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Noninvasive continuous blood pressure monitoring has the potential to improve patient treatment in the hospital setting. Such noninvasive devices can be applied earlier in the treatment process to empower nurses and clinicians to react more quickly to patient deterioration with the added benefit of eliminating the risks associated with invasive monitoring. However, emerging technologies must be capable of reproducing current clinical measures for medical decision making. This study aimed to determine the usability and willingness of nurses to implement a noninvasive continuous blood pressure monitoring device. The secondary aim directly compared the systolic blood pressure, diastolic blood pressure, and mean arterial pressure values recorded by the device (VitalStream; CareTaker Medical LLC, Charlottesville, VA) with the "gold standard" brachial cuff and arterial line measures recorded in the emergency department and intensive care unit settings. VitalStream was similarly received by nurses in the emergency department and intensive care setting, but ultimately had greater promotion from emergency nurses. Despite some statistical similarity between measurement methodologies, all direct comparisons were found to not meet the Association for the Advancement of Medical Instrumentation 2008 and Association for the Advancement of Medical Instrumentation / European Society of Hypertension / International Organization for Standardization 2019 consensus statement criteria for acceptable blood pressure measure differences between the VitalStream and "gold standard" clinical measures. In all instances, the standard deviation of the Bland-Altman bias exceeded 8 mm Hg with less than 85% of paired differences falling within 10 mm Hg of the "gold standard." Taken together, the tested device requires additional postprocessing for medical decision making in trauma or emergent care. [ABSTRACT FROM AUTHOR]

Introduction: Trauma is one of the most common reasons for patients to be referred to the emergency room, which is one of the most important diagnostic methods for trauma patients upon arrival. According to the many requests of doctors to perform CT scans of patients, the researchers consider the reasons for this to be the lack of clarity of the existing instructions or the lack of knowledge and concern of doctors regarding the mandatory cases of imaging. Regarding the lack of specific guidelines for obtaining CT scans in children in Birjand hospitals, the aim of this study was to investigate the rate of unnecessary CT scans and related factors in children with head trauma referred to the emergency department of Imam Reza Hospital. Materials and methods: In this cross-sectional study, 250 children with Trauma complaint were included in the study. After entering the emergency room and being examined by an emergency medicine specialist, the patients were referred to the radiology department for a brain CT scan if necessary. The CT scan taken from the patients was reviewed by the radiology assistant and the CT scan findings were recorded in the study checklist. Indications for CT scan were reviewed based on NEXUS II guideline. SPSS version 22 software was used. Chisquare statistical test was used to compare the differences. P value ≤0.05 was considered statistically significant. Results: The average age of children was 7.19 ± 3.38 years. The most common clinical symptom of children was headache. The most common indication based on the NEXUS II guideline was scalp hematoma followed by decreased consciousness. The most common CT scan finding was a fracture. 38.4% of the obtained CT scans were unnecessary. The frequency distribution of necessary CT scan did not differ significantly in terms of gender, age group of children and the symptoms of headache, nausea, vomiting, diplopia, raccoon sign and ettore (P>0.05), but the frequency distribution of necessary CT scan showed a significant difference in terms of Mechanism of trauma, GCS level, final outcome of patients, amnesia, battle sign and rhinorrhea (P<0.05). Conclusion: Based on the data presented herein, the rate of brain CT scans of children with unnecessary head trauma in Imam Reza Hospital was 38.4%. The frequency distribution of necessary CT scan showed significant differences from each other in terms of trauma mechanism, GCS level, patients' final outcome, amnesia, battle sign, rhinorrhea, neurological deficit, decreased consciousness, abnormal behavior and persistent nausea. [ABSTRACT FROM AUTHOR]

Background: The clinical use of factor VIII inhibitor bypassing activity (FEIBA) for factor Xa (FXa) inhibitor reversal is derived from small studies with notable variation in patient eligibility for use, dosage regimens, concurrent supportive care, and outcome measures. Consequently, additional effectiveness and safety data are warranted to expand the literature evaluating FEIBA for FXa inhibitor reversal. Objective: This study sought to determine the incidence of observed effective hemostasis within 24 hours of post-FEIBA® administration as well as in-hospital and 30-day post-discharge incidences of thromboembolic event (TEE) and mortality between apixaban and rivaroxaban in the intracranial hemorrhage (ICH) and non-ICH populations. Methods: This case series evaluated patients between January 1, 2014 through July 1, 2019 who received at least one FEIBA® dose for apixaban or rivaroxaban reversal secondary to acute ICH or non-ICH. Patient demographics, FEIBA® dosages, adjunct treatments, effectiveness, and safety outcomes were retrospectively collected from electronic medical record review. Modified hemostasis outcomes, adapted from criteria previously published by Sarode et al., TEE, and mortality between apixaban and rivaroxaban in the ICH and non-ICH populations were evaluated. Results: Among the 104 patients evaluated, 62 received apixaban and 42 rivaroxaban. Thirty apixaban and 25 rivaroxaban users experienced ICH, whereas 32 apixaban and 17 rivaroxaban users experienced non-ICH. Among the combined ICH and non-ICH populations, effective hemostasis occurred in 89%, TEE in 8%, and mortality in 13%. No statistically significant differences were observed within ICH and non-ICH populations receiving apixaban or rivaroxaban regarding effective hemostasis, TEE, or mortality. Conclusion and Relevance: The combined ICH and non-ICH overall rates of effective hemostasis, TEE, and mortality were comparable to preexisting studies of FEIBA for factor Xa inhibitor reversal. The limitations inherent to the study design warrant a randomized controlled trial with an active comparator to confirm these observations. [ABSTRACT FROM AUTHOR]

BACKGROUND: En route care (ERC) is a military aeromedical mission designed to transport a patient to a higher level of care. With the exception of one manual, there are no other formal Navy ERC guidelines, leaving the service to provide such missions ad hoc. Based on the authors' review of available literature, it seems no prior research has been done on Navy rescue swimmers performing ERC, though many search and rescue (SAR) missions take place without designated medical personnel. This study specifically examines the type of provider involved in Navy ERC missions and the types of cases involved with the purpose of influencing Navy policy. METHODS: A cross-sectional study examining 829 air evacuations performed by Navy SAR flight crews from 2016 to 2019 was analyzed. RESULTS: Of 829 cases reviewed, patients were more likely to be active-duty personnel (51%) than civilian (47%), and there were 2.5 times more male than female patients. There were more trauma (54%) than medical (43%) patients, with Basic Life Support (BLS) level care (60%) delivered twice as often as Advanced Life Support (ALS) (28%). Search and Rescue Medical Technicians (SMTs) and rescue swimmers provided 83% of ERC, with rescue swimmers supporting 33% of all ERC missions alone. DISCUSSION: The results of this study are in contrast to previous ERC studies, in which rescue swimmer-only transports were excluded from the data. The results raise the question, do rescue swimmers need to be trained to a higher level of care? [ABSTRACT FROM AUTHOR]

Objective: To describe the efficacy and safety of pharmacologic neurostimulants after neurological injuries such as ischemic or hemorrhagic stroke and traumatic brain injury (TBI), critically evaluate the available literature, and make recommendations regarding which neurostimulants should be considered for use in clinical practice. Data Sources: A literature search of PubMed was performed (1953 to October 2020) to identify relevant articles. Search terms included the following: "neurostimulant, neurorehabilitation" AND "traumatic brain injury, cerebrovascular accident, or stroke." This review is limited to prospective studies and observational trials. Study Selection and Data Extraction: Relevant English-language studies conducted in humans were considered. Data Synthesis: Cognitive and motor deficits caused by stroke and TBI account for high rates of long-term disability. Although not well-established, pharmacologic agents, broadly characterized as neurostimulants, may be prescribed after brain injury to treat these deficits. When prescribing these medications, it is imperative to be aware of the supporting evidence in order to accurately gauge the risk-benefit profile of each agent. Relevance to Patient Care and Clinical Practice: The following presents a literature review critically evaluating clinical studies that investigate neurostimulant use after brain injury. The intent of this review is to serve as an evidence-based guide for clinicians. Conclusions: The pharmacologic agent with the most supporting literature is amantadine used for cognitive improvement after TBI. Other neurostimulants with positive, despite more limited, evidence include methylphenidate, modafinil, levodopa, and citalopram. Caution is warranted with other neurostimulants given higher rates of adverse effects or lack of benefit observed in clinical trials. [ABSTRACT FROM AUTHOR]

Background: Rib fractures account for more than one-third of blunt thoracic injuries and are associated with serious complications. Use of nonopioid adjunctive agents such as methocarbamol for pain control has increased considerably.Objective: This study aimed to assess the impact of methocarbamol addition to the pain control regimen on daily opioid requirements for young adults with rib fractures.Methods: This observational, retrospective study included patients aged 18 to 39 years with 3 or more rib fractures who were admitted to a level 1 trauma center between July 2014 and July 2018. Patients were dichotomized based on admission before and after methocarbamol addition to the institutional rib fracture protocol. The primary outcome was to determine the impact of methocarbamol on daily opioid requirements. Secondary outcomes included hospital length of stay (LOS) and diagnosis of pneumonia.Results: A total of 50 patients were included, with 22 and 28 patients in the preprotocol and postprotocol groups, respectively. All patients in the latter group received methocarbamol, whereas no patient in the preprotocol group received methocarbamol. Cumulative opioid exposure was significantly less for patients admitted after methocarbamol addition to the protocol (219 vs 337 mg oral morphine equivalents; P = 0.01), and hospital LOS was also decreased (4 vs 3 days; P = 0.03). No significant differences in the incidence of pneumonia or adverse effects were observed.Conclusion and Relevance: This is the first study to evaluate the impact of methocarbamol on reducing opioid requirements. Given the risks associated with opioids, use of methocarbamol as an analgesia-optimizing, opioid-sparing multimodal agent may be reasonable. [ABSTRACT FROM AUTHOR]

To enable selection of a safer suspension site to use in face and neck lifting procedures, the spatial relationship between the tympanoparotid fascia and the great auricular nerve should be clarified. In this study, we aimed to elucidate the position of the tympanoparotid fascia and the pathway of the lobular branch of the great auricular nerve traversing the tympanoparotid fascia. Twenty hemifaces from non-preserved bequeathed Korean cadavers (5 males, 7 females; mean age, 77.0 years) were dissected to determine the great auricular nerve distribution close to the tympanoparotid fascia of clinical significance for face and neck lift procedures. We observed the tympanoparotid fascia in all specimens (20 hemifaces). The tympanoparotid fascia was located anteriorly between the tragus and intertragic notch. Regarding the spatial relationship between the tympanoparotid fascia and the great auricular nerve, we found the sensory nerve entering the tympanoparotid fascia in all specimens (100%), and the depth from the skin was approximately 4.5 mm; in 65% of the specimens, the lobular branch was found to run close to the tympanoparotid fascia before going into the earlobe. Provided with relatively safer surface mapping to access the tympanoparotid fascia free of the lobular branch of the great auricular nerve, surgeons may better protect the lobular branch by anchoring the SMAS-platysma flap and thread to the deeper superior and anterior portions of the expected tympanoparotid fascia. [ABSTRACT FROM AUTHOR]

Introduction: Videolaryngoscopy (VL) as a new airway management technique has evolved in recent decades, and a large number of videolaryngoscopes are now available on the market. Most recent major guidelines already recommend the immediate availability and use of VL in difficult airway management scenarios. However, national data on the availability of VL, introduction into practice and patterns of use are rarely published. Therefore, the current study aimed to provide data on VL in Hungary. Materials and methods: An electronic survey was designed and popularized with the help of the Hungarian Society of Anaesthesiology and Intensive Therapy to explore the availability, use, and practice of and attitudes toward VL among Hungarian anesthesiologists. The survey was conducted between 01.01.2018 and 31.12.2018. Results: In total, 324 duly completed forms were returned and analyzed. Responders were mainly males (58%), specialists (80%) and those involved mainly in anesthesia practice (68%) in the public sector. Two hundred and ten (65%) responders had access to various videolaryngoscopes and were mainly from surgery, intensive care and traumatology units. No responders reported the availability of eight videolaryngoscopes out of the eighteen listed devices, and 32% of the responders had never used any videolaryngoscope in clinical settings. The most commonly available devices were KingVision, MacGrath Mac and Airtraq. Most of the responders reported using videolaryngoscopes mainly for difficult airway management and reported using a fiberscope as the first alternative device. Popular methods for selecting videolaryngoscopes included the following: short clinical trial (n = 67/324), decision of the departmental lead (n = 65/324) and price (n = 54/324). The majority of responders had some training prior to clinical application, but training was mainly voluntary. Overall, 98% of the responders considered videolaryngoscopes beneficial. Conclusions: Approximately two-thirds of Hungarian anesthesiologists have immediate access to videolaryngoscopes, which are used mainly for difficult airway management. The overall attitude towards VL is positive, and many videolaryngoscopes are known and have been used by Hungarian anesthesiologists. However, only a few devices on the market are used commonly. Based on the results, further improvement might be recommended regarding VL training and availability. [ABSTRACT FROM AUTHOR]

Vehicles can be classified by configuration as either bonnet-type or cab-over type according to engine location. Compared to bonnet-type, the front compartment of cab-over type vehicles is considerably shorter; thus, it may be less likely to absorb the energy generated in a collision, and in turn be unable to prevent deformation of the occupant space and protect occupants from injury. This study was a cohort study involving 943 occupants of mini-vehicles who were injured in frontal collision accidents between 2001 and 2015 and transferred to Ohta Nishinouchi Hospital. The vehicle configuration was divided into bonnet-type and cab-over type (i.e., truck-type and wagon-type). The tested outcomes were anatomical-specific severe injury of the pelvis and extremities, the head and neck, the abdomen, and the chest. To estimate adjusted odds ratios (AOR) for associations between vehicle configuration and anatomical-specific severe injury, we fitted generalized estimating equations for each outcome. Compared with bonnet-type vehicles, a greater risk of serious pelvis and extremities injury was found for both truck (AOR: 2.21; 95% Confidence Interval [95% CI]: 1.22–4.00) and wagon-type vehicles (AOR: 3.43; 95%CI 1.60–7.39). For serious head and neck injury, truck-type vehicles were associated with greater risk (AOR: 2.04; 95% CI: 1.10–3.79) than bonnet-type vehicles, whereas wagon-type vehicles were not. Compared with the occupants of bonnet-type vehicles, cab-over type vehicle occupants were more likely to have serious pelvis and extremities injury during frontal collisions. Additionally, truck-type vehicle occupants were more likely to have serious head and neck injury than bonnet-type vehicle occupants. These findings are expected to promote safer behaviors for vehicle occupants and the automobile industry. [ABSTRACT FROM AUTHOR]

Trauma and hemorrhagic shock can lead to acute traumatic coagulopathy (ATC) that is not fully reversed by prehospital resuscitation as simulated with a limited volume of fresh whole blood (FWB) in a rat model. Tranexamic Acid (TXA) is used as an anti-fibrinolytic agent to reduce surgical bleeding if administered prior to or during surgery, and to improve survival in trauma if given early after trauma. It is not clear from the existing clinical literature whether TXA has the same mechanism of action in both settings. This study sought to explore the molecular mechanisms of TXA activity in trauma and determine whether administration of TXA as a supplement to FWB resuscitation could attenuate the established ATC in a rat model simulating prehospital resuscitation of polytrauma and hemorrhagic shock. In a parallel in-vitro study, the effects on clotting assays of adding plasmin at varying doses along with either simultaneous addition of TXA or pre-incubation with TXA were measured, and the results suggested that maximum anti-fibrinolytic effect of TXA on plasmin-induced fibrinolysis required pre-incubation of TXA and plasmin prior to clot initiation. In the rat model, ATC was induced by polytrauma followed by 40% hemorrhage. One hour after trauma, the rats were resuscitated with FWB collected from donor rats. Vehicle or TXA (10mg/kg) was given as bolus either before trauma (TXA-BT), or 45min after trauma prior to resuscitation (TXA-AT). The TXA-BT group was included to contrast the coagulation effects of TXA when used as it is in elective surgery vs. what is actually feasible in real trauma patients (TXA-AT group). A single dose of TXA prior to trauma significantly delayed the onset of ATC from 30min to 120min after trauma as measured by a rise in prothrombin time (PT). The plasma d-dimer as well as plasminogen/fibrinogen ratio in traumatized liver of TXA-BT were significantly lower as compared to vehicle and TXA-AT. Wet/dry weight ratio and leukocytes infiltration of lungs were significantly decreased only if TXA was administrated later, prior to resuscitation (TXA-AT). In conclusion: Limited prehospital trauma resuscitation that includes FWB and TXA may not correct established systemic ATC, but rather may improve overall outcomes of resuscitation by attenuation of acute lung injury. By contrast, TXA given prior to trauma reduced levels of fibrinolysis at the site of tissue injury and circulatory d-dimer, and delayed development of coagulopathy independent of reduction of fibrinogen levels following trauma. These findings highlight the importance of early administration of TXA in trauma, and suggest that further optimization of dosing protocols in trauma to exploit TXA’s various sites and modes of action may further improve patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: To investigate if animal-assisted therapy (AAT) leads to higher consciousness in patients in a minimally conscious state during a therapy session, measured via behavioral reactions, heart rate and heart rate variability. Methods: In a randomized two treatment multi-period crossover trial, 10 patients in a minimally conscious state participated in eight AAT sessions and eight paralleled conventional therapy sessions, leading to 78 AAT and 73 analyzed control sessions. Patients’ responses during sessions were assessed via behavioral video coding and the Basler Vegetative State Assessment (BAVESTA), heart rate and heart rate variability (SDNN, RMSSD, HF and LF). Data were analyzed with generalized linear mixed models. Results: Patients showed more eye movements (IRR = 1.31, 95% CI: 1.23 to 1.40, p < 0.001) and active movements per tactile input during AAT compared to control sessions (IRR = 1.13, 95% CI: 1.02 to 1.25, p = 0.018). No difference was found for positive emotions. With BAVESTA, patients’ overall behavioral reactions were rated higher during AAT (b = 0.11, 95% CI: 0.01 to 0.22, p = 0.038). AAT led to significantly higher LF (b = 5.82, 95% CI: 0.55 to 11.08, p = 0.031) and lower HF (b = -5.80, 95% CI: -11.06 to -0.57, p = 0.030), while heart rate, SDNN, RMSSD did not differ. Conclusions: Patients in a minimally conscious state showed more behavioral reactions and increased physiological arousal during AAT compared to control sessions. This might indicate increased consciousness during therapeutic sessions in the presence of an animal. Trial registration: ClinicalTrials.gov . [ABSTRACT FROM AUTHOR]

Objective: To describe the efficacy, safety, dosing regimen, and administration technique of intrapleural alteplase for the treatment of retained hemothorax. Data Sources: A PubMed, EMBASE, and Google Scholar search (January 2000 to February 2019) was conducted with the search terms intrapleural, fibrinolytic, fibrinolysis, alteplase, tissue plasminogen activator, and hemothorax. Study Selection and Data Extraction: Articles were included if they described the use of intrapleural alteplase in adult patients with a retained hemothorax; single patient case reports and abstracts were excluded. Data Synthesis: A total of 6 retrospective reviews and 1 meta-analysis were identified for inclusion. A variety of dosing strategies have been defined for the administration of intrapleural alteplase ranging from 6 to 100 mg, volume of fluid from 50 to 120 mL of normal saline, and the number of total doses has ranged from 1 to 8 over the treatment course. A majority of studies showed a greater than 80% success rate and less than 7% bleeding rate. Relevance to Patient Care and Clinical Practice: Because of the paucity of data for use of alteplase in retained hemothorax and administration of a high-risk medication, this review provides dosing and administration recommendations based on reported safety and efficacy. Conclusion: Administration of intrapleural alteplase should be considered in patients with retained hemothorax as an alternative to surgical intervention. In contrast to intrapleural alteplase administration for other indications such as empyema, higher doses and volumes of alteplase are recommended for retained hemothorax. [ABSTRACT FROM AUTHOR]

Background: Referral networks are critical in the timely delivery of surgical care, particularly for populations residing in rural areas who have limited access to specialist services. However, in low- and middle-income countries (LMICs) referral networks are often undermined by systemic inefficiencies. If equitable access to essential surgical services is to be achieved, sound evidence is needed to ensure efficient patient care pathways. The aim of this scoping review was to investigate current knowledge regarding inter-hospital surgical referral systems in LMICs to identify the main obstacles to their functioning and to critically assess proposed solutions. Methods: MEDLINE, EMBASE and Global Health databases and grey literature were systematically searched to identify relevant studies. The search generated 2261 unique records, of which 14 studies were selected for inclusion in the review. The narrative synthesis of retrieved data is based on a conceptual framework developed though a thematic analysis approach. Results: Multiple shortages in surgical infrastructure, equipment and personnel, as well as gaps in surgical and decision-making skills of clinicians at sending hospitals, act as obstacles to safe and appropriate referrals. Comprehensive protocols for surgical referrals are lacking in most LMICs and established patient pathways, when in place, are not correctly followed. Interventions to improve coordination and communication between different level facilities may enhance efficiency of referral pathways. Strengthening capacity of referring hospitals to manage more surgical conditions locally could improve outcomes, decrease the need for referral and reduce the burden on tertiary facilities. Discussion: The field of surgical referrals is still an uncharted territory and the limited empirical evidence available is of low quality. Developing strategies for assessing functionality and effectiveness of referral systems in surgery is essential to improve access, coverage and quality of services in resource-limited settings, as well as overall health systems performance. [ABSTRACT FROM AUTHOR]

Background: Vitamin A and D deficiency is prevalent in pregnant women worldwide. Both vitamins are involved in fetal skeletal development. A positive association between maternal vitamin D levels and offspring bone mineral density (BMD) at adulthood has been observed. The impact of maternal vitamin A status in pregnancy on offspring peak bone mass remains unclear. Method and findings: Forty-one mother-child pairs were recruited from a population-based prospective cohort study in Trondheim, Norway, where pregnant women were followed from gestational week 17. Their term-born infants were followed from birth (1986–88). Regression analyses were performed for vitamin A (retinol), 25-hydroxyvitamin D [25(OH)D] and 1,25-dihydroxyvitamin D [1,25(OH)2D] in maternal serum (gestational weeks 17, 33, 37) and cord blood. Offspring BMD and spine trabecular bone score (TBS), a measure of bone quality, were analyzed by dual x-ray absorptiometry at 26 years. Average levels during pregnancy of retinol, 25(OH)D and 1,25(OH)2D were 1.66 (0.32) μmol/L, 59.0 (20.6) nmol/L, and 251.3 (62.4) pmol/L, respectively. 1,25(OH)2D levels were similar in those with 25(OH)D levels <30 and >75 nmol/L. After adjustment for maternal age, BMI, smoking, and education, and offspring birth weight, maternal serum retinol was positively associated with offspring spine BMD [mean change 30.8 (CI 7.6, 54.0) mg/cm2 per 0.2 μmol/L retinol], and with offspring TBS, although non-significant (p = 0.08). No associations were found between maternal 25(OH)D and 1,25(OH)2D levels and offspring bone parameters. Vitamin levels in cord blood were not associated with offspring BMD or TBS. Conclusions: This is the first study to show an association between maternal vitamin A status and offspring peak bone mass. Our findings may imply increase future risk for osteoporotic fracture in offspring of mothers with suboptimal vitamin A level. No associations were observed between 25(OH)D and 1,25(OH)2D and offspring BMD. [ABSTRACT FROM AUTHOR]

Background: Road Traffic Accidents have become an enormous global public health problem killing approximately 1.25 million people and injuring 20 to 50 million others yearly. It is the 10th leading cause of death universally and the number one cause of mortality of the young population between the ages of 5 and 29. Only few studies have been conducted on the severity of road traffic injuries in Ethiopia hence the need for the study. Objective: To assess injury severity level and associated factors among road traffic accident victims. Methods: A cross-sectional study of patients involved in road traffic accident and attended Tirunesh Beijing hospital, Addis Ababa, Ethiopia. Victims were consecutively recruited until sample size (164) attained during the study period. Data collectors administered a structured questionnaire. The collected data was then entered and cleaned using Epi info and exported to IBM SPSS for statistical analysis. Independent factors associated with injury severity were assessed using bivariate and multivariate logistic regression. Results: A total of 164 road traffic injury victims were included to the study. Prevalence of severe injury accounted for 36.6% of cases. “can read and write” educational status OR 35.194(95% CI; 3.325–372.539), sustaining multiple injury OR 18.400(95% CI; 5.402–62.671), sustaining multiple injury type OR 6.955(95% CI; 1.716–28.185) and being transported by ambulance from the scene of accident OR 13.800(95% CI; 1.481–128.635) were the explanatory variables found to have a statistically significant association with severe injury. Conclusion: This study showed road traffic accident is predominantly affecting the economically active, male young population. Not a single victim received pre-hospital care, majority were extracted by bystanders and most used commercial vehicle to be transported to a health institution reflecting the need for improvements in pre-hospital emergency services and socio-economic related infrastructures. [ABSTRACT FROM AUTHOR]

Transcutaneous spinal cord or transspinal stimulation over the thoracolumbar enlargement, the spinal location of motoneurons innervating leg muscles, modulates neural circuits engaged in the control of movement. The extent to which daily sessions (e.g. repeated) of transspinal stimulation affects soleus H-reflex excitability in individuals with chronic spinal cord injury (SCI) remains largely unknown. In this study, we established the effects of repeated cathodal transspinal stimulation on soleus H-reflex excitability and spinal inhibition in individuals with and without chronic SCI. Ten SCI and 10 healthy control subjects received monophasic transspinal stimuli of 1-ms duration at 0.2 Hz at subthreshold and suprathreshold intensities of the right soleus transspinal evoked potential (TEP). SCI subjects received an average of 16 stimulation sessions, while healthy control subjects received an average of 10 stimulation sessions. Before and one or two days post intervention, we used the soleus H reflex to assess changes in motoneuron recruitment, homosynaptic depression following single tibial nerve stimuli delivered at 0.1, 0.125, 0.2, 0.33 and 1.0 Hz, and postactivation depression following paired tibial nerve stimuli at the interstimulus intervals of 60, 100, 300, and 500 ms. Soleus H-reflex excitability was decreased in both legs in motor incomplete and complete SCI but not in healthy control subjects. Soleus H-reflex homosynaptic and postactivation depression was present in motor incomplete and complete SCI but was of lesser strength to that observed in healthy control subjects. Repeated transspinal stimulation increased homosynaptic depression in all SCI subjects and remained unaltered in healthy controls. Postactivation depression remained unaltered in all subject groups. Lastly, transspinal stimulation decreased the severity of spasms and ankle clonus. The results indicate decreased reflex hyperexcitability and recovery of spinal inhibitory control in the injured human spinal cord with repeated transspinal stimulation. Transspinal stimulation is a noninvasive neuromodulation method for restoring spinally-mediated afferent reflex actions after SCI in humans. [ABSTRACT FROM AUTHOR]

In pediatric burns the use of systemic antibiotic prophylaxis is a standard procedure in some burn centers, though its beneficial effect on the infectious complications is debated. The present meta-analysis aimed at determining whether systemic antibiotic prophylaxis prevents infectious complications in pediatric patients with burn injuries. We searched the PubMed, EMBASE, and Cochrane Library databases from inception to August 2019. We included 6 studies, in which event rates of infectious complications were reported in children with burn injuries receiving or not receiving systemic antibiotic prophylaxis. We found that the overall odds ratio (OR) of developing an infection (including local and systemic) was not different between the groups (OR = 1.35; 95% CI, 0.44, 4.18). The chances for systemic infectious complications alone were also not different between antibiotic-treated and non-treated patients (OR = 0.74; 95% CI, 0.38, 1.45). Based on the age, affected total body surface area, and country income level, we did not find any subgroup that benefited from the prophylaxis. Our findings provide quantitative evidence for the inefficacy of systemic antibiotic prophylaxis in preventing infections in pediatric burns. To validate our conclusion, multinational, randomized trials in a diverse population of children with burn injuries are warranted. [ABSTRACT FROM AUTHOR]

Objective: To analyze and compare the performance of the Simplified-Acute-Physiology-Score (SAPS) 2 and SAPS 3 among intermediate care patients with internal disorders. Materials and methods: We conducted a retrospective single-center analysis in patients (n = 305) admitted to an intermediate-care-unit (ImCU) for internal medicine at the University Hospital Essen, Germany. We employed and compared the SAPS 2 vs. the SAPS 3 scoring system for the assessment of disease severity and prediction of mortality rates among patients admitted to the ImCU within an 18-month period. Both scores, which utilize parameters recorded at admission to the intensive-care-unit (ICU), represent the most widely applied scoring systems in European intensive care medicine. The area-under-the-receiver-operating-characteristic-curve (AUROC) was used to evaluate the SAPS 2 and SAPS 3 discrimination performance. Ultimately, standardized-mortality-ratios (SMRs) were calculated alongside their respective 95%-confidence-intervals (95% CI) in order to determine the observed-to-expected death ratio and calibration belt plots were generated to evaluate the SAPS 2 and SAPS 3 calibration performance. Results: Both scores provided acceptable discrimination performance, i.e., the AUROC was 0.71 (95% CI, 0.65–0.77) for SAPS 2 and 0.77 (95% CI, 0.72–0.82) for SAPS 3. Against the observed in-hospital mortality of 30.2%, SAPS 2 showed a weak performance with a predicted mortality of 17.4% and a SMR of 1.74 (95% CI, 1.38–2.09), especially in association with liver diseases and/or sepsis. SAPS 3 performed accurately, resulting in a predicted mortality of 29.9% and a SMR of 1.01 (95% CI, 0.8–1.21). Based on Calibration belt plots, SAPS 2 showed a poor calibration-performance especially in patients with low mortality risk (P<0.001), while SAPS 3 exhibited a highly accurate calibration performance (P = 0.906) across all risk levels. Conclusions: In our study, the SAPS 3 exhibited high accuracy in prediction of mortality in ImCU patients with internal disorders. In contrast, the SAPS 2 underestimated mortality particularly in patients with liver diseases and sepsis. [ABSTRACT FROM AUTHOR]

Mild traumatic brain injury in the Veteran population is frequently comorbid with pain, post-traumatic stress disorder, and/or depression. However, not everyone exposed to mild traumatic brain injury experiences these comorbidities and it is unclear what factors contribute to this variability. The objective of this study was to identify comorbidity phenotypes among Post-9/11 deployed Veterans with no or mild traumatic brain injury and examine the association of comorbidity phenotypes with adverse outcomes. We found that Veterans with mild traumatic brain injury (n = 93,003) and no brain injury (n = 434,378) were mean age of 32.0 (SD 9.21) on entering Department of Veterans Health Administration care, were predominantly Caucasian non-Hispanic (64.69%), and served in the Army (61.31%). Latent class analysis revealed five phenotypes in each subcohort; and phenotypes were common to both. The phenotype was found only in no brain injury. Unique phenotypes in mild traumatic brain injury included , , and . There was substantial variation in adverse outcomes. The phenotype had the lowest likelihood of adverse outcomes. There were no differences between and phenotypes. Phenotypes of comorbidity vary significantly by traumatic brain injury status including divergence in phenotypes (and outcomes) over time in the mild traumatic brain injury subcohort. Understanding risk factors for the divergence between vs. and vs. , will improve our ability to proactively mitigate risk, better understand the early patterns of comorbidity that are associated with neurodegenerative sequelae following mild traumatic brain injury, and plan more patient-centered care. [ABSTRACT FROM AUTHOR]

Objective: Local antibiotic delivery systems with differing chemical and mechanical properties have been developed to assist in the management of osteomyelitis. We investigated the bone conductive and resorptive capabilities of a calcium phosphate-calcium sulfate (CaP/CaS) composite compared with commercially available polymethylmethacrylate (PMMA). In addition, we compared the in vivo preventative and treatment efficacies of both biomaterials in a proven osteomyelitis model. Methods: Sixty-four, male Sprague-Dawley rats were inoculated with 10 μl of 1.5 x 108 CFU/ml of Staphylococcus aureus in a surgically drilled defect in the right proximal tibia. Infected animals were randomly allocated into prevention and treatment groups with 32 rats each. In the prevention group, the defect was filled with a plug containing either PMMA or CaP/CaS immediately after the inoculation. In the treatment group, the infected defects were irrigated, debrided, and filled with either a PMMA or CaP/CaS plug. Both CaP/CaS and PMMA were impregnated with 10% weight of vancomycin. Rats were sacrificed 6 weeks after cement insertion. Infection was detected by bacterial culture and histological analysis. Bone formation in the defect was assessed with micro-computed tomography and histology. Results: No bacteria were detected in any group. Both the prevention and treatment groups using CaP/CaS had significantly more bone volume fraction, bone area, and cartilage area than the PMMA groups. Conclusions: When loaded with 10% of vancomycin, CaP/CaS and PMMA have the same efficacy for treatment and prevention of osteomyelitis. CaP/CaS enhances bone defect healing through improved bone remodeling in our osteomyelitis rat model. [ABSTRACT FROM AUTHOR]

Background: Lactate is used to evaluate the prognosis of adult patients with trauma. However, the prognostic significance of admission serum lactate in the setting of pediatric traumatic brain injury (TBI) is still unclear. We aim to investigate the impact of admission lactate on the outcome in children with moderate to severe TBI. Methods: This retrospective study was conducted in a tertiary pediatric hospital between May 2012 and Jun 2018 included children with an admission Glasgow Coma Scale (GCS) of ≤13. Two hundred and thirteen patients were included in the analysis and 45 patients died in hospital. Results: Admission lactate and glucose were significantly higher in non-survivors than those in survivors (P < 0.05). Admission lactate was positively correlated with admission glucose and negatively correlated with GCS in all patients (n = 213), subgroup of isolated TBI (n = 112) and subgroup of GCS ≤ 8 (n = 133), respectively. AUCs of lactate could significantly predict the mortality and were higher than those of glucose in all patients, subgroup of isolated TBI and subgroup of GCS ≤ 8, respectively. Multivariate logistic regression showed that admission lactate (Adjusted OR = 1.189; 95% CI: 1.002–1.410; P = 0.047) was independently associated with mortality, while admission glucose (Adjusted OR = 1.077; 95% CI: 0.978–1.186; P = 0.133) wasn’t an independent risk factor of death. Elevated admission lactate (> 2 mmol/L) was associated with death, reduced 14-day ventilation-free days, 14-day ICU-free days and 28-day hospital-free days. Conclusions: Admission serum lactate can effectively predict the mortality of children with moderate to severe TBI. Elevated admission lactate is associated with death, reduced ventilator-free, ICU-free, and hospital-free days. Admission serum lactate could be used as a prognostic biomarker of mortality in children with moderate to severe TBI. [ABSTRACT FROM AUTHOR]

The present study aimed to investigate the prevalence and clinical consequences of occult intra-operative periprosthetic femoral fractures in total hip arthroplasty (THA). Between 2012 and 2017, a total of 113 primary THAs were enrolled. The mean age of the patients was 66.4 ± 7.6 years. We assessed occult intra-operative periprosthetic femoral fractures with the use of computed tomography (CT) and risk factors, including age, sex, body mass index, diagnosis, stem size, and radiographic parameters of proximal femoral geometry were analyzed. We also assessed the differences in thigh pain and stem subsidence and alignment between the patients with and without occult periprosthetic femoral fracture. Occult intra-operative periprosthetic femoral fractures were found in 13 of 113 hips (11.5%). In 9/13 (69.2%) of occult fractures, fracture lines were started from the region below the tip of the lesser trochanter. Six periprosthetic femoral fractures (5.3%) were found during the operation. Out of the five hips that had detected femoral fractures around the lesser trochanter intra-operatively, four hips (80%) showed concurrent occult fractures on different levels. The female sex (P = .01) and canal filling ratio at 7 cm below the tip of the lesser trochanter (P = .01) were significantly different between the patients with and without occult periprosthetic femoral fracture. The sex was significantly associated with an increased risk in predicting an occult intra-operative periprosthetic femoral fracture (odds ratio of male, 0.25 compared with the female; 95% CI, 0.08–0.85; p = .02). There was a significant difference in the incidence of thigh pain between occult fracture group and non-occult fracture group (P < .05). There were no significant differences in stem subsidence and alignment between the patients with and without occult periprosthetic femoral fracture. All 13 cases of occult intra-operative periprosthetic femoral fractures were healed at the final follow-up. Occult periprosthetic femoral fractures are common during a long, trapezoidal, double-tapered cementless femoral stem fixation in primary THA, that CT scans are helpful to identify them, and that these fractures do not adversely affect the implant’s survival if a rigid fixation of the implants has been achieved. [ABSTRACT FROM AUTHOR]

Background: An assessment of bone strength based on bone mineral density (BMD) underestimates the risk of fracture in patients with diabetes mellitus (T2DM). However, using the trabecular bone score (TBS) for estimating bone microarchitecture, previous studies showed that bone fragility is associated with deterioration of the microstructure concomitantly with decreased BMD. This study was conducted to clarify which of these skeletal-related factors had a more prominent relationship with bone fragility. Research design and methods: A retrospective cross-sectional study was performed at Shimane University Hospital. A total of 548 Japanese patients with T2DM [257 postmenopausal women and 291 men aged over 50 years] were included. TBS of the spine was computed from dual-energy X-ray absorptiometry images obtained from BMD measurements. Results: Vertebral fractures (VFs) were identified in 74 (28.8%) women and 115 (39.5%) men. A relationship between BMD and VFs was observed in the limited subgroup of women with a BMD T-score ≤-1.0. According to multivariate logistic regression analysis, low TBS was significantly correlated with prevalent VFs, independent of BMD in both genders, except for men with a BMD T-score > -1.0. The decision tree showed that the priority factor for determining VFs was TBS, not BMD. Conclusion: Spinal microarchitecture represented by TBS was a more dominant skeletal factor for bone fragility than the decrease in bone mass, independent of BMD, in patients with T2DM. This observation suggests that loss of structural bone quality was crucial underlying pathogenesis for bone brittleness in these populations, regardless of gender. An integrated assessment of bone strength by BMD and TBS would help diagnose diabetic osteoporosis. [ABSTRACT FROM AUTHOR]

Background: Veteran patients with traumatic brain injury (TBI) and their family members regularly receive care from nurses. Understanding nurses’ training and beliefs can provide direction for intervention work aimed at ensuring the best possible care is delivered to this population. Aims: We examined Veterans Health Administration (VHA) nurses’ training and beliefs related to care of patients with moderate-to-severe TBI. Design and methods: We conducted an exploratory, cross-sectional survey with 211 VHA nurses and analyzed data using descriptive statistics. Results: The average years of nursing experience was 18 years, and 90% reported ever caring for a patient with TBI. Most nurses (70%) reported only seeing patients with TBI ≤1–2 times per year in their current role; 20% reported seeing these patients 1–2 times per month. Even with infrequent care, almost 50% reported previously receiving TBI-related training. Beliefs items with the highest accuracy indicated nurses agreed that they need specialized training to care for patients with TBI and that TBI recovery may continue for several years (96.39% accuracy respectively). The beliefs item with the lowest accuracy indicated focus on whether nurses agreed that TBI severity was important in developing care plans (27.84% accuracy). Nurses reported the need for clarity of the nursing role in caring for patients with TBI (77.32% agreement). Conclusion: VHA nurses do have accurate beliefs about caring for Veteran patients with moderate-to-severe TBI; however, there is the need for further role clarification regarding nursing care of patients with TBI. Impact: These findings have implications for development of education and training interventions for nurses who care for Veteran patients with TBI. [ABSTRACT FROM AUTHOR]

A recently published review of 45 studies concluded that approximately half of individuals who sustain a single mild traumatic brain injury (MTBI) experience long-term cognitive impairment (McInnes et al. Mild Traumatic Brain Injury (mTBI) and chronic cognitive impairment: A scoping review. PLoS ONE 2017;12:e0174847). Stratified by age, they reported that 50% of children and 58% of adults showed some form of cognitive impairment. We contend that the McInnes et al. review used a definition of “cognitive impairment” that was idiosyncratic, not applicable to individual patients or subjects, inconsistent with how cognitive impairment is defined in clinical practice and research, and resulted in a large number of false positive cases of cognitive impairment. For example, if a study reported a statistically significant difference on a single cognitive test, the authors concluded that every subject with a MTBI in that study was cognitively impaired–an approach that cannot be justified statistically or psychometrically. The authors concluded that impairment was present in various cognitive domains, such as attention, memory, and executive functioning, but they did not analyze or report the results from any of these specific cognitive domains. Moreover, their analyses and conclusions regarding many published studies contradicted the interpretations provided by the original authors of those studies. We re-reviewed all 45 studies and extracted the main conclusions from each. We conclude that a single MTBI is not associated with a high incidence of chronic cognitive impairment. [ABSTRACT FROM AUTHOR]

Introduction: A substantial percentage of traffic crashes involve people under the influence of ethyl alcohol. In such circumstances, we speak of the possible effect of ethanol upon trauma outcomes. The present research aimed to assess the state of sobriety fatal pedestrian victims and the correlation between the level of sobriety and the severity of injuries. Research material and method: The data was obtained from the Warsaw Medical University’s Department of Forensic Medicine. The analysis covered the data for the period of 2009–2013; it encompassed 158 fatal pedestrian victims hit by passenger cars. The appropriate methods of statistical analysis were applied. Results: The majority of the fatal pedestrian victims were individuals under the influence of ethyl alcohol (72.15%). Significant correlations were observed between the concentration of ethyl alcohol and the victims’ gender (p<0.0001) and age (p = 0.0026). The analysis showed that pedestrians under the influence of ethyl alcohol more often died on the scene (78.95%). Conclusions: Pedestrians under the influence of ethyl alcohol are a significant group of victims of traffic crashes. Ethyl alcohol is not an independent factor affecting the severity of injuries. A higher percentage of pedestrian victims die on the scene, especially in rural areas. [ABSTRACT FROM AUTHOR]

Objective: To investigate junior secondary school students’ experiences and perspectives of in-school and out-of-school sport-safety, with a particular focus on the meaning and content that they applied to the motivational and social cognitive factors of sport injury prevention. Design: Focus-group interview. Method: Participants were 128 junior secondary school students (Form 1 to Form 3) aged between 12 and 16 years from two secondary schools. We organised focus-group interviews by class (group size = six to nine students). Seventeen groups completed semi-structured interviews regarding their experience, beliefs, and motives for injury prevention in-school and out-of-school. We analysed data by thematic content analysis using a typological approach. Results: Higher order themes (N = 7) including in-school and out-of-school motives and social cognitive factors and associated lower-order themes (N = 16), emerged from the analysis corresponding to constructs from trans-contextual model tenets. Conclusions: The current study is the first qualitative study to explore junior secondary school students’ experience and perspectives on sport injury prevention, using trans-contextual model as a framework for investigation. The findings contribute to a better understanding on their motivational and social cognitive factors in adopting sport injury prevention. The content of the theme behavior also indicated the inadequacy of students’ knowledge of effective sport injury prevention techniques, and underscored the importance of sport safety education. [ABSTRACT FROM AUTHOR]

Objective: Antipsychotic agents can increase circulating serum prolactin levels, potentially leading to osteoporosis and increased risk of bone fracture. The risk appears to be lower for atypical antipsychotics. We investigated whether risperidone was associated with an increased fracture risk by estimating the incidence of hip/femur and non-hip/femur fractures in users of risperidone, other atypical, and typical antipsychotics. Methods: This retrospective cohort study with a nested case-control study used claims data from the Taiwan National Healthcare Insurance database. All new users of antipsychotics between 2000–2012 were included. Incident fractures were identified using ICD-9 codes from inpatient records. Cox proportional hazards models compared fracture incidence among exposure groups. Conditional logistic regression models compared antipsychotic exposure among fracture cases versus matched controls. Results: 340,948 patients were included in the analysis. There were 2832 hip/femur fractures and 2693 non-hip/femur fractures: Hip/femur fracture incidence 636.8/100,000 person-years (Risperidone), 885.7/100,000 person-years (Other Atypical), 519.4/100,000 person-years (Typical). The adjusted hazard ratio of hip/femur fracture was 0.92 (95%CI 0.84–1.01) comparing Other Atypical with Risperidone, and 1.00 (95%CI 0.89–1.11) comparing Typical with Risperidone. The adjusted hazard ratio of non-hip/femur fracture was 1.08 (95%CI 0.98–1.20) for Other Atypical versus Risperidone, and 1.10 (95%CI 0.99–1.22) for Typical versus Risperidone. The adjusted odds ratio for hip/femur fractures was 0.92 (95% CI 0.83–1.01) in cases and controls exposed to other atypical antipsychotics compared with risperidone for 1 year prior to fracture date, 0.97 (95% CI 0.87–1.07) during 1–3 years, and 0.92 (95% CI 0.81–1.06) during 3–5 years prior to fracture date. The adjusted odds ratio for non-hip/femur fractures were 1.11 (95% CI 0.99–1.24), 1.02 (95% CI 0.0.91–1.14), and 0.95 (95% CI 0.82–1.09), respectively. Conclusion: There was no increased risk of bone fracture in long-term users of risperidone compared to users of other atypical antipsychotics. [ABSTRACT FROM AUTHOR]

There is strong evidence to suggest a link between repeated head trauma and cognitive and emotional disorders, and Repetitive concussive brain injuries (rCBI) may also be a risk factor for depression and anxiety disorders. Animal models of brain injury afford the opportunity for controlled study of the effects of injury on functional outcomes. In this study, male and cycling female C57BL/6J mice sustained rCBI (3x) at 24-hr intervals and were tested in a context and cued fear conditioning paradigm, open field (OF), elevated zero maze and tail suspension test. All mice with rCBI showed less freezing behavior than sham control mice during the fear conditioning context test. Injured male, but not female mice also froze less in response to the auditory cue (tone). Injured mice were hyperactive in an OF environment and spent more time in the open quadrants of the elevated zero maze, suggesting decreased anxiety, but there were no differences between injured mice and sham-controls in depressive-like activity on the tail suspension test. Pathologically, injured mice showed increased astrogliosis in the injured cortex and white matter tracts (optic tracts and corpus callosum). There were no changes in the number of parvalbumin-positive interneurons in the cortex or amygdala, but injured male mice had fewer parvalbumin-positive neurons in the hippocampus. Parvalbumin-reactive interneurons of the hippocampus have been previously demonstrated to be involved in hippocampal-cortical interactions required for memory consolidation, and it is possible memory changes in the fear-conditioning paradigm following rCBI are the result of more subtle imbalances in excitation and inhibition both within the amygdala and hippocampus, and between more widespread brain regions that are injured following a diffuse brain injury. [ABSTRACT FROM AUTHOR]

Background: Severe centrum semiovale perivascular spaces (CSO-PVSs) are associated with the onset of brain atrophy and dementia. This study explored the relationship between severity of CSO-PVS and development of subdural fluid (SDF) in patients with mild traumatic brain injury (TBI), with the aim of investigating independent radiological risk factors for development of SDF. Methods: The study cohort comprised 222 patients with a mean age of 51 years (64.0% men) who presented with mild TBI from January 2013 to November 2016. In this study, mild TBI was defined as a Glasgow Coma Scale (GCS) of ≥ 13, Post-Traumatic Amnesia (PTA) of <1 day, and Loss of Consciousness (LOC) of <30 minutes. The severity of CSO-PVS was categorized as low or high-degree. Results: Among the 222 enrolled patients, 38 (17.1%) and 90 (40.5%) had high-degree PVS in the basal ganglia (BG) and centrum semiovale, respectively. Compared with patients who did not develop SDF, the mean age of patients who developed SDF was significantly higher (47.41 years versus 60.33 years, P < 0.0001). The incidence of de novo SDF was significantly higher in men than in women (77.8% versus 59.5%, P = 0.0151). Patients who showed SDF on brain computed tomography at admission more frequently developed de novo SDF (68.5% versus 38.1%, P < 0.0001). In multivariate logistic regression analysis of risk factors, high-degree CSO-PVS, male sex, initial SDF on admission, and old age were independently associated with development of de novo SDF after mild TBI. In Cox proportional hazards models of risk factors for SDF-development free survival rate, high-degree CSO-PVS, old age, and initial subdural hemorrhage showed statistically significant differences. Conclusions: Our study might help neurosurgeons determine the frequency of brain CT or the duration of follow-up for patients who present with mild TBI with high-degree CSO-PVS. [ABSTRACT FROM AUTHOR]

The aim of this paper is to test the hypothesis that healed traumatic injuries in the pre-Neolithic assemblage of Con Co Ngua, northern Vietnam (c. 6800–6200 cal BP) are consistent with large wild animal interactions prior to their domestication. The core sample included 110 adult (aged ≥ 18 years) individuals, while comparisons are made with an additional six skeletal series from Neolithic through to Iron Age Vietnam, Thailand, and Mongolia. All post cranial skeletal elements were assessed for signs of healed trauma and identified cases were further x-rayed. Crude trauma prevalence (14/110, 12.7%) was not significantly different between males (8/52) and females (5/37) (χ2 = 0.061, p = 0.805). Nor were there significant differences in the prevalence of fractured limbs, although males displayed greater rates of lower limb bone trauma than females. Further, distinct from females, half the injured males suffered vertebral fractures, consistent with high-energy trauma. The first hypothesis is supported, while some support for the sexual divisions of labour was found. The prevalence and pattern of fractured limbs at CCN when compared with other Southeast and East Asian sites is most similar to the agropastoral site of Lamadong, China. The potential for skeletal trauma to assess animal trapping and herding practices prior to domestication in the past is discussed. [ABSTRACT FROM AUTHOR]

In this paper, from the practical point of view, we focus on modeling traumatic brain injury data considering different stages of hospitalization, related to patients’ survival rates following traumatic brain injury caused by traffic accidents. From the statistical point of view, the primary objective is related to overcoming the limited number of traumatic brain injury patients available for studying by considering different estimation methods to obtain improved estimators of the model parameters, which can be recommended to be used in the presence of small samples. To have a general methodology, at least in principle, we consider the very flexible Generalized Gamma distribution. We compare various estimation methods using extensive numerical simulations. The results reveal that the penalized maximum likelihood estimators have the smallest mean square errors and biases, proving to be the most efficient method among the investigated ones, mainly to be used in the presence of small samples. The Simulated Annealing technique is used to avoid numerical problems during the optimization process, as well as the need for good initial values. Overall, we considered an amount of three real data sets related to traumatic brain injury caused by traffic accidents to demonstrate that the Generalized Gamma distribution is a simple alternative to be used in this type of applications for different occurrence rates and risks, and in the presence of small samples. [ABSTRACT FROM AUTHOR]

Diabetes is associated with poor outcomes in critically ill populations. The goal of this study was to determine if diabetic patients suffer poorer outcomes following trauma. Collaborative trauma patient data from 2012–2018 was analyzed. Patients with no signs-of-life, Injury Severity Score (ISS) <5, age <16 years, and hospitalization <1 day were excluded. Multivariable logistic and linear regression were used to compare patients with and without diabetes for selected outcomes. Risk-adjustment variables included demographics, physiology, comorbidities, and injury scoring. Of 106,141 trauma patients, 14,150 (13%) had diabetes. On admission, diabetes was associated with significantly increased risk of any, serious, infectious, urinary tract, sepsis, pneumonia, and cardiac complications. Diabetes was also associated with increased ventilator days (7.5 vs. 6.6 days, p = 0.003), intensive care unit days (5.8 vs. 5.3 days, p<0.001), and hospital length of stay (5.7 vs. 5.3 days, p<0.001). Subgroup analysis revealed the least injured diabetic category (ISS 5–15) suffered higher odds of hospital mortality and any, serious, infectious and cardiac complications. The association between diabetes, hospital mortality and complication rates in mild traumatic injury is independent of age. Trauma patients with diabetes experience higher rates of complications and resource utilization. The largest cohort of diabetics experience the least severe injuries and suffer the greatest in hospital mortality and complication rates. A better understanding of the physiologic derangements associated with diabetes is necessary to develop novel approaches to reduce excess trauma morbidity, mortality and resource consumption. [ABSTRACT FROM AUTHOR]

In Japan, a range of patients with traumatic brain injury (TBI) has been recorded in a nationwide database (Japan Neurotrauma Data Bank; JNTDB). This study aimed to externally validate three international prediction models using JNTDB data: Trauma and Injury Severity Score (TRISS), Corticosteroid Randomization After Significant Head Injury (CRASH), and International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT). We also aimed to validate the applicability of these models in the Japanese population. Of 1,091 patients registered in the JNTDB from July 2009 to June 2011, we analyzed data for 635 patients. We examined factors associated with mortality in-hospital and unfavorable outcomes 6 months after TBI by applying the TRISS, CRASH, and IMPACT models. We also conducted an external validation of these models based on these data. The patients’ mean age was 60.1 ±21.1 years, and 342 were alive at the time of discharge (53.9%). Univariate analysis revealed eight major risk factors for mortality in-hospital: age, Glasgow Coma Scale (GCS), Injury Severity Score (ISS), systolic blood pressure, heart rate, mydriasis, acute epidural hematoma (AEDH), and traumatic subarachnoid hemorrhage. A similar analysis identified five risk factors for unfavorable outcomes at 6 months: age, GCS, ISS, mydriasis, and AEDH. For mortality in-hospital, the TRISS had a satisfactory area under the curve value (0.75). For unfavorable outcomes at 6 months, the CRASH (basic and computed tomography) and IMPACT (core and core extended) models had satisfactory area under the curve values (0.86, 0.86, 0.81, and 0.85, respectively). The TRISS, CRASH, and IMPACT models were suitable for application to the JNTDB population, indicating these models had high value in Japanese patients with neurotrauma. [ABSTRACT FROM AUTHOR]

Patients with traumatic brain injury (TBI) are frequently diagnosed with depression. Together, these two leading causes of death and disability significantly contribute to the global burden of healthcare costs. However, there are no drug treatments for TBI and antidepressants are considered off-label for depression in patients with TBI. In molecular profiling studies of rat hippocampus after experimental TBI, we found that TBI altered the expression of a subset of small, non-coding, microRNAs (miRNAs). One known neuroprotective compound (17β-estradiol, E2), and two experimental neuroprotective compounds (JM6 and PMI-006), reversed the effects of TBI on miRNAs. Subsequent in silico analyses revealed that the injury-altered miRNAs were predicted to regulate genes involved in depression. Thus, we hypothesized that drug-induced miRNA profiles can be used to identify compounds with antidepressant properties. To confirm this hypothesis, we examined miRNA expression in hippocampi of injured rats treated with one of three known antidepressants (imipramine, fluoxetine and sertraline). Bioinformatic analyses revealed that TBI, potentially via its effects on multiple regulatory miRNAs, dysregulated transcriptional networks involved in neuroplasticity, neurogenesis, and circadian rhythms- networks known to adversely affect mood, cognition and memory. As did E2, JM6, and PMI-006, all three antidepressants reversed the effects of TBI on multiple injury-altered miRNAs. Furthermore, JM6 reduced TBI-induced inflammation in the hippocampus and depression-like behavior in the forced swim test; these are both properties of classic antidepressant drugs. Our results support the hypothesis that miRNA expression signatures can identify neuroprotective and antidepressant properties of novel compounds and that there is substantial overlap between neuroprotection and antidepressant properties. [ABSTRACT FROM AUTHOR]

Introduction: Long-term treatment is used in patients with osteoporosis, and bisphosphonates (BPs) are the most commonly prescribed medications. However, in some patients this therapy is not effective, cause different side effects and complications. Unfortunately, at least one year is needed to identify and confirm an ineffectiveness of BPs therapy on bone mineral density (BMD). Among other factors, a response to BPs therapy may also be explained by genetic factors. The aim of this study was to analyze the influence of SOST, PTH, FGF2, FDPS, GGPS1, and LRP5 gene variants on the response to treatment with aminobisphosphonates. Materials and methods: Women with postmenopausal osteoporosis were included to this study if they used aminobisphosphonates for at least 12 months. Exclusion criteria were: persistence on BPs therapy less than 80%, bone metabolic diseases, diseases deemed to affect bone metabolism, malignant tumours, using of any medications influencing BMD. The study protocol was approved by the local ethics committee. The BMD at the lumbar spine and femoral neck were measured using dual x-ray absorptiometry (GE Lunar) before and at least 12 months after treatment with BPs. According to BMD change, patients were divided in two groups–responders and non-responders to BPs terapy. Polymorphic variants in SOST, PTH, FGF2, FDPS, GGPS1, and LRP5 genes were determined using PCR analysis with TaqMan probes (Thermo Scientific). Results: In total, 201 women with BPs therapy were included in the study. No statistically significant differences were observed in age, age at menopause, weight, height, BMI and baseline BMD levels between responders (122 subjects) and non-responders (79 subjects). As single markers, the SOST rs1234612 T/T (OR = 2.3; P = 0.02), PTH rs7125774 T/T (OR = 2.8, P = 0.0009), FDPS rs2297480 G/G (OR = 29.3, P = 2.2×10−7), and GGPS1 rs10925503 C/C+C/T (OR = 2.9; P = 0.003) gene variants were over-represented in non-responders group. No significant association between FGF2 rs6854081 and LRP5 rs3736228 gene variants and response to BPs treatment was observed. The carriers of T-T-G-C allelic combination (constructed from rs1234612, rs7125774, rs2297480, and rs10925503) were predisposed to negative response to BPs treatment (OR = 4.9, 95% CI 1.7–14.6, P = 0.005). The C-C-T-C combination was significantly over-represented in responders (OR = 0.1, 95% CI 0.1–0.5, P = 0.006). Conclusions: Our findings highlight the importance of identified single gene variants and their allelic combinations for pharmacogenetics of BPs therapy of osteoporosis. Complex screening of these genetic markers could be used as a new strategy for personalized antiresorptive therapy. [ABSTRACT FROM AUTHOR]

Aim and methods: The aim of this study was to compare the dynamics of heart rate (HR) response to exercise using a cycle ergometer (CE) and a treadmill (TM). Using a sample of 25 healthy male participants, the time constant of HR dynamics was estimated for both modalities in response to square-wave excitation. Results: The principal finding was that the time constant of heart-rate dynamics around somewhat-hard exercise intensity (Borg rating of perceived exertion = 13) does not differ significantly between the CE and TM (68.7 s ± 21.5 s vs. 62.5 s ± 18.5 s [mean ± standard deviation]; CE vs. TM; p = 0.20). An observed moderate level of evidence that root-mean-square model error was higher for the CE than for the TM (2.5 bpm ± 0.5 bpm vs. 2.2 bpm ± 0.5 bpm, p = 0.059) may reflect a decrease in heart rate variability with increasing HR intensity because, in order to achieve similar levels of perceived intensity, mean heart rate for the CE was ∼25 bpm lower than for the TM. Conclusion and significance: These results have important implications for model-based design of automatic HR controllers, because, in principle, the same dynamic controller, merely scaled according to the differing steady-state gains, should be able to be applied to the CE and TM exercise modalities. [ABSTRACT FROM AUTHOR]

Introduction: The fixation of unstable zygomaticomaxillary complex (ZMC) fractures can be achieved by open reduction with rigid internal fixation (ORIF) and/or by closed reduction with percutaneous transfacial Kirschner wire fixation (CRWF). The aim of this study was to tomographically assess the symmetry and the protrusion of the cheekbone with unstable ZMC fractures that had been treated by ORIF vs. CRWF. Materials and methods: Sixty patients exhibiting a surgically unstable tetrapodal ZMC fracture were included in this multicenter retrospective study. The coordinates of 5 landmarks representing the zygomatic protrusion were comparatively studied on the healthy and on the broken side using preoperative and postoperative tridimensional computed tomography (CT) scans or cone beam CT. Results: No significant difference was found in the zygomatic protrusion irrespective of the surgical technique that was used. The zygomatico-maxillary ansa was found to be the most complicated area to reduce, particularly in the frontal plane with both the CRWF and the ORIF technique (p1 = 0.001 and p2 = 0.0009, respectively). There was no difference in terms of the level of complications, while the mean duration of the surgery was significantly less for the CRWF group. Conclusion: With good postoperative radiographic outcomes, the CRWF can be proposed as an alternative or in association with the ORIF technique for fixation of tetrapodal fractures of the ZMC. [ABSTRACT FROM AUTHOR]

Repeated exposure to blast overpressure remains a major cause of adverse health for military personnel who, as a consequence, are at a higher risk for neurodegenerative disease and suicide. Acute, early tracking of blast related effects holds the promise of rapid health assessment prior to onset of chronic problems. Current techniques used to determine blast-related effects rely upon reporting of symptomology similar to that of concussion and neurocognitive assessment relevant to operational decrement. Here, we describe the results of a cross sectional study with pared observations. The concentration of multiple TBI-related proteins was tested in serum collected within one hour of blast exposure as a quantitative and minimally invasive strategy to augment assessment of blast-exposure effects that are associated with concussion-like symptomology and reaction time decrements. We determined that median simple reaction time (SRT) was slowed in accordance with serum Nf-L, tau, Aβ-40, and Aβ-42 elevation after overpressure exposure. In contrast, median levels of serum GFAP decreased. Individual, inter-subject analysis revealed positive correlations between changes in Nf-L and GFAP, and in Aβ-40 compared to Aβ-42. The change in Nf-L was negatively associated with tau, Aβ-40, and Aβ-42. Participants reported experiencing headaches, dizziness and taking longer to think. Dizziness was associated with reaction time decrements, GFAP or NfL suppression, as well as Aβ peptide elevation. UCH-L1 elevation had a weak association with mTBI/concussion history. Multiplexed serum biomarker quantitation, coupled with reaction time assessment and symptomology determined before and after blast exposure, may serve as a platform for tracking adverse effects in the absence of a head wound or diagnosed concussion. We propose further evaluation of serum biomarkers, which are often associated with TBI, in the context of acute operational blast exposures. [ABSTRACT FROM AUTHOR]

Although injury-related deaths have been documented among children and adult populations, insufficient attention has been directed towards injury-related infant deaths. The objective of this retrospective study was to investigate maternal and infant characteristics associated with injury-related infant deaths in West Virginia. Birth and infant mortality data for 2010–2014 were sourced from the West Virginia Bureau for Public Health, Charleston. Relative risk was calculated using log-binomial regression utilizing generalized estimating equations. Maternal characteristics associated with injury-related infant mortality in West Virginia were race/ethnicity ( = 7.48, p = .03), and smoking during pregnancy (, p < .00). Risk of a Black Non-Hispanic infant suffering an injury-related death was 4.0 (95% CL 1.7, 9.3) times that of infants of other races/ethnicities. Risk of an infant dying from an injury-related cause, if the mother smoked during pregnancy, was 2.9 (95% CL 1.6, 5.0) times the risk of such a death if maternal smoking status during pregnancy is unknown or no smoking, controlling for race/ethnicity. This study provides important information to public health stakeholders at both the state and local levels in designing interventions for partial reduction or prevention of injury-related infant mortality in West Virginia. [ABSTRACT FROM AUTHOR]

We investigated the incidences and characteristics of pediatric traumatic injuries requiring emergency department visits, through a complementary approach using both nationwide-sample and single-institutional data. Data for children (aged <15 years) identified with traumatic injuries during a 10-year period from the Korean National Health Insurance Sharing Service (n = 35,064 among 10,114,909 randomly sampled cases from the claim records of the National Health Insurance) and the authors' institute (n = 39,228) were retrospectively reviewed. The incidences and characteristics of the injuries were investigated using both datasets; additionally, detailed information regarding the injury environments was investigated using the single-institutional data. The findings were similar across both datasets. The incidence of injuries increased during the study period; the head was most commonly injured, whereas the trunk or proximal extremities were rarely injured; low-energy head injuries accounted for >50% of the cases in children aged <5 years, although the incidences of lower-extremity injuries and fractures increased in older children. Single-institutional data demonstrated that the proportion of indoor playground and trampoline-related injuries increased rapidly during the study period, and outdoor injuries and seasonal variation (with peak incidences in May and June) were more prominent in older children. Based on similarities between both datasets, the detailed results regarding pediatric traumatic injuries obtained from the single-institutional data could be generalized nationally with adequate external validity. To prevent traumatic injuries, it may be more effective to wear protective equipment covering the head and distal extremities rather than the trunk or proximal extremities; simple clothing, such as caps, could prevent many injuries in preschoolers. Among older children, safety guidelines for outdoor sports/leisure activities are needed. The increase in pediatric traumatic injuries may be partially explained by the increased availability of indoor playgrounds and installation of trampolines. Stricter adherence to the preventive guidelines is needed. [ABSTRACT FROM AUTHOR]

Osteoporosis is a continuous process of loss of bone tissue. Compared to women, osteoporosis in men is associated with greater morbidity and mortality. In this study, we conducted tomographic and biomechanical evaluations of trabecular and cortical bone in the early stage of male osteoporosis. Male Wistar rats were subjected to orchiectomy and sham operation. Four weeks after being castrated, decreased levels of testosterone in plasma were found and resulted in concurrent bone loss. Separately, the orchiectomy led to significant tomographic alterations in the trabecular bone number, trabecular separation, and trabecular pattern factor. Data of a mechanistic compression test further showed that the orchiectomy diminished the maximum loading force, displacement at maximum load, energy at maximum load, and ultimate stress. Interestingly, orchiectomy-triggered changes in the maximum loading force and tomographic parameters were highly correlated. In contrast, tomographic and biomechanical analyses showed that 4 weeks after rats were orchiectomized, the thickness, area, maximum loading force, bone stiffness, energy at maximum load, and ultimate stress of the cortical bone were not changed. Taken together, this study showed specific differences in the microarchitecture and strength of trabecular bone in the early stage of male osteoporosis. [ABSTRACT FROM AUTHOR]

Bone remodeling is an essential physiological process in growth and healing. In modern systems deviations from normal bone physiology in the form of pathologies aid in the understanding of normal bone metabolism. Here we use external morphology and X-ray microtomography to diagnose and describe a metabolic bone disease in an amniote from the early Permian. The specimen consists of two fused tail vertebrae of a small varanopid from early Permian (289 million years old) cave deposits near Richards Spur, Oklahoma, USA. Inspection of the outer morphology reveals that the fusion encompasses the vertebral centra, zygopophyses and haemal arches, with the fusion zones distinctly swollen on the left side of the specimen. With visualization of its internal structure by microCT, this specimen is diagnosed as a complex metabolic bone disease. The radiological imaging suggests a pathologically high bone turnover rate, as shown by abnormal bone formation in some areas and increased bone resorption in others. This supports that the varanopid suffered from a metabolic bone disease similar to Paget’s disease of bone as seen in humans today, which is linked to both genetic and viral factors. This finding extends the occurrence of Paget-like disease to the early Permian, and–provided a viral component was present–would also be by far the oldest evidence of viral infection in the fossil record. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate the use of a lyophilized and gamma-sterilized allogeneic freeze-dried bone wedge as a spacer for advancement of a modified tibial tuberosity (mTTA) in 16 knees that were clinically diagnosed with cranial cruciate ligament disease. Patients underwent radiography before the surgical procedure as well as immediately after surgery and at 30, 60, 90 and 120 days post-surgery, and their locomotion was evaluated at the same time points except for the immediate postoperative period. The surgical wounds were evaluated for signs of infection and rejection of the bone implant. Locomotion was graded on a scale of 0–5, with 0 indicating no limping and 5 indicating limb functional impotence. The "tibial-tibial bone-tibial implant" interfaces were evaluated radiographically, and each interface was assigned scores of 0–3, with 0 indicating no contact between the implant and adjacent bone and 3 indicating a bone bridge throughout the interface. The patients showed good clinical and radiographic recovery. The lyophilized bone spacer allowed for easy storage and transport and rapid and satisfactory execution of mTTA while showing resistance to drilling and fixation with screws in 87.5% of cases and a mean surgical time of 45.9 minutes. No immunogenic reactions were observed in 93.7% of the cases. One patient presented infection of the surgical focus, which showed remission after antimicrobial therapy. All patients showed functional recovery of the operated limb, with the number of clinically healthy patients being higher than those with claudication at 120 days (p ≤ 0.05). In all patients, it was possible to verify the incorporation of the bone implant into the tibia. Bone union occurred progressively, and the degrees of bone union observed on radiographs at postoperative days 60, 90, and 120 were significantly greater (p < 0.05) than those observed in the immediate postoperative period and at 30 days. [ABSTRACT FROM AUTHOR]

Non-contact anterior cruciate ligament (ACL) rupture is mostly caused by a pivot shift mechanism including valgus collapse and internal tibial rotation. In female athletes, the incidence of ACL rupture has been reported to be significantly higher than in their male counterparts. However, to date, there have been limited reports and controversy regarding sex differences underlying injury mechanisms of ACL and severity of injury. In this study, we hypothesized that 1) in patients with non-contact ACL rupture, the incidence and severity of pivot shift injury, which are determined by injury pattern on MRI, would be significantly higher in females, and 2) anatomical factors associated with pivot shift injury would be significantly associated with female sex. A total of 148 primary ACL ruptures (145 patients) caused by non-contact injury mechanisms were included in this study. Among them, 41 knees (41 patients) were female and 107 knees (104 patients) were male. The status of the osseous lesions, lateral and medial tibial slope, depth of the medial tibial plateau, collateral ligaments, and menisci were assessed by MRI and compared between sexes. The severity of osseous lesions at the lateral tibial plateau, lateral femoral condyle, medial tibial plateau, and medial femoral condyle were comparable between sexes. There were no significant differences between sexes in the location of tibial contusions (p = 0.21), femoral contusions (p = 0.23), or meniscus tears (p = 0.189). Lateral tibial slope was found to be significantly larger in females (8.95° vs. 6.82°; p<0.0001; odds ratio = 1.464), and medial tibial depth was significantly shallower in females (1.80mm vs. 2.41mm; p<0.0001; odds ratio = 0.145). In conclusion, females showed greater lateral tibial slope and shallower medial tibial depth compared to males, however it did not affect the sex differences in injury pattern. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to evaluate the role of a non-locking plate applied to the anteromedial surface of the proximal humerus on loads at the implant-bone interface of non-locking and locking lateral plate fixation of proximal humeral fractures with a medial gap. Methods: Twenty synthetic humeri models were used. In fifteen, the proximal portion of the humerus was osteotomized to create a two-part surgical neck fracture, with a 10-mm medial gap and a 5-mm lateral gap; five models were controls. In the osteotomized humeri, five models were stabilized with a locking lateral plate (group L), five with a locking lateral plate and an anteromedial non-locking plate (group L+T), and five with a non-locking lateral plate and a non-locking anteromedial plate (group T+T). All humeri were tested under axial loading until catastrophic failure, which was characterized as complete closure of the medial gap. Stiffness was calculated using force vs. displacement curves. The data were analyzed via descriptive and inferential studies, at a 5% significance level. Results: Statistically significant differences were seen among all the constructions. The combination of a lateral locking plate with an anteromedial non-locking plate (group L+T) was the stiffest construction, while the combination of a non-locking lateral plate with a non-locking anteromedial plate (group T+T) was the least stiff, even in comparison with a single locking lateral plate (p = 0.01). When the two groups which utilized a lateral locking plate (groups L+T and L) were compared, the group with additional anteromedial support demonstrated greater stiffness (p = 0.03), and stiffness values for the control group comprised of intact humeri models were even higher (p = 0.01). Conclusion: Combining a lateral locking plate with a non-locking anteromedial plate provides a stiffer construction for fixation of unstable two-part proximal humerus fractures with a medial gap. Mechanical benefits of medial support with a second non-locking antero-medial plate seems to be related with better construct stability in terms of strength and fatigue, potentially reducing the risk of varus collapse of the humerus head and fracture healing disturbances. [ABSTRACT FROM AUTHOR]

The objective of this study was to develop a new calibration method that enables calibration of Hounsfield units (HU) to bone mineral densities (BMD) without the use of a calibration phantom for fracture risk prediction of femurs with metastases using CT-based finite element (FE) models. Fifty-seven advanced cancer patients (67 femurs with bone metastases) were CT scanned atop a separate calibration phantom using a standardized protocol. Non-linear isotropic FE models were constructed based on the phantom calibration and on two phantomless calibration methods: the “air-fat-muscle” and “non-patient-specific” calibration. For air-fat-muscle calibration, peaks for air, fat and muscle tissue were extracted from a histogram of the HU in a standardized region of interest including the patient’s right leg and surrounding air. These CT peaks were linearly fitted to reference “BMD” values of the corresponding tissues to obtain a calibration function. For non-patient-specific calibration, an average phantom calibration function was used for all patients. FE failure loads were compared between phantom and phantomless calibrations. There were no differences in failure loads between phantom and air-fat-muscle calibration (p = 0.8), whereas there was a significant difference between phantom and non-patient-specific calibration (p<0.001). Although this study was not designed to investigate this, in four patients who were scanned using an aberrant reconstruction kernel, the effect of the different kernel seemed to be smaller for the air-fat-muscle calibration compared to the non-patient-specific calibration. With the air-fat-muscle calibration, clinical implementation of the FE model as tool for fracture risk assessment will be easier from a practical and financial viewpoint, since FE models can be made using everyday clinical CT scans without the need of concurrent scanning of calibration phantoms. [ABSTRACT FROM AUTHOR]

Introduction: Injury accounts for more than 5.8 million deaths globally with an increasing burden in the developing world. In Kenya, trauma is one of the top 10 leading causes of death. However, no formal continuous injury surveillance systems are in place to inform injury prevention, pre-hospital care or emergency department management. The aim of this study was to implement a hospital-based trauma registry to characterize high acuity injuries presenting to a private tertiary, teaching and referral hospital in Kenya. Methods: From January to December 2015, data was prospectively collected at a private tertiary, teaching and referral hospital in Nairobi, Kenya. Patients presenting with a traumatic injury for the first time who were admitted to the hospital for at least 48 hours were included in the study. Basic information pertaining to demographics, details of the injury, pre-hospital care and transport, hospital-based management, length of stay and disposition were collected. An injury severity score (ISS) was calculated on each patient and stratified by the mechanism of injury. Descriptive statistics and multivariate logistic regression were used to analyze data and assess risk factors associated with injury severity. Results: There were 101 patients included in the study, the majority of whom were 30 to 39 years of age and male (63%). Seventy-one per cent of patients had a preexisting medical condition with hypertension (26%) and diabetes (13%) being the most common. The most common mechanism of injury was fall (46%) followed by road traffic incidents (RTI) (32%). Most injuries took place at home (43%). Most RTI were caused by cars (63%), with the driver being the most frequently injured (38%). The most common mode of arrival to the emergency department was by private car (72%). The median time between the accident and arrival at the emergency department was 1hr 10 minutes. The majority of the patients had injuries to one area (83%) with the extremities/bony pelvis (72%) being the most common. The median Injury Severity Score was 5 (range 1–34) with the majority (90%) classified as minor injuries (ISS<12). The highest severity of injury as determined by ISS was seen in gunshot wounds. Conclusions: Injured patients in Kenya showed concordance with prior studies looking at injury prevalence in the developing world when looking at demographics and place of injury. However, differences were found when looking at the mechanism of injury, with falls surpassing road traffic incidents. A delayed presentation to the hospital was also noted in this patient population. Given the rate of traumatic injuries in Kenya and their contribution to morbidity, mortality and overall healthcare costs, there is a need to implement formal trauma registries in all major hospitals in Kenya to generate more data that can be used to improve injury prevention, the overall trauma system and enhance training and preparedness. [ABSTRACT FROM AUTHOR]

Objective: Traumatic brain injury (TBI) is common and associated with a marked increased risk of developing epilepsy. Animal studies indicate that treatment with selective serotonin reuptake inhibitors (SSRIs) may increase the risk of epilepsy after TBI. The aim of this study was to investigate whether use of SSRIs modifies the risk of epilepsy after TBI. Methods: This was a cohort study of 205,715 persons, who suffered a TBI in Denmark from 1996 to 2013. For each person with TBI, we matched 10 reference persons (N = 2,057,150) who were alive on the day of TBI and who had the same age and gender but had no history of TBI. We used a stratified Cox regression to calculate the relative risk of epilepsy after TBI for persons exposed to TBI, SSRI or both after adjustment for income, civil status, medical and neurological comorbidities, severe mental disease, and substance abuse. Results: The risk of epilepsy was 5.61 times higher for persons who used SSRI at time of TBI (adjusted Hazard Ratio (aHR): 5.61 (95% CI: 4.88; 6.45)), 3.23 times higher for persons who had a TBI but did not use SSRI at time of TBI (aHR: 3.23 (95% CI: 3.12;3.35)), and 1.31 times higher for persons who used SSRI but had no TBI (aHR: 1.31 (95% CI: 1.18; 1.45)) compared to persons unexposed to both TBI and SSRI. Conclusions: This large population based cohort study showed that people using SSRI at the time of a TBI had higher risk of developing epilepsy compared to people not using SSRI at the time of TBI. The results are in line with those of animal studies and calls for further studies to evaluate whether the association is due to SSRIs or to the underlying disease (e.g. depression or anxiety). [ABSTRACT FROM AUTHOR]