polarization-resolved femtosecond midinfrared pump-probe spectroscopy. We observe that the addition of protons leads to a very strong decrease of the dielectric response of liquid water that corresponds to 19+/-2 water molecules per dissolved proton. This depolarization results from water molecules ( approximately 4) that are irrotationally bound to the proton and from the motion of water (corresponding to the response of approximately 15 water molecules) involved in the transfer of the proton charge.

Does acute psychological stress increase perception of oesophageal acid?

Gastro-oesophageal reflux disease (GORD) patients often report an increase in their reflux symptoms during stressful situations. The aim of this study was to assess the influence of acute psychological stress on oesophageal acid perception. In 15 healthy volunteers and 10 GORD patients with a positive symptom-reflux association an oesophageal acid perfusion test was performed, once with and once without the presence of an acute psychological stressor (IQ test). The order of the measurements was randomized. The time from onset of the acid infusion to first acid perception, discomfort and pain was noted. Blood pressure was measured to assess the effect of the stress task. In healthy volunteers, the time to first perception (control task: 617 +/- 174 s vs stress task: 561 +/- 162 s), discomfort (control task: 969 +/- 158 s vs stress task: 940 +/- 151 s) or pain (control task: 1393 +/- 122 s vs stress task: 1366 +/- 121 s) did not differ significantly between both measurements. In GORD patients, no significant differences between both measurements were found either in time to first perception (control task: 63 +/- 26 s vs stress task: 43 +/- 15 s), discomfort (control task: 153 +/- 44 s vs stress task: 249 +/- 62 s) or pain (control task: 558 +/- 139 s vs stress task: 633 +/- 118 s). Systolic blood pressure rose significantly during the stress task in both the healthy volunteers (6 +/- 1 mmHg) and the GORD patients (9 +/- 2 mmHg). Neither in the healthy volunteers nor in the GORD patients, the acute psychological stress induced by an IQ test increased oesophageal acid perception. The observed increase in systolic blood pressure shows that the experimental stressors were effective.

Hydrogen bond fluctuations of the hydration shell of the bromide anion.

We study the hydrogen bond dynamics of solutions of LiBr and NaBr in isotopically diluted water (2% HDO:D2O) with femtosecond spectral hole-burning spectroscopy. We study the frequency fluctuations of the O-H stretch vibrations of the HDO molecules and observe spectral dynamics with time constants of 0.8 +/- 0.1 ps and 4.3 +/- 0.3 ps. The slow process we assign to the hydrogen bond fluctuations of the O-H...Br- hydrogen bonds of the hydration shell of the Br- anion. We find that the time scale of the hydrogen bond fluctuations of the hydration shell of Br- is independent of the nature of the cation and the concentration.