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Sixty-two centres in 16 countries contributed with 2,694 open fractures cases to an international, multi-centric, retrospective cohort study involving different healthcare settings. The INTELLECT study results show that there are significant disparities on the management of open lower limb fractures internationally. A timely, multidisciplinary, guideline-directed care is a protective factor for developing infective complications, non-union and requiring an amputation. more...

Objectives Initial trauma care could potentially be improved when conventional imaging and selective CT scanning is omitted and replaced by immediate total-body CT (iTBCT) scanning. Because of the potentially increased radiation exposure by this diagnostic approach, proper selection of the severely injured patients is mandatory. Methods In the REACT-2 trial, severe trauma patients were randomized to iTBCT or conventional imaging and selective CT based on predefined criteria regarding compromised vital parameters, clinical suspicion of severe injuries, or high-risk trauma mechanisms in five trauma centers. By logistic regression analysis with backward selection on the 15 study inclusion criteria, a revised set of criteria was derived and subsequently tested for prediction of severe injury and shifts in radiation exposure. Results In total, 1083 patients were enrolled with median ISS of 20 (IQR 9–29) and median GCS of 13 (IQR 3–15). Backward logistic regression resulted in a revised set consisting of nine original and one adjusted criteria. Positive predictive value improved from 76% (95% CI 74–79%) to 82% (95% CI 80–85%). Sensitivity decreased by 9% (95% CI 7–11%). The area under the receiver operating characteristics curve remained equal and was 0.80 (95% CI 0.77–0.83), original set 0.80 (95% CI 0.77–0.83). The revised set retains 8.78 mSv (95% CI 6.01–11.56) for 36% of the non-severely injured patients. Conclusions Selection criteria for iTBCT can be reduced from 15 to 10 clinically criteria. This improves the positive predictive value for severe injury and reduces radiation exposure for less severely injured patients. Key Points • Selection criteria for iTBCT can be reduced to 10 clinically useful criteria. • This reduces radiation exposure in 36% of less severely injured patients. • Overall discriminative capacity for selection of severely injured patients remained equal. more...

Among orthodox reformed Christians in the Netherlands fierce debates have occurred on moral aspects of Christian life. This essay discusses three major controversial moral issues that are related to conceptions of sex, gender, and sexuality: divorce/remarriage, women’s ordination, and homosexuality. By analysing several contributions to debates on these issues, it proposes and explores a hypothesis that concerns the role of a particular understanding of marriage as characterized by a hermeneutical construct: a communal, deeply rooted and subconscious normative principle that drives our interpretations of texts and practices. This essay illustrates the problems of both the dominance of marriage within Christian communities and lived faith, as well as the modern, romantic aspects of this particular understanding of marriage. more...

From the perspective of care ethics, developed by Joan Tronto, we reflect on four attunement patterns identified in stories of hospitalized patients. Presuming that all patients can be approached as autonomous clients does not fit with the variety of patients’ expectations about the role and responsibilities they are able and willing to take. We therefore conclude that many professional caregivers fail in attuning to patients’ expectations regarding the taking up of roles. We argue that good care only works out when professional caregivers are involved in a continuous dialogue with patients about the mutual responsibilities they are able and willing to take. The typology we offered might help care professionals to improve quality of care from a moral point of view. more...

In dit hoofdstuk gaan we in op de relatie tussen narratieve toekomstverbeelding en positieve gezondheid. We doen dit aan de hand van een schets van een onderzoeksproject van het ‘Levensverhalen lab’ van de Universiteit Twente. In dit onderzoeksproject wordt de psychologische werking onderzocht van het schrijven en delen van ‘brieven vanuit de toekomst’. Wij gaan uit van de aanname dat verhalen mensen in staat stellen zich een nieuwe, hoopvolle en motiverende werkelijkheid voor te stellen en deze tegelijkertijd als ‘echt’ te ervaren. Na een theoretische begripsverkenning en samenvatting van wat uit empirisch onderzoek bekend is over de werking van toekomstverbeelding ter bevordering van de gezondheid, sluit dit hoofdstuk af met een beschrijving van een werkwijze om individueel en in groepsverband narratieve toekomstverbeelding in te zetten. more...

The number of patients waiting for a transplant exceeds the number of donor organs suitable for transplantation. Therefore, the search for new organ sources continues. uDCD donors are patients that died as result of an out of hospital cardiac arrest (OHCA). They are scarcely used in the Netherlands as a source of organ grafts. A possible reason for the minimal use of this donor type is the complexity of the protocol in terms of logistics. Three transplant centres in the Netherlands started a pilot with the aim to assess the uDCD donor potential. The innovative part of the pilot was the use of normothermic regional perfusion for resuscitation of the kidneys before procurement and ex vivo lung perfusion after retrieval to assess lung functioning. All patients deceased on the emergency department (ED) between October 2014 and October 2015 within the age range of 18 – 50 were potential donors for kidneys and lungs, and in the age range of 51 – 65 potential lung donors. Donors could only be included when fulfilling all of the following inclusion criteria: a witnessed arrest, basic life support which started within 10 minutes, advanced life support within 20 minutes and resuscitation time within an organ-specific time span. Furthermore, the donors were excluded if there were any medical contraindications and permission for donation was not given. In total, 208 OHCA patients died on the ER from whom 32 were potential kidney donor and 68 lung donor. From the 32 potential kidney donors, 15 did not meet the inclusion criteria (47%), in 7 cases, there was no consent (22%), 9 showed medical contra-indications (28%), and once logistical problems occurred (3%). From the 68 potential lung donors, 22 did not meet the inclusion criteria (33%).18 did not consent (27%), 24 had medical contra-indications (35%) and 3 were cancelled due to logistical problems (5%). One donor satisfied all the criteria and was taken to the operating theatre for lung retrieval. However, during procurement the lungs were not suitable for transplantation. This pilot shows there is definitely a group of potential uDCD donors in the Netherlands. Nevertheless, due to a wide variety of reasons, up till now no uDCD donor resulted in organ retrieval. Although there were a wide variety of reasons why donation in this pilot was not successful, combining new techniques with new organ sources remains at least part of the solution for the organ shortage. We are obliged to explore these organ sources furthermore. more...