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Background Seroma is the most common complication following breast cancer surgery, with reported incidence up to 90%. Seroma causes patient discomfort, is associated with surgical site infections (SSI), often requires treatment and increases healthcare consumption. The quilting suture technique, in which the skin flaps are sutured to the pectoralis muscle, leads to a significant reduction of seroma with a decrease in the number of aspirations and surgical site infections. However, implementation is lagging due to unknown side effects, increase in operation time and cost effectiveness. Main objective of this study is to assess the impact of large scale implementation of the quilting suture technique in patients undergoing mastectomy and/or axillary lymph node dissection (ALND). Methods The QUILT study is a stepped wedge design study performed among nine teaching hospitals in the Netherlands. The study consists of nine steps, with each step one hospital will implement the quilting suture technique. Allocation of the order of implementation will be randomization-based. Primary outcome is ‘textbook outcome’, i.e.no wound complications, no re-admission, re-operation or unscheduled visit to the outpatient clinic and no increased use of postoperative analgesics. A total of 113 patients is required based on a sample size calculation. Secondary outcomes are shoulder function, cosmetic outcome, satisfaction with thoracic wall and health care consumption. Follow-up lasts for 6 months. Discussion This will be one of the first multicentre prospective studies in which quilting without postoperative wound drain is compared with conventional wound closure. We hypothesize that quilting is a simple technique to increase textbook outcome, enhance patient comfort and reduce health care consumption.

Background The incorporation of repeated measurements into multivariable prediction research may greatly enhance predictive performance. However, the methodological possibilities vary widely and a structured overview of the possible and utilized approaches lacks. Therefore, we [1] propose a structured framework for these approaches, [2] determine what methods are currently used to incorporate repeated measurements in prediction research in the critical care setting and, where possible, [3] assess the added discriminative value of incorporating repeated measurements. Methods The proposed framework consists of three domains: the observation window (static or dynamic), the processing of the raw data (raw data modelling, feature extraction and reduction) and the type of modelling. A systematic review was performed to identify studies which incorporate repeated measurements to predict (e.g. mortality) in the critical care setting. The within-study difference in c-statistics between models with versus without repeated measurements were obtained and pooled in a meta-analysis. Results From the 2618 studies found, 29 studies incorporated multiple repeated measurements. The annual number of studies with repeated measurements increased from 2.8/year (2000–2005) to 16.0/year (2016–2018). The majority of studies that incorporated repeated measurements for prediction research used a dynamic observation window, and extracted features directly from the data. Differences in c statistics ranged from − 0.048 to 0.217 in favour of models that utilize repeated measurements. Conclusions Repeated measurements are increasingly common to predict events in the critical care domain, but their incorporation is lagging. A framework of possible approaches could aid researchers to optimize future prediction models.

PurposeA time sequence occurs in pathogens leading to infections in Intensive Care Unit (ICU) patients with a compromised immune system. A similar pattern may also occur in (multi)trauma patients characterized by similar impaired immunological responses. Such immune malfunction might be prolonged and enable hospital-acquired pathogens (selected through antibiotic regimens) to cause infections. This study investigated the timing of infections and associated pathogens in severely injured trauma patients.MethodsA retrospective, single-center cohort study was conducted at a level-1 trauma center. Severely injured trauma patients from 2013 to 2022 with an ICU stay >48 hours were included. Infections compliant with the criteria of the Centers for Disease Control and Prevention and causative pathogens were documented. Timing of infections was scored as days after trauma.Results109 out of 572 severely injured trauma patients developed infectious complications. All patients received antibiotics. A time sequence of pathogens that caused infections was observed. Staphylococcus aureus, Enterococcus spp., and CoNS were mainly responsible for infections before day 40 after trauma. From day 60 onward, Klebsiella spp., Candida spp., Enterobacter spp., and Pseudomonas spp. became more frequent.ConclusionA time sequence in occurrence of pathogens and associated infections was found in severely injured trauma patients. Commensal micro-organisms were predominant in the first weeks after trauma, which shifted toward hospital-acquired microorganisms over time. This observed time sequence is consistent with the hypothesis that a long-term imbalanced innate immune system facilitates infections with these normally non-pathogenic organisms during months after severe trauma. Level of evidenceThis was a retrospective cohort study with level III evidence.

ObjectivesTo determine whether and to what extent the surgical intermediate care unit (IMCU) reduces healthcare costs.DesignRetrospective cohort study.SettingThe mixed-surgical IMCU of a tertiary academic referral hospital.ParticipantsAll admissions (n=2577) from 2012 to 2015.Primary and secondary outcome measuresThe outcome measure was the hypothetical cost savings due to the presence of the IMCU. For this, each admission day was classified as either low-acuity or high-acuity, based on the Therapeutic Intervention Scoring System-28, the required specific nursing interventions and the indication for admission at the IMCU. Costs (2018) used were €463 per hospital ward, €1307 per IMCU and €2224 per intensive care unit (ICU) admission day. Savings were calculated by subtracting the actual IMCU costs from the hypothetical costs in the absence of the IMCU.ResultsThere were 9037 admission days (n=2577 admissions) at the IMCU. The proportion of high-acuity admissions was 87.6%. Total costs at the IMCU were €11.808 888. Total hypothetical costs in absence of the IMCU were €18.115 284. Total cost savings were thus €6.306 395, or €1.576 599, per year.ConclusionsThe surgical IMCU may substantially reduce societal healthcare costs, making it a cost saving alternative to ICU care. Constant adequate triage is essential to optimise its potential.

Purpose Fracture-Related Infection (FRI) is associated with high medical costs and prolonged healthcare utilization. However, limited data is available on the financial impact. The purpose of this study was to investigate the impact of FRI on direct hospital costs and healthcare utilization. Methods This was a retrospective cohort study in a level-1 trauma centre in the Netherlands. Patients ≥ 18 years, after open reduction and internal fixation of a long bone fracture between January 1st 2016 and November 1st 2021, were included. Exclusion criteria were Injury Severity Score (ISS) ≥ 16, indefinable data on costs or incomplete follow-up. Hospital costs related to fracture treatment were individually calculated based on procedure codes raised with a fixed percentage of overhead expenses, in line with hospital billing policies. Results In total, 246 patients were included with a median follow-up of 1 year (IQR 0.6–1.8). A total of 45 patients developed FRI, of whom 15 patients had an FRI recurrence. Compared to non-FRI patients, median hospital costs from an FRI patient without and with recurrence, were respectively three (3.1) and seven (7.6) times higher. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries, and 21 or 55 days of intravenous antibiotic treatment. Conclusion Direct healthcare costs of patients with single occurrence of FRI after long bone fracture treatment are three times higher compared to non-FRI patients. In case of FRI-recurrence, the differences in costs might even increase to sevenfold. To put this in perspective, cost of severely injured trauma patients were recently established at approximately 25.000 euros. Compared to non-FRI patients, increased costs in patients with FRI or recurrent FRI are due to respectively a fivefold or even tenfold prolonged length-of-stay, two or seven additional infection-related surgeries and 21 or 55 days of intravenous antibiotic treatment. Not only from patient perspective but also from a financial aspect, it is important to focus on prevention of (recurrent) FRI.

Under-triage is a major threat when admitting patients at the Intermediate Care Unit (IMCU). This study aims to identify risk factors and predict early deterioration of IMCU admissions, to reduce the risk of under-triage. This retrospective cohort study included all admissions to the mixed-surgical stand-alone IMCU of a tertiary referral hospital (2001–2015). Variables included were age, sex, admission indication, admitting specialty, re-admission, and nursing interventions. Early clinical deterioration was defined as ICU transfer or death ≤24 h of admission. Multinomial and logistic regression analyses were performed to identify risk factors and obtain predictions, for several frequently encountered subgroups. A total of 9103 admissions were included, of which 350 (3.8%) early deteriorated. Patients admitted for hemodynamic and respiratory instability had a high risk of early deterioration (OR 16.3 (CI 4.5-59.1)), probability 47.1%. Patients admitted with respiratory insufficiency and active diuresis or complicated sepsis had a high probability of early deterioration (≥29% and ≥26% respectively). The model had an optimism-corrected c-statistic of 0.79 (IQR 0.78-0.80). Patients with combined hemodynamic and respiratory instability should not be admitted to the IMCU. Patients with respiratory insufficiency and active diuresis, or complicated sepsis require close monitoring. •The presented nomogram can be used to assess the probability of early clinical deterioration•Patients with hemodynamic and respiratory instability should be admitted at the ICU•IMCU Patients with respiratory insufficiency and active diuresis, or complicated sepsis require close monitoring

Abstract Study Objectives Encephalopathy with electrical status epilepticus in sleep (ESES) is characterized by non-rapid eye movement (non-REM)-sleep-induced epileptiform activity and acquired cognitive deficits. The synaptic homeostasis hypothesis describes the process of daytime synaptic potentiation balanced by synaptic downscaling in non-REM-sleep and is considered crucial to retain an efficient cortical network. We aimed to study the overnight decline of slow waves, an indirect marker of synaptic downscaling, in patients with ESES and explore whether altered downscaling relates to neurodevelopmental and behavioral problems. Methods Retrospective study of patients with ESES with at least one whole-night electroencephalogram (EEG) and neuropsychological assessment (NPA) within 4 months. Slow waves in the first and last hour of non-REM-sleep were analyzed. Differences in slow-wave slope (SWS) and overnight slope course between the epileptic focus and non-focus electrodes and relations to neurodevelopment and behavior were analyzed. Results A total of 29 patients with 44 EEG ~ NPA combinations were included. Mean SWS decreased from 357 to 327 µV/s (−8%, p < 0.001) across the night and the overnight decrease was less pronounced in epileptic focus than in non-focus electrodes (−5.6% vs. −8.7%, p = 0.003). We found no relation between SWS and neurodevelopmental test results in cross-sectional and longitudinal analyses. Patients with behavioral problems showed less SWS decline than patients without and the difference was most striking in the epileptic focus (−0.9% vs. −8.8%, p = 0.006). Conclusions Slow-wave homeostasis—a marker of synaptic homeostasis—is disturbed by epileptiform activity in ESES. Behavioral problems, but not neurodevelopmental test results, were related to severity of this disturbance.

Purpose18F-Fluorodeoxyglucose positron emission tomography (18F-FDG PET/CT) is frequently used to diagnose fracture-related infections (FRIs), but its diagnostic performance in this field is still unknown. The aims of this study were: (1) to assess the diagnostic performance of qualitative assessment of 18F-FDG PET/CT scans in diagnosing FRI, (2) to establish the diagnostic performance of standardized uptake values (SUVs) extracted from 18F-FDG PET/CT scans and to determine their associated optimal cut-off values, and (3) to identify variables that predict a false-positive (FP) or false-negative (FN) 18F-FDG PET/CT result.MethodsThis retrospective cohort study included all patients with suspected FRI undergoing 18F-FDG PET/CT between 2011 and 2017 in two level-1 trauma centres. Two nuclear medicine physicians independently reassessed all 18F-FDG PET/CT scans. The reference standard consisted of the result of at least two deep, representative microbiological cultures or the presence/absence of clinical confirmatory signs of FRI (AO/EBJIS consensus definition) during a follow-up of at least 6 months. Diagnostic performance in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) was calculated. Additionally, SUVs were measured on 18F-FDG PET/CT scans. Volumes of interest were drawn around the suspected and corresponding contralateral areas to obtain absolute values and ratios between suspected and contralateral areas. A multivariable logistic regression analysis was also performed to identify the most important predictor(s) of FP or FN 18F-FDG PET/CT results.ResultsThe study included 156 18F-FDG PET/CT scans in 135 patients. Qualitative assessment of 18F-FDG PET/CT scans showed a sensitivity of 0.89, specificity of 0.80, PPV of 0.74, NPV of 0.91 and diagnostic accuracy of 0.83. SUVs on their own resulted in lower diagnostic performance, but combining them with qualitative assessments yielded an AUC of 0.89 compared to an AUC of 0.84 when considering only the qualitative assessment results (p = 0.007). 18F-FDG PET/CT performed <1 month after surgery was found to be the independent variable with the highest predictive value for a false test result, with an absolute risk of 46% (95% CI 27–66%), compared with 7% (95% CI 4–12%) in patients with 18F-FDG PET/CT performed 1–6 months after surgery.ConclusionQualitative assessment of 18F-FDG PET/CT scans had a diagnostic accuracy of 0.83 and an excellent NPV of 0.91 in diagnosing FRI. Adding SUV measurements to qualitative assessment provided additional accuracy in comparison to qualitative assessment alone. An interval between surgery and 18F-FDG PET/CT of <1 month was associated with a sharp increase in false test results.

BackgroundInvolved lateral lymph nodes (LLNs) have been associated with increased local recurrence (LR) and ipsi-lateral LR (LLR) rates. However, consensus regarding the indication and type of surgical treatment for suspicious LLNs is lacking. This study evaluated the surgical treatment of LLNs in an untrained setting at a national level.MethodsPatients who underwent additional LLN surgery were selected from a national cross-sectional cohort study regarding patients undergoing rectal cancer surgery in 69 Dutch hospitals in 2016. LLN surgery consisted of either ‘node-picking’ (the removal of an individual LLN) or ‘partial regional node dissection’ (PRND; an incomplete resection of the LLN area). For all patients with primarily enlarged (≥7 mm) LLNs, those undergoing rectal surgery with an additional LLN procedure were compared to those undergoing only rectal resection.ResultsOut of 3057 patients, 64 underwent additional LLN surgery, with 4-year LR and LLR rates of 26% and 15%, respectively. Forty-eight patients (75%) had enlarged LLNs, with corresponding recurrence rates of 26% and 19%, respectively. Node-picking (n = 40) resulted in a 20% 4-year LLR, and a 14% LLR after PRND (n = 8; p = 0.677). Multivariable analysis of 158 patients with enlarged LLNs undergoing additional LLN surgery (n = 48) or rectal resection alone (n = 110) showed no significant association of LLN surgery with 4-year LR or LLR, but suggested higher recurrence risks after LLN surgery (LR: hazard ratio [HR] 1.5, 95% confidence interval [CI] 0.7–3.2, p = 0.264; LLR: HR 1.9, 95% CI 0.2–2.5, p = 0.874).ConclusionEvaluation of Dutch practice in 2016 revealed that approximately one-third of patients with primarily enlarged LLNs underwent surgical treatment, mostly consisting of node-picking. Recurrence rates were not significantly affected by LLN surgery, but did suggest worse outcomes. Outcomes of LLN surgery after adequate training requires further research.