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Background: To analyze and report on the changes in epidemiology traumatic causes of death in the USA. Methods: Data were extracted from the annual National Vital Statistics Reports (2008–2017) from Center for Disease Control and analyzed for trends during the time period given. Generalized additive model was applied to evaluate the significance of trend using R software. Results: Firearm deaths (39,790) and firearm death rate (12.2/100,000) in 2017 were the highest reported, and this increasing trend was significant (p < 0.001) the last ten years. Deaths from motor vehicle crash (MVC) and firearm homicides did not change significantly during the same time period. Firearm deaths were lower than MVC deaths by 21% (8,197/39,790) in 2008, but after 10 years, the difference was only 1% (458/40,231). Years of life lost from firearms is now higher than MVC. Suicides by firearm in 2017 were the highest reported at 23,854/39,773 (60%). In 2017, suicides by firearm victims were predominantly white 20,328/23,562 (85%), men 20,362/23,562 (86%), and the largest group was between the ages of 55–64. Conclusions: Death from firearms in the USA is increasing and endemic. They were the highest ever reported in 2017 by the CDC. While deaths from MVC used to be the main cause of traumatic death in the USA, deaths from firearms now almost equal it. Calculated years of life lost from firearms is now more than from MVC. Most firearm deaths are not from homicides but are from suicides, and they are predominantly in white older males of the baby boomer generation (born 1946–1964). [ABSTRACT FROM AUTHOR]

Cellular prion protein (PrPC) can replace other pivotal molecules due to its interaction with several partners in performing a variety of important biological functions that may differ between embryonic and mature stem cells. Recent studies have revealed major advances in elucidating the putative role of PrPC in the regulation of stem cells and its application in stem cell therapy. What is special about PrPC is that its expression may be regulated by hypoxia‑inducible factor (HIF)‑1α, which is the transcriptional factor of cellular response to hypoxia. Hypoxic conditions have been known to drive cellular responses that can enhance cell survival, differentiation and angiogenesis through adaptive processes. Our group recently reported hypoxia‑enhanced vascular repair of endothelial colony‑forming cells on ischemic injury. Hypoxia‑induced AKT/signal transducer and activator of transcription 3 phosphorylation eventually increases neovasculogenesis. In stem cell biology, hypoxia promotes the expression of growth factors. According to other studies, aspects of tissue regeneration and cell function are influenced by hypoxia, which serves an essential role in stem cell HIF‑1α signaling. All these data suggest the possibility that hypoxia‑mediated PrPC serves an important role in angiogenesis. Therefore, the present review summarizes the characteristics of PrPC, which is produced by HIF‑1α in hypoxia, as it relates to angiogenesis. [ABSTRACT FROM AUTHOR]

Most distal radius fractures are the result of low-energy mechanisms that can be successfully treated either non-operatively or with a variety of operative techniques if indicated. Complex distal radius fractures occur most commonly in high-energy injuries with extensive comminution or bone loss and associated soft tissue or vascular injuries. These high-energy fractures can present many challenges in reconstructing the distal radius. Effective restoration of the bony architecture requires a thorough knowledge of distal radius anatomy, understanding of the goals of treatment, versatility in surgical approaches, and familiarity with multiple fixation options. [ABSTRACT FROM AUTHOR]

Most distal radius fractures are the result of low-energy mechanisms that can be successfully treated either non-operatively or with a variety of operative techniques if indicated. Complex distal radius fractures occur most commonly in high-energy injuries with extensive comminution or bone loss and associated soft tissue or vascular injuries. These high-energy fractures can present many challenges in reconstructing the distal radius. Effective restoration of the bony architecture requires a thorough knowledge of distal radius anatomy, understanding of the goals of treatment, versatility in surgical approaches, and familiarity with multiple fixation options. [ABSTRACT FROM AUTHOR]

Purpose: To determine if distraction bridge plate (DBP) fixation as the primary method of stabilization can effectively correct and maintain acceptable radiographic parameters in the treatment of comminuted, intra-articular distal radius fractures while allowing early load-bearing. Methods: A retrospective review was performed of all consecutive intra-articular distal radius fractures that underwent DBP fixation with or without supplemental fixation methods (fragment-specific implants or K-wires). Patients treated with a volar locked plate in addition to DBP were excluded. Radiographic outcomes measures included volar tilt (°), radial height (mm), radial inclination (°), articular step-off (mm), lunate-lunate facet ratio (LLFR), and teardrop angle (°) measured on post-reduction, immediately post-operative, prior to and after DBP removal. Results: Twenty-three comminuted, intra-articular distal radius fractures were treated with primary DBP fixation. Supplemental fixation was utilized in 10 fractures and included fragment-specific implants (n = 6) and/or K-wires (n = 5). Distraction bridge plates were removed after a mean of 13.6 weeks. At a mean radiographic follow-up of 11.4 weeks (range: 2–45 weeks) following DBP removal, all fractures had united with a mean volar tilt of 6.3° ± 5.8°, radial height of 11.3 ± 2.3 mm, radial inclination of 20.2° ± 4.5°, articular step-off of 0.6 mm ± 0.8, and LLFR of 1.05 ± 0.06. However, the teardrop angle could not be restored to a normal value with DBP fixation. Complications included 1 plate breakage and 1 peri-hardware radial shaft fracture. Conclusion: Distraction bridge plate fixation is a reliable method to stabilize highly comminuted, intra-articular distal radius fractures in patients with a well-aligned volar rim fragment of the lunate facet. [ABSTRACT FROM AUTHOR]

Background: Basidiobolomycosis is a rare fungal infection caused by the fungus Basidiobolus ranarum. Gastrointestinal basidiobolomycosis (GIB) is an unusual presentation of the fungal infection that is reported sparsely in the literature, but is an emerging infection in the southwestern United States. Lack of awareness of GIB has resulted in its delayed diagnosis and in extensive morbidity and mortality in patients with GIB. Methods: Case report and literature review. Case Report: We report the rare case of a young female with GIB that presented as perforated appendicitis with abscess formation. Conclusion: Although GIB is rare, immediate and aggressive therapy should be initiated when it is diagnosed. Both long-term medical and surgical treatment is required for its definitive management. [ABSTRACT FROM AUTHOR]

Contrasting reports exist in the literature regarding the management of patients with blunt assault to the head, neck, and face and more importantly for clearing the cervical spine. The purpose of our study was to determine the risk of cervical spine injuries after blunt assault to the head, neck, and face and its association with other injuries. We performed a retrospective case review of all blunt assault trauma admissions to the head, neck, and face at our Level I trauma center. We identified all patients who were assaulted with hands and feet and blunt instruments. A total of 3286 patients with blunt assault to the head, neck, and face were identified of whom 11 (0.003%) were found to have a cervical spine fracture or cervical spine subluxation. None of the patients had a cervical spinal cord injury. The 11 patients composed our study population with a mean age of 39 ± 7.8 years, 100 per cent were male, 6 and the mean Injury Severity Score was 12 ± 7.9. Five (45%) patients required surgery for stabilization 6 of the cervical spine. Mortality was reported in only one patient who had a C7 transverse process fracture. Cervical spine injury after blunt assault is rare but does occur and encompasses significant injuries requiring surgical intervention. However, these injuries are the result of direct blows to the cervical spine and we suggest that assaulted patients with no direct trauma to the neck do not require an exhaustive evaluation of the cervical spine. [ABSTRACT FROM AUTHOR]

The article describes cases of patients with iatrogenic brachial plexus injuries (BPI) which are diagnoses ofter evaluating open subpectoral biceps tenodisis (OSPBT). The specific injuries cover posterior and media cord, median nerve, medial and posterior cord, and the musculocutaneous nerve. The injuries in these areas may occur because of erroneous positions retractors and retraction or overpentration during OSPBT.

BACKGROUND: Alcohol use may alter mental status and vital signs in injured patients, leading to increased testing during emergency department (ED) evaluation. We hypothesized that alcohol use increases the hospital charges when caring for these injured patients. METHODS: The National Hospital Ambulatory Medical Care Survey collects weighted populationbased estimates of ED use. We analyzed injury-related visits of adult patients, and resource use and admission rates were compared by the presence of alcohol. RESULTS: Alcohol was involved in 6.0% of injury-related ED visits. Alcohol-present patients arrived by ambulance more frequently (45% vs 21%, P, .001), had a 26% longer ED stay (211 vs 167 minutes, P, .001), and underwent more diagnostic testing. They were twice as likely to be admitted (14.0% vs 6.5%, P, .001). Additional ED charges were over $217 million. [ABSTRACT FROM AUTHOR]

The article presents information on the management of thumb metacarpophalangeal ulnar collateral ligament (UCL) injuries. It discusses long-term pain and functional limitations caused by untreated UCL injury of the thumb metacarpophalangeal joint (MCPJ). Recommendation of MCP arthrodesis is also considered as the treatment for chronic UCL insufficiency in the joints in which arthrosis is present.

Background: Combined injuries to the spinal cord and brachial plexus present challenges in the detection of both injuries as well as to subsequent treatment. The purpose of this study is to describe the epidemiology and clinical factors of concomitant spinal cord injuries in patients with a known brachial plexus injury. Methods: A retrospective review was performed on all patients who were evaluated for a brachial plexus injury in a tertiary, multidisciplinary brachial plexus clinic from January 2000 to December 2008. Patients with clinical and/or imaging findings for a coexistent spinal cord injury were identified and underwent further analysis. Results: A total of 255 adult patients were evaluated for a traumatic traction injury to the brachial plexus. We identified thirty-one patients with a combined brachial plexus and spinal cord injury, for a prevalence of 12.2%. A preganglionic brachial plexus injury had been sustained in all cases. The combined injury group had a statistically greater likelihood of having a supraclavicular vascular injury (odds ratio [OR] = 22.5; 95% confidence interval [Cl] = 1.9, 271.9) and a cervical spine fracture (OR = 3.44; 95% Cl = 1.6, 7.5). These patients were also more likelyto exhibit a Homer sign (OR = 3.2; 95% Cl = 1.5, 7.2) and phrenic nerve dysfunction (OR = 2.5; 95% Cl = 1.0, 5.8) compared with the group with only a brachial plexus injury. Conclusion: Heightened awareness for a combined spinal cord and brachial plexus injury and the presence of various associated clinical and imaging findings may aid in the early recognition of these relatively uncommon injuries. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to determine whether the RetroScrew tibial fixation system offers a biomechanical advantage over the Delta screw for anterior cruciate ligament (ACL) reconstruction in cadaveric tibias with low bone mineral density (BMD). Methods: Ten matched pairs of osteoporotic cadaveric tibiae underwent simulated ACL reconstruction using quadrupled hamstring grafts with one of the two tibial fixation constructs. Group 1 was fixed with the Delta screw (DS; 35-mm antegrade biointerference screw), and group 2 was fixed with the RetroScrew system (RSS; 20-mm retrograde and 17-mm antegrade biointerference screws). Each construct was cyclically loaded (50-200 N, 1 Hz, 500 cycles) and subsequently loaded to failure (20 mm/s). Results: All specimens were osteoporotic without significant segmental (proximal, middle, and distal) BMD differences between groups by quantitative computed tomography ( P = n.s.). A trend was noted for more construct failures due to graft slippage in the DS group ( n = 3) over the RSS group ( n = 1). There were no significant differences in cyclic displacement ( P = n.s.), maximum cyclic stiffness ( P = n.s.), maximum load at failure ( P = n.s.), or pullout stiffness ( P = n.s.) between groups. Conclusions: In an osteoporotic cadaveric model, there was no significant biomechanical advantage of the RetroScrew system versus the Delta screw for tibial fixation in soft tissue graft ACL reconstruction. However, a trend toward lower graft fixation failure to cyclic loading was noted with the RetroScrew system. Level of evidence: Biomechanical comparative study, Level II. [ABSTRACT FROM AUTHOR]

Contrast-induced nephropathy (CIN) in trauma patients is uncommon and the incidence is unknown. We studied the incidence of CIN and its outcome. A retrospective chart review of trauma patients 16 years of age and older who were admitted to our Level I trauma center during 2005 was performed. Patients who received the intravenous contrast CT scan and had their serum creatinine (Cr) monitored at admission and at 48 to 72 hours were identified. CIN was defined as a 0.5-mg/dL rise of serum Cr or a 25 per cent increase from the baseline if the baseline Cr was abnormal. We excluded patients transferred from an outside facility, patients without repeated serum Cr measurements, patients who had cardiac arrest or persistent hypotension, and patients who had received N-acetylcysteine (Mucomyst) before their CT scan. We compared CIN and non-CIN groups. During 2005, 543 fit our study criteria, of whom 19 (3.5%) had CIN. CIN (vs non-CIN) had a higher baseline serum Cr (1.48 + 0.23 vs 1.06 + 0.02, P < 0.001), a longer intensive care unit stay (17 vs 5 days, P < 0.001), and a longer hospital stay (19 vs 8 days, P < 0.001); the mortality rate was not different (10 vs 4%, P = 0.2). We found elevated baseline serum Cr (OR, 1.92; 95% CI, 1.13 to 3.27; P = 0.016) to be associated with increased risk for CIN. All but two serum Cr levels peaked within 48 hours; all returned to baseline. One patient with an underlying congenital kidney disease required temporary dialysis. CIN incidence in trauma is low and the clinical course is benign. [ABSTRACT FROM AUTHOR]

Background: Undetected developmental dysplasia of the hip can progress to hip instability, which can lead to the development of early osteoarthritis. The purpose of the present study was to determine the reliability and accuracy of the Shenton line in the diagnosis of acetabular dysplasia in the skeletally mature patient. Methods: Supine anteroposterior pelvic radiographs were obtained for a total of 128 hips in patients with a diagnosis of developmental dysplasia of the hip prior to pelvic osteotomy (sixty-four hips, including thirty-two left and thirty-two right hips) and normal patients (sixty-four hips, including thirty-two left and thirty-two right hips). Six orthopaedic surgeons determined if the Shenton line was broken or intact to determine interobserver reliability. Four observers reviewed the randomized radiographs again after four weeks to determine intraobserver reliability. Results: The mean intraclass kappa value was 0.90 (range, 0.79 to 0.97), indicating excellent agreement between each reviewer's primary and secondary reviews. The kappa estimate for interobserver reliability among all six reviewers was 0.80 (95% confidence interval, 0.75 to 0.84), indicating an excellent agreement. The determination of a normal or abnormal Shenton line had a mean sensitivity of 83.3% (range, 60.9% to 93.8%) and specificity of 98.4% (range, 92.2% to 100%). Conclusions: The Shenton line is a reliable and accurate radiographic marker to detect superior femoral head subluxation indicative of acetabular dysplasia. [ABSTRACT FROM AUTHOR]

Background: Undetected developmental dysplasia of the hip can progress to hip instability, which can lead to the development of early osteoarthritis. The purpose of the present study was to determine the reliability and accuracy of the Shenton line in the diagnosis of acetabular dysplasia in the skeletally mature patient.Methods: Supine anteroposterior pelvic radiographs were obtained for a total of 128 hips in patients with a diagnosis of developmental dysplasia of the hip prior to pelvic osteotomy (sixty-four hips, including thirty-two left and thirty-two right hips) and normal patients (sixty-four hips, including thirty-two left and thirty-two right hips). Six orthopaedic surgeons determined if the Shenton line was broken or intact to determine interobserver reliability. Four observers reviewed the randomized radiographs again after four weeks to determine intraobserver reliability.Results: The mean intraclass kappa value was 0.90 (range, 0.79 to 0.97), indicating excellent agreement between each reviewer's primary and secondary reviews. The kappa estimate for interobserver reliability among all six reviewers was 0.80 (95% confidence interval, 0.75 to 0.84), indicating an excellent agreement. The determination of a normal or abnormal Shenton line had a mean sensitivity of 83.3% (range, 60.9% to 93.8%) and specificity of 98.4% (range, 92.2% to 100%).Conclusions: The Shenton line is a reliable and accurate radiographic marker to detect superior femoral head subluxation indicative of acetabular dysplasia. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to determine the effect of bioabsorbable interference screw (BIS) tibial fixation with the Delta screw (antegrade) and RetroScrew (retrograde) on initial (time zero) intra-articular graft tension in soft tissue anterior cruciate ligament (ACL) reconstruction in a cadaveric model. Methods: Ten matched pairs of cadaveric tibias received one of two tibial fixation constructs using quadrupled hamstring grafts, Delta screw (antegrade) or the RetroScrew (retrograde). Each specimen was mounted to the materials testing device with the displacement force vector in line with the tibial tunnel. The construct was pre-tensioned (10-30 N, 0.1 Hz, 10 cycles), a baseline tension of 25 N was introduced, and the change in intra-articular graft tension before and after screw insertion was recorded. Results: Segmental (proximal, middle, distal) BMD was utilized to assess BMD using quantitative computed tomography (qCT). The Delta screw had a higher maximum insertion torque ( P = 0.03) and exhibited a larger increase in intra-articular graft tension as compared to the RetroScrew (38.3 ± 17.9 N, 7.6 N ± 14.4, P = 0.004), respectively. There were no significant correlations between intra-articular graft tension increase to maximum insertion torque ( P = NS) or corresponding segmental BMD ( P = NS). Conclusions: Delta screw tibial fixation (antegrade) in soft tissue ACL reconstruction significantly increases the initial intra-articular graft tension as compared to RetroScrew screw fixation (retrograde) in this cadaveric model. Delta screw (antegrade) tibial fixation may increase initial quadrupled hamstring graft intra-articular tension with currently accepted insertion techniques. [ABSTRACT FROM AUTHOR]

The delivery of combat casualty care poses numerous challenges including austere conditions, limited supplies and medical personnel, and multiple simultaneous patients. However, the exigent circumstances of the battlefield compel the development of research and the advancement of adaptive, practical medical technologies to support and sustain military health. In Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), modern changes in medical management, coupled with improved protective gear and evacuation capabilities, have facilitated the highest survival rate in combat history [ABSTRACT FROM AUTHOR]

Developments in high-throughput technologies such as genome sequencing and gene expressions have created interest among scientists, biotech companies and general public. There has been a need for easy access and availability of several community databases related to plant researches. There must be a seamless connection of community databases, public repositories and journals for better development. The article suggests different ways to resolve, various issues related, to conundrum of the need for high-quality, integrated information and gaps in existing infrastructure.

Effects of hydrogen sulfide (1–3%) on the reduction rate of iron oxide pellets were investigated in temperature range of 800–1100°C. It was found that the reduction rate increased slightly with the addition of 1% H2 S, whereas it decreased significantly with the addition of 3% H2 S. The fractured surface of partially reduced pellets was observed by an optical microscope, a scanning electron microscope (SEM) as well as analyzed by an energy dispersion spectrometer (EDS). It is indicated that small amounts of sulfur may have promoted the formation of porous iron to accelerate the reduction rate, whereas the dense iron sulfide shells formed at higher H2 S offered resistance to the intraparticle diffusion of reducing gas to significantly decrease the reduction rate of pellets. [ABSTRACT FROM AUTHOR]

Rhabdomyolysis (RHAB) is a known complication following blunt trauma. RHAB after penetrating trauma has not been studied. The objective of this study was to evaluate the incidence, risk factors, and complications of RHAB following penetrating trauma. Over a 5-year period, penetrating trauma patients admitted to our intensive care unit (ICU) were studied. Significant RHAB was defined as a CK level of 5000 U/L or higher. There were 873 patients (29 ± 12 years old, 92% male), of whom 767 (88%) bad abnormal CK levels (range 520-165,943 U/L), and 111 patients (13%) developed significant RHAB. Victims of penetrating trauma who sustain vascular and severe extremity injury are at a sixfold increased risk to develop significant RHAB. Patients with significant RHAB had a higher rate of renal failure (23% vs 7%, P < 0.0001) and longer ICU stay (15 ± 26 days us 8 ± 12 days, P < 0.0001). CK elevations and significant RHAB are common after penetrating trauma. Patients who sustain vascular and severe extremity injury as a result of their penetrating wounds are at high risk to develop significant RHAB, resulting in renal failure and prolonged ICU stay. Therefore, critically injured penetrating trauma patients should be routinely screened with CK levels. [ABSTRACT FROM AUTHOR]

Objectives: Using rectal contrast computed tomography (CT) to identify traumatic colorectal injuries has become commonplace; however, these injuries remain relatively infrequent findings on CTs obtained for penetrating back and flank trauma. We conducted a meta-analysis to ascertain the efficacy of rectal contrast CT in identifying such injuries in victims penetrating injuries. Methods: PubMed and Embase were queried for relevant articles between 1974 and 2022. Review articles, case studies, and non-English manuscripts were excluded. Studies without descriptive CT and operative findings were excluded. Positive scans refer to rectal contrast extravasation. Sensitivity and specificity of rectal contrast CT scans were calculated with aggregated CT findings that were cross-referenced with laparotomy findings. Results: Only 8 manuscripts representing 506 patients quantified colorectal injuries and specified patients with rectal contrast extravasation. Seven patients with true colorectal injuries had no contrast extravasation on CT. There was one true positive scan. Another scan identified contrast extravasation, but laparotomy revealed no colorectal injury. Rectal contrast had sensitivity of 12.5%, specificity 99.8%, positive predictive value (PPV) 50%, negative predictive value (NPV) 99%, and a false negative rate of 88% in identifying colonic injuries. Discussion: The summation of 8 manuscripts suggest that the addition of rectal contrast in identifying colonic and rectal injuries may be of limited utility given its poor sensitivity and may be unnecessary. In its absence, subtle clues such as hematomas, extraluminal air, IV-dye extravasation, and trajectory may be additional indicators of injury. Further investigations are required to demonstrate a true benefit for the addition of rectal contrast. [ABSTRACT FROM AUTHOR]

Background The most recent management guidelines advocate computed tomography angiography (CTA) for any suspected vascular or aero-digestive injuries in all zones and give zone II injuries special consideration. We hypothesized that physical examination can safely guide CTA use in a “no zone” approach. Methods An 8-year retrospective analysis of all adult trauma patients with penetrating neck trauma (PNT) was performed. We included all patients in whom the platysma was violated. Patients were classified into three groups as follows: hard signs, soft signs, and asymptomatic. CTA use, positive CTA (contrast extravasation, dissection, or intimal flap) and operative details were reported. Primary outcomes were positive CTA and therapeutic neck exploration (TNE) (defined by repair of major vascular or aero-digestive injuries). Results A total of 337 patients with PNT met the inclusion criteria. Eighty-two patients had hard signs and all of them went to the operating room, of which 59 (72%) had TNE. One hundred fifty-six patients had soft signs, of which CTA was performed in 121 (78%), with positive findings in 12 (10%) patients. The remaining 35 (22%) underwent initial neck exploration, of which 14 (40%) were therapeutic yielding a high rate of negative exploration. Ninty-nine patients were asymptomatic, of which CTA was performed in 79 (80%), with positive findings in 3 (4%), however, none of these patients required TNE. On sub analysis based on symptoms, there was no difference in the rate of TNE between the neck zones in patients with hard signs ( P = 0.23) or soft signs ( P = 0.51). Regardless of the zone of injury, asymptomatic patients did not require a TNE. Conclusions Physical examination regardless of the zone of injury should be the primary guide to CTA or TNE in patients with PNT. Following traditional zone-based guidelines can result in unnecessary negative explorations in patients with soft signs and may need rethinking. [ABSTRACT FROM AUTHOR]

The aim of our study was to assess the impact of helmet legislations on the incidence and the mortality rate of motorcycle collision (MCC)-related traumatic brain injury (TBI) in young adult trauma patients. A 1-year (2011) retrospective analysis was performed of all patients under 21 years old with trauma-related hospitalization using the Nationwide Inpatient Sample database (representing 20% of all in-patient admissions). Patients with MCC were identified using E-codes. States were classified into three groups based on helmet legislations: universal age helmet legislation, <18 years helmet legislation, and <21 years helmet legislation. Outcome measures were the rates of TBI and mortality. Linear regression analysis was used to assess outcomes among the states. A total of 1,165,150 patients with trauma-related hospitalizations across 29 states were reviewed of which, 587 patients with MCC were included. Ten states had universal age legislation; 13 states had age <18 years legislation, and 6 states had age <21 years legislation. There was a lower incidence in the rate of TBI (P = 0.03) in states with universal helmet legislations compared with states with age-restricted helmet legislation. Universal helmet legislations lowered the rate of MCC-related TBI injures by a factor of 2.15 (β coefficient: 2.15; 95% confidence interval: 0.91-10.18; P = 0.04). States with age-restricted helmet legislations have a higher rate of traumatic brain injury and mortality compared with states with universal helmet legislations. Establishing universal helmet legislations across the states may provide a potential preventive strategy against traumatic brain injury. [ABSTRACT FROM AUTHOR]

The type, location, and size of intracranial hemorrhage are known to be associated with variable outcomes in patients with traumatic brain injury (TBI). The aim of our study was to assess the outcomes in patients with isolated epidural hemorrhage (EDH) based on the location of EDH. We performed a 3-year (2010-2012) retrospective chart review of the patients with TBI in our level 1 trauma center. Patients with an isolated EDH on initial head CT scan were included. Patients were divided into four groups based on the location of EDH: frontal, parietal, temporal, and occipital. Differences in demographics and outcomes between the four groups were assessed. Outcome measures were progression on repeat head CT and neurosurgical intervention (NI). A total of 76 patients were included in this study. The mean age was 20.6 ± 15.2 years, 68.4 per cent were male, median Glasgow Coma Scale (GCS) score 15 (13-15), and median head Abbreviated Injury Scale score was 3 (2-4). About 32.9 per cent patients (n = 25) had frontal EDH, 26.3 per cent (n = 20) had temporal EDH, 10.5 per cent (n = 8) had occipital EDH, while the remaining 30.3 per cent (n = 23) had parietal EDH. The overall progression rate was 21.1 per cent (n = 12) and NI rate was 29 per cent (n = 22). There was no difference in the outcome of patients based on location of EDH. Patients with NI had a longer hospital length of stay (P = 0.02) and longer intensive care unit length of stay (P = 0.05). The incidence of isolated EDH is low in patients with blunt TBI. Patients with isolated EDH undergoing NI have longer hospital stays compared to patients without NI. Further investigation is warranted to identify factors associated with need for NI and adverse outcomes in the cohort of patients with isolated EDH. [ABSTRACT FROM AUTHOR]

Case: A 53-year-old man sustained an injury to his left index finger and underwent presumably traumatic neuroma excision from the radial digital nerve 2 years ago. He presented with a painful mass distal to the prior site of neuroma excision with distinctly different symptoms from those that led to his index surgery. Thus, he underwent excisional biopsy of the mass which was adherent to his radial digital nerve consistent with a benign glomus tumor on histologic examination. Conclusion: Digital nerve glomus tumors are rare. In most of the cases, some portion of the digital nerve requires excision but decreased pain can be expected. [ABSTRACT FROM AUTHOR]

The use of 1:1:1 (packed red blood cells: fresh frozen plasma: platelets) transfusion ratio has been shown to improve survival in severely injured trauma patients. The aim of this study was to assess the outcomes in patients with traumatic brain injury (TBI) receiving 1:1:1 ratio-based blood product transfusion (RBT). We hypothesized that RBT improves survival in patients with TBI as only major injury. We performed a 3-year retrospective analysis of all patients with TBI as only major injury presenting to our Level I trauma center. Patients receiving blood transfusion were included. Patients were stratified into two groups: those who received RBT and those who did not receive RBT (No-RBT). The outcome measure was inhospital mortality. Multivariate logistic regression analysis was performed. A total of 189 patients were included of which 29 per cent (n = 55) received RBT. The mean age was 48 ± 24 years, median (range) Glasgow Coma Scale score was 12 (3-15), and median head abbreviated injury severity scale was 3 (3-5). The overall mortality rate was 28.5 per cent. Patients in the RBT group had a higher survival rate compared with the patients in the No-RBT group (83.6% vs 66.5%, P = 0.02). In conclusion, the survival benefit of RBT exists even in patients with TBI as major injury. Guidelines for the initial management of TBI patients should focus on the use of RBT. The beneficial effect of platelets in RBT among TBI patients requires further evaluation. [ABSTRACT FROM AUTHOR]

Background Multiple prior studies have suggested an association between survival and beta-blocker administration in patients with severe traumatic brain injury (TBI). However, it is unknown whether this benefit of beta-blockers is dependent on heart rate control. The aim of this study was to assess whether rate control affects survival in patients receiving metoprolol with severe TBI. Our hypothesis was that improved survival from beta-blockade would be associated with a reduction in heart rate. Methods We performed a 7-y retrospective analysis of all blunt TBI patients at a level-1 trauma center. Patients aged >16 y with head abbreviated injury scale 4 or 5, admitted to the intensive care unit (ICU) from the operating room or emergency room (ER), were included. Patients were stratified into two groups: metoprolol and no beta-blockers. Using propensity score matching, we matched the patients in two groups in a 1:1 ratio controlling for age, gender, race, admission vital signs, Glasgow coma scale, injury severity score, mean heart rate monitored during ICU admission, and standard deviation of heart rate during the ICU admission. Our primary outcome measure was mortality. Results A total of 914 patients met our inclusion criteria, of whom 189 received beta-blockers. A propensity-matched cohort of 356 patients (178: metoprolol and 178: no beta-blockers) was created. Patients receiving metoprolol had higher survival than those patients who did not receive beta-blockers (78% versus 68%; P = 0.04); however, there was no difference in the mean heart rate (89.9 ± 13.9 versus 89.9 ± 15; P = 0.99). Nor was there a difference in the mean of standard deviation of the heart rates (14.7 ± 6.3 versus 14.4 ± 6.5; P = 0.65) between the two groups. In Kaplan–Meier survival analysis, patients who received metoprolol had a survival advantage ( P = 0.011) compared with patients who did not receive any beta-blockers. Conclusions Our study shows an association with improved survival in patients with severe TBI receiving metoprolol, and this effect appears to be independent of any reduction in heart rate. We suggest that beta-blockers should be administered to all severe TBI patients irregardless of any perceived beta-blockade effect on heart rate. [ABSTRACT FROM AUTHOR]

Case: A 53-year-old man sustained an injury to his left index finger and underwent presumably traumatic neuroma excision from the radial digital nerve 2 years ago. He presented with a painful mass distal to the prior site of neuroma excision with distinctly different symptoms from those that led to his index surgery. Thus, he underwent excisional biopsy of the mass which was adherent to his radial digital nerve consistent with a benign glomus tumor on histologic examination. Conclusion: Digital nerve glomus tumors are rare. In most of the cases, some portion of the digital nerve requires excision but decreased pain can be expected. [ABSTRACT FROM AUTHOR]

BACKGROUND: The aim of our study was to evaluate the clinical outcomes in patients on preinjury Ibuprofen with traumatic brain injury. METHODS: We performed a 2-year analysis of all patients on prehospital Ibuprofen with traumatic brain injury and intracranial hemorrhage. Patients on preinjury Ibuprofen were matched using propensity score matching to patients not on Ibuprofen in a 1:2 ratio for age, Glasgow Coma Scale, head-abbreviated injury scale, injury severity score, International Normalized Ratio, and neurologic examination. Outcome measures were progression on repeat head computed tomography (RHCT) and neurosurgical intervention. RESULTS: A total of 195 matched (Ibuprofen 65, no-Ibuprofen 130) patients were included. There was no difference in the progression on RHCT (Ibuprofen 18% vs no-Ibuprofen 24%; P = .50). The neurosurgical intervention rate was 18.9% (n = 37). There was no difference for need for neurosurgical intervention (26% vs 16%; P = .10) between the 2 groups. CONCLUSIONS: In a matched cohort of trauma patients, preinjury Ibuprofen use was not associated with progression of initial intracranial hemorrhage and the need for neurosurgical intervention. Preinjury use of Ibuprofen as an independent variable should not warrant the need for a routine RHCT scan. [ABSTRACT FROM AUTHOR]

Background Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI. Methods Version 7.2 of the National Trauma Data Bank (2007-2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications. Results A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1-2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1-2.8, P = 0.009) in patients with isolated severe TBI. Conclusions ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification. [ABSTRACT FROM AUTHOR]

Background: Left atrial volume (LAV) and emptying fraction (LAEF) are phasic during cardiac cycle. Their relationships to left ventricular end diastolic pressure (LVEDP) have not been fully defined. Methods: Forty one patients undergoing clinically indicated left heart catheterization were recruited for same day cardiovascular magnetic resonance (CMR). LAV and LAEF were assessed in cine images using biplane area and length method. Three phasic LAV was assessed at LV end systole (LAVmax), LV end diastole (LAVmin) and late LV diastole prior to LA contraction (LAVac). LAEF was assessed as global LAEF (LAEFTotal), passive (LAEFPassive) and active LAEF (LAEFContractile). The relationships of phasic LAV and LAEF to LVEDP were assessed using Receiver operating characteristic comparing areas under the curves (AUC). Results: The mean age of the patients was 59 years. A history of heart failure was present in 16 (39%) with NYHA functional class III or IV in 8 (20%) patients. Average LV ejection fraction was 49 ± 16% ranging from 10% to 74% and LVEDP by catheterization 14 ± 8 mmHg ranging from 4 mmHg to 32 mmHg. LAVmin had the strongest association with LVEDP elevation (>12 mmHg) (AUC 0.765, p = 0.002), as compared to LAVmax (AUC 0.677, p = 0.074) and LAVac (AUC 0.735, p = 0.008). Among three phasic LAEF assessed, LAEFTotal had the closest association with LVEDP elevation (AUC 0.780, p = 0.001), followed by LAEFContractile (AUC 0.698, p = 0.022) and LAEFPassive (AUC 0.656, p = 0.077). Conclusions: Increased LAVmin and decreased LAEFTotal have the best performance in identifying elevated LVEDP among three phasic LAV and LAEF analyzed. Future studies should further characterize LA phasic indices in clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: A major clinical issue affecting 10-40% of cancer patients treated with oxaliplatin is severe peripheral neuropathy with symptoms including cold sensitivity and neuropathic pain. Rat models have been used to describe the pathological features of oxaliplatin-induced peripheral neuropathy; however, they are inadequate for parallel studies of oxaliplatin's antineoplastic activity and neurotoxicity because most cancer models are developed in mice. Thus, we characterized the effects of chronic, bi-weekly administration of oxaliplatin in BALB/c mice. We first studied oxaliplatin's effects on the peripheral nervous system by measuring caudal and digital nerve conduction velocities (NCV) followed by ultrastructural and morphometric analyses of dorsal root ganglia (DRG) and sciatic nerves. To further characterize the model, we examined nocifensive behavior and central nervous system excitability by in vivo electrophysiological recording of spinal dorsal horn (SDH) wide dynamic range neurons in oxaliplatin-treated mice Results: We found significantly decreased NCV and action potential amplitude after oxaliplatin treatment along with neuronal atrophy and multinucleolated DRG neurons that have eccentric nucleoli. Oxaliplatin also induced significant mechanical allodynia and cold hyperalgesia, starting from the first week of treatment, and a significant increase in the activity of wide dynamic range neurons in the SDH. Conclusions: Our findings demonstrate that chronic treatment with oxaliplatin produces neurotoxic changes in BALB/c mice, confirming that this model is a suitable tool to conduct further mechanistic studies of oxaliplatinrelated antineoplastic activity, peripheral neurotoxicity and pain. Further, this model can be used for the preclinical discovery of new neuroprotective and analgesic compounds. [ABSTRACT FROM AUTHOR]

Background: The impact of platelet transfusion in trauma patients undergoing a massive transfusion (MT) was evaluated. Study Design: The Institutional Trauma Registry and Blood Bank Database at a Level I trauma center was used to identify all patients requiring an MT (≥10 packed red blood cells [PRBC] within 24 hours of admission). Mortality was evaluated according to 4 apheresis platelet (aPLT):PRBC ratios: Low ratio (<1:18), medium ratio (≥1:18 and <1:12), high ratio (≥1:12 and <1:6), and highest ratio (≥1:6). Results: Of 32,289 trauma patients, a total of 657 (2.0%) required an MT. At 24 hours, 171 patients (26.0%) received a low ratio, 77 (11.7%) a medium ratio, 249 (37.9%) a high ratio, and 160 (24.4%) the highest ratio of aPLT:PRBC. After correcting for differences between groups, the mortality at 24 hours increased in a stepwise fashion with decreasing aPLT:PRBC ratio. Using the highest ratio group as a reference, the adjusted relative risk of death was 1.67 (adjusted p = 0.054) for the high ratio group, 2.28 (adjusted p = 0.013) for the medium ratio group, and 5.51 (adjusted p < 0.001) for the low ratio group. A similar stepwise increase in mortality with decreasing platelet ratio was observed at 12 hours after admission and for overall survival to discharge. After stepwise logistic regression, a high aPLT:PRBC ratio (adjusted p < 0.001) was independently associated with improved survival at 24 hours. Conclusions: For injured patients requiring a massive transfusion, as the apheresis platelet-to-red cell ratio increased, a stepwise improvement in survival was seen. Prospective evaluation of the role of platelet transfusion in massively transfused patients is warranted. [ABSTRACT FROM AUTHOR]

Background: For trauma patients requiring massive blood transfusion, aggressive plasma usage has been demonstrated to confer a survival advantage. The aim of this study was to evaluate the impact of plasma administration in nonmassively transfused patients. Study Design: Trauma patients admitted to a Level I trauma center (2000–2005) requiring a nonmassive transfusion (<10 U packed RBC [PRBC] within 12 hours of admission) were identified retrospectively. Propensity scores were calculated to match and compare patients receiving plasma in the first 12 hours with those who did not. Results: The 1,716 patients (86.1% of 1,933 who received PRBC transfusion) received a nonmassive transfusion. After exclusion of 31 (1.8%) early deaths, 284 patients receiving plasma were matched to patients who did not. There was no improvement in survival with plasma transfusion (17.3% versus 14.1%; p = 0.30) irrespective of the plasma-to-PRBC ratio achieved. However, the overall complication rate was significantly higher for patients receiving plasma (26.8% versus 18.3%, odds ratio [OR] = 1.7; 95% CI, 1.1–2.4; p = 0.016). As the volume of plasma increased, an increase in complications was seen, reaching 37.5% for patients receiving >6 U. The ARDS rate specifically was also significantly higher in patients receiving plasma (9.9% versus 3.5%, OR = 3.0; 95% CI, 1.4–6.2; p = 0.004]. Patients receiving >6 U plasma had a 12-fold increase in ARDS, a 6-fold increase in multiple organ dysfunction syndrome, and a 4-fold increase in pneumonia and sepsis. Conclusions: For nonmassively transfused trauma patients, plasma administration was associated with a substantial increase in complications, in particular ARDS, with no improvement in survival. An increase in multiple organ dysfunction, pneumonia, and sepsis was likewise seen as increasing volumes of plasma were transfused. The optimal trigger for initiation of a protocol for aggressive plasma infusion warrants prospective evaluation. [Copyright &y& Elsevier]

Abstract: Background: Teletrauma programs allow rural patients access to advanced trauma and emergency medical services that are often limited to urban areas. Methods: A retrospective analysis of 59 teleconsults between 5 rural hospitals and a level I trauma center was performed. The objectives of this study were to report the initial experience with a telemedicine program connecting 5 rural hospitals with a level I trauma center. Results: A total of 59 trauma and general surgery patients were evaluated. Of those, 35 (59%) were trauma patients, and 24 (41%) were general surgery patients. Fifty patients (85%) were from the first hospital at which teletrauma was established. For 6 patients, the teletrauma consults were considered potentially lifesaving; 17 patients (29%) were kept in the rural hospitals (8 trauma and 9 general surgery patients). Treating patients in the rural hospitals avoided transfers, saving an average of $19,698 per air transport or $2,055 per ground transport. Conclusions: The telepresence of a trauma surgeon aids in the initial evaluation, treatment, and care of patients, improving outcomes and reducing the costs of trauma care. [Copyright &y& Elsevier]

Background Admission hypothermia (core temperature ≤ 35°C) is an independent risk factor for mortality after trauma. The predictive value of perioperative core temperatures during acute trauma surgery, however, although widely employed as a criterion for initiating damage control, is unknown. We hypothesized that for trauma patients undergoing laparotomy or thoracotomy, early postoperative hypothermia is a predictor of mortality.Methods After institutional review board (IRB) approval, all critically ill trauma patients undergoing cavitary surgery (laparotomy or thoracotomy) at a level 1 trauma center from 01/1998 to 07/2006 were identified from the trauma registry. Immediate postoperative core temperature (Tc) was used to classify patients as hypothermic (Tc ≤ 35°C) or normothermic (Tc > 35°C). The profoundly hypothermic subgroup of patients with a Tc < 33°C was also analyzed.Results During the study period, 2,489 patients required cavitary surgery, 1,252 of whom (50%) were admitted to the intensive care unit (ICU). On arrival in the ICU 15% of the patients had a Tc ≤ 35°C and were more likely to be ≥ 55 years old (12% versus 7%; p = 0.04); in addition, they were hypotensive on admission (25% versus 13%; p < 0.001), had a lower admission Glasgow Coma Score (GCS; 11 ± 5 versus 14 ± 3; p < 0.001), a higher Injury Severity Score (ISS; 29 ± 15 versus 22 ± 12; p < 0.001), higher head and chest Abbreviated Injury Scale (AIS), and greater intraoperative blood loss (2.6 ± 2.4 l versus 1.7 ± 1.8 l; p < 0.001). When compared to patients who were normothermic at the end of their operation, hypothermic patients had a significantly higher mortality (35% versus 8%; p < 0.001). With decreasing Tc, there was a stepwise increase in mortality. Compared to patients with a Tc > 35°C, the relative risk of death for patients with a Tc between 35°C and 33°C was 4.0, and that for patients with a Tc ≤ 33°C it was 7.1. After adjusting for multiple differences between groups, postoperative hypothermia remained an independent predictor of mortality (adjusted odds ratio [OR] 3.2; 95% confidence interval [CI] 1.9–5.3; p < 0.001).Conclusions Postoperative hypothermia is common in critically injured patients requiring cavitary surgery and is an independent predictor of mortality. The impact of measures to maintain or restore normothermia in the operating room warrants further investigation. [ABSTRACT FROM AUTHOR]

Background: Resuscitation with racemic lactated Ringer’s solution induces cellular apoptosis. This study was conducted to determine if the elimination of D-lactate isomer would attenuate apoptosis in the liver, and to investigate the possible mechanisms. Study design: Sprague Dawley rats (n=30, 5 per group) were subjected to modified volume-controlled hemorrhage and randomized to the following groups: no hemorrhage (sham); no resuscitation (NR); resuscitation with racemic lactated Ringer’s (DL-LR); L-isomer LR (L-LR); ketone (β-hydroxybuturate) Ringer’s (KR); or pyruvate Ringer’s (PR). Animals were sacrificed 2hours later and expressions of proapoptotic proteins (BAD), antiapoptotic (bcl-2) proteins, and poly-ADP ribose polymerase (PARP) cleavage in liver were analyzed by Western blotting. Contribution of the phosphatidylinositol 3-kinase/serine/threonine kinase (PI3k/Akt) pathway was assessed by measuring total and phosphorylated PI3K, Akt, BAD, and endothelial nitric oxide synthase (eNOS) proteins. The terminal deoxynucleotidyl transferase mediated dUTP nick end labeling (TUNEL) assay was used to detect the apoptotic cells. Liver ATP levels were measured using a luciferase reaction assay. Results: Hemorrhage significantly decreased the hepatic ATP level and resuscitation improved it, but it returned to normal only in the L-isomer lactated Ringer’s and ketone Ringer’s groups. Expression of proapoptotic proteins was significantly lower in the pyruvate Ringer’s and ketone Ringer’s groups; L-isomer lactated Ringer’s and pyruvate Ringer’s resuscitation significantly increased bcl-2 expression. Poly-ADP ribose polymerase fragmentation and total number of apoptotic cells were significantly increased in the racemic lactated Ringer’s group. There was no significant induction of Akt activity or changes in phosphorylated BAD, Akt, or eNOS levels. Conclusions: Resuscitation with racemic lactated Ringer’s induces hepatic apoptosis, which is decreased if the D-isomer of lactate is eliminated. Apoptosis is reduced even more when lactate is substituted with β-hydroxybutyrate or pyruvate. The beneficial effects are not through improvements in the energy status or activation of the PI3K/Akt pathway. [Copyright &y& Elsevier]

Abstract: Profound hypothermic arrest (“suspended animation”) is a new strategy to improve outcome following uncontrolled lethal hemorrhage (ULH). However, the impact of this approach on the immune/inflammatory response is unknown. This experiment was conducted to test the influence of profound hypothermia on markers of immune/inflammatory system. Methods:: ULH was induced in 32 female swine (80–120lb) by creating an iliac artery and vein injury, followed 30min later by laceration of the descending thoracic aorta. Through a left thoracotomy approach, total body hypothermic hyperkalemic metabolic arrest was induced by infusing organ preservation fluids into the aorta using a cardiopulmonary bypass machine (CPB). Experimental groups were (1) normothermic controls (no cooling, NC), or hypothermia induced at the following rates: (2) 0.5°C/min (slow, SC), (3) 1°C/min (medium, MC) and (4) 2°C/min (fast, FC). Vascular injuries were repaired during 60min of profound (10°C) hypothermic arrest. Hyperkalemia was reversed by hypokalemic fluid exchange, and blood was infused for resuscitation during re-warming (0.5°C/min). The surviving animals were monitored for 6 weeks. Levels of IL-1, TNFα, IL-6, IL-10, TGF-1β and heat shock protein (HSP-70) were measured by ELISA in serum samples collected serially during the experiment and post-operatively. Results:: Some of the immune markers were influenced by the use of CPB, independent of hypothermia (decrease in TGF-1β and increase in IL-1β). Hypothermia caused a significant decrease in IL-6, and an increase in HSP-70 expression compared to normothermic controls, independent of the cooling rate. An increase in IL-10 levels was noted which was influenced by the rate of cooling (p &#60;0.05, MC versus NC). Conclusions:: Profound hypothermia modulates the post-shock immune/inflammatory system by attenuating the pro-inflammatory IL-6, increasing anti-inflammatory IL-10 and augmenting the protective heat shock responses. [Copyright &y& Elsevier]