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Background: The incidence of interpersonal violence resulting in penetrating traumatic injury has increased in the UK. Violence reduction initiatives vary across the world, from reactive diversionary schemes to proactive educational intervention. To be successful a collaborative public health approach to violence reduction is vital. We examined regional data collected in a trauma network area as part of mandatory national trauma data submission to establish whether useful data could be extracted from this type of registry to inform regional violence reduction initiatives. Key information required to accurately target initiatives includes: who are the victims? where do incidents occur? and when do incidents occur?, Methods: Data were obtained from the national Trauma Audit and Research Network (TARN). This study utilised TARN inclusion criteria. Data for penetrating trauma patients from hospital sites in the Severn Major Trauma Network over an eight-year period were included in the analysis (1 June 2012 to 5 April 2020). The data were analysed using SPSS Statistics V27 and TARN analytics software. Existing ethical approval for anonymised registry data (PIAG section 60) was used., Results: Over the eight-year study period, 299 cases of penetrating trauma were registered in the Major Trauma Network. Overall, the incidence of penetrating trauma is increasing (R value +0.470, and +0.900 when 2020 excluded). Male victims account for 87.3% of cases (n=261). Younger individuals are more likely to be victims of penetrating trauma. The proportion of victims aged 13-18 years increased from 0% in 2012 to 21.6% in 2019. There were 43 (14.3%) incidents of victims presenting more than once during the study period. The early evening and hour after midnight had the highest numbers of penetrating trauma incidents. Most incidents occurred in a small proportion of postcodes. All the postcodes identified as having high incidence of penetrating injuries were also areas with high deprivation., Conclusion: This study demonstrated that national trauma registry data can be used to establish valuable information about serious penetrating trauma in a region. This data provides key information with which to target a proactive approach to violence reduction in our region with implications for public health, police, and clinical policymakers., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier Ltd.)

During ganglion impar block, the needle may approach the presacral space and the sacrum may be penetrated during caudal anesthesia. Because the rectum is in front of the sacrococcyx and is thus at risk for puncture, it is important to determine the distance between the sacrococcyx and rectum, as well as the thickness of the sacrococcyx.Computed tomography was used to measure the distance between the rectum and sacrococcyx, as well as the thickness of the sacrococcyx. The distances between the coccyx and rectum, sacrococcygeal joint and rectum, sacral level 5 ('sacrum 5') and rectum, and 'sacrum 4 to 5 junction' and rectum were measured. The results were compared based on the presence or absence of stools in the rectum. The thickness of the sacrococcyx was measured at the sacrum 4 to 5 junction and sacrococcygeal joint.In total, 1264 patients were included in this study. All distances were less than 1 mm in both males and females, with the exception of the distance between the coccyx and rectum in males. In both males and females, there was no significant difference in distance between the sacrococcyx and rectum according to the presence or absence of feces in the rectum, but there was a difference in the distance between sacrum 5 and the rectum in males (P = .048). Several male and female patients showed thicknesses of less than 5 mm at the sacrococcygeal joint.Some patients have a distance of less than 1 mm between the sacrum and rectum. Practitioners should exercise caution when applying a needle to the presacral space. If the sacrum is accidentally penetrated during caudal block, rectum puncture cannot be ruled out. Excretion of feces does not influence the distance between the sacrococcyx and rectum in females.

Background: The act of applying, univalving, and spreading a plaster cast to accommodate swelling is commonly performed; however, cast saws can cause thermal and/or abrasive injury to the patient. This study aims to identify the optimal time to valve a plaster cast so as to reduce the risk of cast-saw injury and increase spreading efficiency., Methods: Plaster casts were applied to life-sized pediatric models and were univalved at set-times of 5, 8, 12, or 25 minutes. Outcome measures included average and maximum force applied during univalving, blade-to-skin touches, cut time, force needed to spread, number of spread attempts, spread completeness, spread distance, saw blade temperature, and skin surface temperature., Results: Casts allowed to set for ≥12 minutes had significantly fewer blade-to-skin touches compared with casts that set for <12 minutes (p < 0.001). For average and maximum saw blade force, no significant difference was observed between individual set-times. However, in a comparison of the shorter group (<12 minutes) and the longer group (≥12 minutes), the longer group had a higher average force (p = 0.009) but a lower maximum force (p = 0.036). The average temperature of the saw blade did not vary between groups. The maximum force needed to "pop," or spread, the cast was greater for the 5-minute and 8-minute set-times. Despite requiring more force to spread the cast, 0% of attempts at 5 minutes and 54% of attempts at 8 minutes were successful in completely spreading the cast, whereas 100% of attempts at 12 and 25 minutes were successful. The spread distance was greatest for the 12-minute set-time at 5.7 mm., Conclusions: Allowing casts to set for 12 minutes is associated with decreased blade-to-skin contact, less maximum force used with the saw blade, and a more effective spread., Clinical Relevance: Adherence to the 12-minute interval could allow for fewer cast-saw injuries and more effective spreading.

Injury modelling of ballistic threats is a valuable tool for informing policy on personal protective equipment and other injury mitigation methods. Currently, the Ministry of Defence (MoD) and Centre for Protection of National Infrastructure (CPNI) are focusing on the development of three interlinking numerical models, each of a different fidelity, to answer specific questions on current threats. High-fidelity models simulate the physical events most realistically, and will be used in the future to test the medical effectiveness of personal armour systems. They are however generally computationally intensive, slow running and much of the experimental data to base their algorithms on do not yet exist. Medium fidelity models, such as the personnel vulnerability simulation (PVS), generally use algorithms based on physical or engineering estimations of interaction. This enables a reasonable representation of reality and greatly speeds up runtime allowing full assessments of the entire body area to be undertaken. Low-fidelity models such as the human injury predictor (HIP) tool generally use simplistic algorithms to make injury predictions. Individual scenarios can be run very quickly and hence enable statistical casualty assessments of large groups, where significant uncertainty concerning the threat and affected population exist. HIP is used to simulate the blast and penetrative fragmentation effects of a terrorist detonation of an improvised explosive device within crowds of people in metropolitan environments. This paper describes the collaboration between MoD and CPNI using an example of all three fidelities of injury model and to highlight future areas of research that are required., Competing Interests: Competing interests: None., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Introduction: Defining the minimum anatomical structural coverage required to protect from ballistic threats is necessary to enable objective comparisons between body armour designs. Current protection for the axilla and arm is in the form of brassards, but no evidence exists to justify the coverage that should be provided by them., Method: A systematic review was undertaken to ascertain which anatomical components within the arm or axilla would be highly likely to lead to either death within 60 min or would cause significant long-term morbidity., Results: Haemorrhage from vascular damage to the axillary or brachial vessels was demonstrated to be the principal cause of mortality from arm trauma on combat operations. Peripheral nerve injuries are the primary cause of long-term morbidity and functional disability following upper extremity arterial trauma., Discussion: Haemorrhage is managed through direct pressure and the application of a tourniquet. It is therefore recommended that the minimum coverage should be the most proximal extent to which a tourniquet can be applied. Superimposition of OSPREY brassards over these identified anatomical structures demonstrates that current coverage provided by the brassards could potentially be reduced., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Introduction: Body armour is a type of equipment worn by military personnel that aims to prevent or reduce the damage caused by ballistic projectiles to structures within the thorax and abdomen. Such injuries remain the leading cause of potentially survivable deaths on the modern battlefield. Recent developments in computer modelling in conjunction with a programme to procure the next generation of UK military body armour has provided the impetus to re-evaluate the optimal anatomical coverage provided by military body armour against high energy projectiles., Methods: A systematic review of the literature was undertaken to identify those anatomical structures within the thorax and abdomen that if damaged were highly likely to result in death or significant long-term morbidity. These structures were superimposed upon two designs of ceramic plate used within representative body armour systems using a computerised representation of human anatomy., Results and Conclusions: Those structures requiring essential medical coverage by a plate were demonstrated to be the heart, great vessels, liver and spleen. For the 50th centile male anthropometric model used in this study, the front and rear plates from the Enhanced Combat Body Armour system only provide limited coverage, but do fulfil their original requirement. The plates from the current Mark 4a OSPREY system cover all of the structures identified in this study as requiring coverage except for the abdominal sections of the aorta and inferior vena cava. Further work on sizing of plates is recommended due to its potential to optimise essential medical coverage., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Purpose: The aims of the study were to optimize surgical safety and to minimize vertebral disc puncture during sacral needle placement at the time of minimally invasive sacrocolpopexy. Cadaveric studies report that the anterior longitudinal ligament (ALL), which covers the vertebral disc and vertebrae, has a reported thickness of only 1.4 to 2.3 mm at L5-S1. Intervertebral disc puncture can accelerate disc degeneration, disc herniation, and loss of disc height, a risk that may be avoidable., Materials and Methods: After institutional review board approval, research consent was obtained from women undergoing primary laparoscopic sacrocolpopexy. Intraoperatively, sacral sutures were placed in the ALL with a 1.5 cm diameter CV-2 needle using Gore-Tex suture. Depth measurements were collected using a laparoscopic ultrasound transducer positioned on the sacral promontory (SP) between the 2 ends of the needle visible through the ALL. Two still-frame US images of the single needle were taken using the BK Medical software. Needle depth was calculated by measuring the distance from the top of the ALL to the needle., Results: Two satisfactory intraoperative images were obtained for all 9 participants. The mean needle depth at the SP was 3.96 mm. The interpatient needle depth varied from 2.07 to 9.04 mm., Conclusions: In most participants (78%), the sacral needle depth exceeded 2.3 mm, suggesting that there may be risk to sacral suture placement without depth guidance at the promontory. During minimally invasive sacrocolpopexy, the depth of the ALL and the placement of the needle at the SP may result in inadvertent disc penetration. Surgeons should be conscious of the minimal depth of the ALL and consider placing the suture below the promontory to avoid the disc.

Background: Placement and removal of fiberglass casts are among the more-common interventions performed in pediatric orthopaedic surgery offices. However, cast removal is associated with abrasive injuries and burns from the oscillating cast saw, and these injuries can occur even when the cast is removed by experienced personnel. It is unknown whether an added barrier, such as a safety strip, can mitigate injuries from blade-to-skin contact during cast removal with the oscillating saw., Questions/purposes: We asked: (1) Can a safety strip provide a physical barrier during cast removal, decreasing blade-to-skin contact? (2) Does the safety strip lessen heat transfer? (3) Will the use of the safety strip prevent cast pressure from being released when the cast is split?, Methods: Standard long-arm fiberglass casts were removed by experienced and inexperienced healthcare personnel (n = 35) from life-sized pediatric models. A commercially available woven cast saw safety strip, commonly incorporated in waterproof cast constructs, was chosen as the protective strip. Each participant removed a cast with and without the safety strip present. All participants were blinded to the presence or absence of the safety strip at the time of cast removal. The number of touches was compared between cast removal with and without protective strips. A separate model was designed to assess prevention of heat transfer. Temperatures were recorded, using thermocouples, for three designated temperatures. Five to six trials were conducted at each designated temperature for each of two conditions, with and without the safety strip. Finally, to assess if the safety strip would prevent cast pressure from being released, a third model was used. Thirty standard short-arm casts were applied and removed from the arm models by one of the authors. Pressure data were collected from between the padding layers, in casts with and without the safety strip present, after application, univalving and bivalving each cast., Results: Use of the safety strip reduced the number of simulated skin touches compared with casts removed without the safety strip, among experienced users (mean, 9.0 [range, 1-28] versus 0.1 [range, 0-1], mean ratio, 0.0012; 95% CI, 0.002-0.063; p < 0.001) and inexperienced users (mean, 8.5 [range, 0-31] versus 0.6 [range, 0-3], mean ratio, 0.07; 95% CI, 0.03-0.15; p < 0.001). The safety strips decreased heat transfer, preventing temperatures at the cast-skin interface from reaching 50 °C. Finally, after splitting the cast, with the numbers available, there was no increase in the pressure beneath the casts in those with the safety strip present (mean without, 0.23 [SD, 0.070] versus safety strip in the padding 0.20 [SD, 0.091] and safety strip on top padding, 0.21 [SD, 0.090]; p = 0.446 and p = 0.65 respectively)., Conclusions: Our study showed the effectiveness of a safety strip in reducing simulated touches with the oscillating cast saw during cast splitting. Additional studies are warranted to investigate the clinical use and utility of the safety strip in practice., Clinical Relevance: The findings of this study suggest that using safety strips in clinical practice could decrease blade-to-skin contact and therefore minimize cast saw injuries. However, validation of these findings in the clinical setting is necessary before drawing a definitive conclusion.

The anatomical position of the inferior epigastric artery (IEA) subjects it to risk of injury during abdominal procedures that are close to the artery, such as laparoscopic trocar insertion, insertion of intra-abdominal drains, Tenckhoff(®) catheter (peritoneal dialysis catheter) and paracentesis. This article aims to raise the awareness of the anatomical variations of the course of the IEA in relation to abdominal landmarks in order to define a safer zone for laparoscopic ancillary trocar placement. Methods of managing the IEA injury as well as techniques to minimise the risk of injury to the IEA are reviewed and discussed., (© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective: Intraarticular screw perforation is a common complication of open reduction and internal fixation of proximal humerus fractures. The purpose of this study was to (1) determine the sensitivity and specificity of the fluoroscopic images used to evaluate whether a screw tip has perforated into the glenohumeral joint, and (2) determine the specific fluoroscopic views that best evaluate screw position in the humeral head., Methods: Twenty-two proximal humeri in 11 lightly embalmed cadavers were instrumented. The articular surface was divided into equal-sized rows (superior, central, inferior) and columns (anterior, middle, posterior). The screws in 10 humeri were inserted and so their tips were located 2 mm beneath the articular surface. Twelve humeri had screws placed such that their tips protruded 2 mm past the articular surface into the glenohumeral joint. Twenty-seven different C-arm views were obtained of each specimen/screw configuration., Results: There were zero false-positives (100% specificity). The average sensitivity was 55% and varied greatly depending on the image view and the screw exit location (range, 0%-100%). The sensitivity for the inferior row of screws was the lowest (39.1%) and was particularly low for the posterior-inferior screw exit location (20.7%)., Conclusions: Screws that are completely located within the bone of the proximal humerus will never appear on C-arm images as intraarticular. However, screws that are intraarticular may appear to be completely located within the bone of the proximal humerus on some C-arm images. A sensitivity of 100% for detecting intraarticular screws for 8 of the 9 screws' exit locations and 90% for the posterior-inferior screw can be achieved by imaging the proximal humerus in 25-degree internal rotation, neutral, and 25-degree external rotation with the C-arm in neutral cant at rainbow 25-degree roll over, neutral rainbow, and rainbow 25-degree roll back for a total of 9 images.

Damage to the coronary arteries and related structures from pacemaker and implantable cardioverter-defibrillator lead implantation is a rarely reported complication that can lead to myocardial infarction and pericardial tamponade that may occur acutely or even years later. We summarize the reported cases of injury to coronary arteries and related structures and review the causes of troponin elevation in the setting of cardiac implantable electronic device implantation., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Background: Acute nail gun injuries can be controlled significantly by using tools with sequential triggers and training. Concern has been raised that sequential triggers, which require that the nose piece of the gun be depressed prior to pulling the trigger, could increase risk of musculoskeletal problems., Methods: We conducted active injury surveillance among union carpenter apprentices to monitor acute injuries and musculoskeletal disorders between 2010 and 2013., Results: Acute injury risk was 70% higher with contact trip rather than sequential triggers. Musculoskeletal risk was comparable (contact trip 0.09/10,000 hr (95% CI, 0.02-0.26); sequential 0.08/ 10,000 hr (95% CI 0.02-0.23))., Conclusions: Concern about excess risk of musculoskeletal problems from nail guns with sequential triggers is unwarranted. Both actuation systems carry comparable musculoskeletal risk which is far less than the risk of acute injury; there is clearly no justification for failure to prevent acute injuries through use of the safer sequential trigger., (© 2015 Wiley Periodicals, Inc.)

Introduction: Cardiac perforation is an infrequent but potentially life-threatening complication associated with placement of a cardiac implantable electronic device (CIED). The objective of this study was to determine the outcomes of percutaneous lead revision in patients who had lead perforation of the myocardium after CIED placement., Methods and Results: We reviewed records of 1,458 patients who underwent CIED lead extraction or repositioning. Of these, 31 (2.1%) had the procedure performed for lead perforation as a complication of CIED placement. Demographic, clinical, and follow-up characteristics of the patients were analyzed. Mean (SD) patient age was 65 (23) years. Cardiac perforation was detected within 24 hours after implantation in 9 patients, within 1 month in 17, and greater than 1 month in 5. Pericardiocentesis was performed with a pigtail drainage catheter in place before the lead revision in 17 patients (55%) who had pericardial effusion, with or without hemodynamic compromise. All culprit leads were successfully managed with percutaneous lead removal (n = 3 [10%]), new lead placement (n = 12 [38%]), or lead repositioning (n = 16 [52%]). Of the 17 patients with pericardiocentesis before the reoperation, none had tamponade develop; in contrast, 3 of the remaining 14 patients had tamponade develop and required urgent pericardiocentesis. All patients survived without requiring open chest surgery., Conclusion: Percutaneous removal or repositioning of the perforating lead is feasible and appears effective. Placement of a prophylactic pericardial drain catheter may reduce the incidence of urgent pericardiocentesis during or after a procedure., (© 2014 Wiley Periodicals, Inc.)

Purpose: To compare the outside-in transtibial lateral and medial approaches for posterior cruciate ligament (PCL) reconstruction regarding the guidewires and popliteal artery integrity., Methods: Twenty-two human cadaveric knees were used. A PCL tibial aimer was arthroscopically placed within the PCL footprint through the anteromedial portal for the medial approach and through the anterolateral portal for the lateral approach. For the medial approach, the drill guide was introduced through the anteromedial tibial cortex and the guidewire was advanced with the reamer beyond the posterior tibial cortex. For the lateral approach, the drill guide was introduced through the anterolateral tibial cortex and the guidewire was advanced with the reamer beyond the posterior tibial cortex. After this, the knee was dissected. The depth distance (DD) was defined as the distance between the popliteal artery and the tibial posterior cortex projected at the tibial level at which the guidewire intersected or passed by the artery. The guidewire travel distance was calculated as the distance the guidewire had to advance beyond the tibial cortex to intersect the popliteal artery or pass by it., Results: With the medial approach, the popliteal artery was intersected in all knees with a mean DD of 12.20 mm and a mean guidewire travel distance of 15.90 mm. With the lateral approach, the popliteal artery was not intersected in any knee; its mean medial distance from the artery was 4.8 mm at a DD of 10.05 mm. There was a significant difference in the popliteal artery intersection incidence and DD between both groups (P < .0001 and P = .0003, respectively)., Conclusions: The transtibial lateral approach for PCL reconstruction was a safer method than the medial approach regarding popliteal artery injury by a guidewire., Clinical Relevance: This study presents a slight modification of the most frequently used PCL reconstruction technique, intending to minimize guidewire injury to the popliteal artery., (Copyright © 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Introduction: Neck injuries sustained by UK service personnel serving on current operations from explosively propelled fragments result in significant mortality and long-term morbidity. Many of these injuries could potentially have been prevented had the soldiers been wearing their issued neck collars at the time of injury. The aim of this research is to develop an accurate method of predicting the resultant damage to cervical neurovascular structures from explosively propelled fragments., Current Status: A finite element numerical model has been developed based on an anatomically accurate, anthropometrically representative 3D mathematical mesh of cervical neurovascular structures. Currently, the model simulates the passage of a fragment simulating projectile through all anatomical components of the neck using material models based upon 20% ballistic gelatin on the simplification that all tissue types act like homogenous muscle., Future Research: The material models used to define the properties of each element within the model will be sequentially replaced by ones specific to each individual tissue within an anatomical structure. However, the cumulative effect of so many additional variables will necessitate experimental validation against both animal models and post-mortem human subjects to improve the credibility of any predictions made by the model. We believe this approach will in the future have the potential to enable objective comparisons between the mitigative effects of different body armour systems to be made with resultant time and financial savings., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Innovations in endovascular tools have permitted an increasingly broad range of neurovascular lesions to be treated via minimally invasive methods. However, some device modifications may carry additional risks, not immediately apparent to operators. A patient with a symptomatic, partially thrombosed basilar apex aneurysm was allocated balloon-assisted coiling. Attempts were made to place a microwire across the basilar apex through the posterior communicating artery. Overlapping courses of the posterior cerebral and posterior choroidal arteries on the roadmap images were not recognized and a flanged-tip microwire was inadvertently advanced deep into the choroidal artery. Following the wire with a microcatheter led to binding of arterial tissue within the microcatheter. Removing the wire led to an avulsion of the choroidal artery and a severe hemorrhagic complication which proved fatal. Tissue was identified on the tip of the guidewire. Pathology showed layers of vascular tissue within the laser-cut flanges of the distal wire tip. A similar complication, also fatal, occurred during balloon angioplasty of a distal vertebral artery, when an exchange wire was accidently introduced into a perforator from a posterior cerebral artery. Ex vivo catheterization of distal mesenteric arterial branches showed that the wall of small arteries can be entrapped by laser-cut, flanged, but not by smooth guidewire tips. Microwires with a flanged instead of smooth distal tip, when placed into small caliber vessels, may cause hemorrhagic complications from avulsions*.

The purpose of this study was to elucidate the role of alpha-tocopherol succinate (TS)- and AMD3100-mobilized progenitors in mitigating combined injury associated with acute radiation exposure in combination with secondary physical wounding. CD2F1 mice were exposed to high doses of cobalt-60 gamma-radiation and then transfused intravenously with 5 million peripheral blood mononuclear cells (PBMCs) from TS- and AMD3100-injected mice after irradiation. Within 1 h after irradiation, mice were exposed to secondary wounding. Mice were observed for 30 d after irradiation and cytokine analysis was conducted by multiplex Luminex assay at various time-points after irradiation and wounding. Our results initially demonstrated that transfusion of TS-mobilized progenitors from normal mice enhanced survival of acutely irradiated mice exposed 24 h prior to transfusion to supralethal doses (11.5-12.5 Gy) of (60)Co gamma-radiation. Subsequently, comparable transfusions of TS-mobilized progenitors were shown to significantly mitigate severe combined injuries in acutely irradiated mice. TS administered 24 h before irradiation was able to protect mice against combined injury as well. Cytokine results demonstrated that wounding modulates irradiation-induced cytokines. This study further supports the conclusion that the infusion of TS-mobilized progenitor-containing PBMCs acts as a bridging therapy in radiation-combined-injury mice. We suggest that this novel bridging therapeutic approach involving the infusion of TS-mobilized hematopoietic progenitors following acute radiation exposure or combined injury might be applicable to humans.

Objective: The purpose of our study was to determine if the rate of lead-related complications was increased with the Medtronic CapSureFix MRI™ SureScan™ 5086 MRI pacing lead (5086; Medtronic Inc., Minneapolis, MN, USA) compared to the previous generation of Medtronic CapSureFix Novus™ 5076 pacing lead (5076)., Background: The 5086 lead is a newly introduced active-fixation pacemaker lead designed to be used conditionally in a magnetic resonance (MR) scanner. This lead has specific design changes compared to the previous generation of 5076 pacing leads., Methods: This study was a retrospective case control study of 65 consecutive patients implanted with two 5086 leads compared to 92 consecutive control patients implanted with two 5076 leads over a 14-month period at a high-volume tertiary care hospital., Results: Pericarditis, pericardial effusion, cardiac tamponade, or death within 30 days of implant were seen in eight patients from the 5086 cohort and two from the 5076 cohort (odds ratio 6.3, 95% confidence interval 1.3-30.8, P = 0.02). Lead dislodgement occurred in four of the 5086 patients and in none of the 5076 patients (P < 0.03)., Conclusions: In a high-volume center, the incidence of pericarditis, cardiac perforation, tamponade, death, and lead dislodgement was significantly higher with the MR-conditional Medtronic 5086 lead when compared to the previous generation Medtronic 5076 lead., (©2013, The Authors. Journal compilation ©2013 Wiley Periodicals, Inc.)

Like Registered Nurses, students too should be considered a risk category during the period of their clinical training. Their lack of experience and the anxiety linked to the first impact with healthcare techniques may lead to accidents. The present study aims to investigate the number, the type, the mode, the cause of occupational injuries, when and where they happened. It also wants to check the level of knowledge of procedures to follow in case of contamination with organic material, the reporting of the event, the level of concern felt by the student and which of the people he/she turned to were supportive. The survey realized through a questionnaire given to 142 undergraduate nursing students at the University of Milan, all attending the Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan. Out of the 127 who replied to the questionnaire, 32 had been directly involved in a total of 38 accidents. The figure shows percentage (25.2%) stating that the sample of nursing students described arises at a lower level of involvement in accidents than reported in the literature for similar series. Preventive measures and specific formative interventions should be implemented in order to reduce the incidence of accidents involving nursing students, especially where cutting devices are used.

With the incidence of work-related injuries decreasing, we continue to observe an unchanged trend in leisure-related accidents. As in any other hobby, model flying devices bear the risk for accidents among builders and flyers ranging from skin lacerations to complicated and even life-threatening injuries. The fast-moving razor-sharp propeller blades predominantly cause trauma to the hands and fingers resulting in typical multiple parallel skin injuries also affecting structures deep to the dermis (e. g., tendons, vessels and nerves). The resultant clinical management involves complex reconstructive surgical procedures and prolonged rehabilitative follow-up. Improving the legal framework (e. g., warnings by the manufacturer) on the one hand, providing informative action and sensitising those affected on the other, should form a basis for an altered prevention strategy to reduce model flying device-related injuries in the future., (© Georg Thieme Verlag KG Stuttgart · New York.)

Cervical transforaminal epidural injections (C-TfEI) are commonly performed in patients with cervical radiculopathy/pain. C-TfEIs are typically performed without incident but adverse events can occur. Using CT-fluoroscopy-guided C-TfEI, we commonly observe the vertebral artery in proximity to the target injection site. The purpose of this study was to assess the position of the vertebral artery relative to the typical C-TfEI injection point. CT-fluoroscopy-guided C-TfEIs were performed at 70 levels in 68 patients with radiculopathy/neck pain (age range 19-83 yrs, mean 50.6 yrs). Degenerative neural foraminal narrowing at each level was characterized (normal-to-mild, moderate, severe). Vertebral artery position was categorized as: anterior (normal), partially covering neural foramen, complete/near-complete covering the neural foramen. Additional measured variables included angle of needle trajectory, foraminal angle, and whether or not needle trajectory intersected with the vertebral artery. Foraminal vertebral artery covering correlated with severity of foraminal degenerative narrowing (p=0.003). Complete/near-complete covering was seen in: 65% severely narrowed foramina, 30% moderately narrowed foramina and 10% normal/mildly-narrowed foramina. Needle trajectory intersected with the vertebral artery in 30 of 70 injections (46%) by CT-fluoroscopy, frequently associated with shallow (lateral) approaches. Foraminal angle, approximating oblique fluoroscopic technique, suggests needle trajectory intersection with the vertebral artery in 27 of 70 foramina (39%). Vertebral artery position is commonly displaced into the foramen in patients with advanced cervical degenerative disease. Operator awareness of altered vertebral artery position is important for determination of optimal needle trajectory and tip placement prior to injection in patients undergoing C-TfEI.

Introduction: Neck injuries from explosively propelled fragments are present in 11% of injured U.K. soldiers and result in significant mortality and long-term morbidity. U.S. forces in contrast sustain only neck wounds in 3 to 4% of those injured, which is believed to be because of their greater acceptance in the wearing of issued neck protection., Method: A three-piece neck collar, two-piece neck collar, a nape pad, a ballistic scarf, and an enhanced protection under body armor shirt (EP-UBACS) reinforced at the collar were objectively compared during a treadmill test using physiological measurements. Designs were subjectively compared regarding their effect on soldier performance using representative military tasks., Results: Both neck collars and the EP-UBACS prototype demonstrated 90% acceptability in terms of military task performance. No statistical difference in tympanic temperature and heart rate was found between prototypes. The statistically significant higher skin temperatures found for prototypes lying close to the skin (EP-UBACS and ballistic scarf) were unrelated to perceived comfort., Discussion: Neck collars remain the most successful design in terms of military performance, comfort, and potential levels of ballistic protection. However the EP-UBACS concept should also be developed further, with future iterations potentially removing the zip and increasing skin standoff., (Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.)

Purpose: Watercraft-associated trauma (WAT) in children has received little attention so far, despite the potentially severe and debilitating resulting injuries. The aim of this study was to evaluate all cases of major watercraft-associated trauma admitted to the Children's of Alabama during the past 10 years, identify patterns in mechanism and injury, and propose future prevention strategies., Methods: We reviewed our (prospective) database for children admitted through our trauma center after major WAT. Charts were abstracted for mechanism, epidemiologic data, injury type and injury severity scale (ISS), as well as outcome., Results: We identified 15 children (6 males, 9 females, age range 7 to 15, mean 12 ± 2 years), involved in 14 accidents. Sharp trauma was inflicted by a propeller (n=4) or a rope (n=1). Towed tubing (riding an inflatable tube while being pulled by a boat) was the most prevalent mechanism (n=6). There was a trend towards higher ISS after towed tubing (24.8 ± 12.4) compared to all other mechanisms (15.1±7.7). Mean length of stay was longer after towed tubing accidents (14.2 ± 7.2 versus 4.9 ± 3.4 days). All patients survived and eventually were discharged home. In one of the incidences, involving 2 victims of this series, the driver of the boat was intoxicated with alcohol., Conclusions: Pediatric watercraft-related accidents are infrequent, but often result in major injuries. More awareness for safety measures to prevent these injuries is warranted. Alcohol is not a major factor in pediatric watercraft-associated trauma. Tubes towed by a boat seem to be particularly dangerous, perhaps because of the rider's limited maneuverability and the fact that centrifugal force lets the tube travel well outside the wake in curves. Limiting boat speed and the use of protective gear on towed tubes when children are involved may decrease the incidence and severity of pediatric WAT., (Copyright © 2013 Elsevier Inc. All rights reserved.)

The majority of proximal humerus fractures are treated conservatively resulting in satisfying results. Fractures which need to be treated operatively are challenging for the therapist, postoperative treatment and the patient. It is inadequate to establish a therapy concept only by using radiological images and the resulting classification. Factors which take the patient, the injury and the surgeon into consideration have to be included in the decision-making process. Operative reconstruction results in a high rate of complications. This could be the reason why even complex fractures are treated conservatively by some therapists, especially in older patients. Locking plates are used increasingly. Specific complications, such as primary or secondary screw perforation result in a high rate of revision surgery.

Liposuction is the most frequent aesthetic procedure worldwide for adipose tissue reduction and treatment of lipedema. It is being employed with increasing frequency. In 2010, in the USA more than 200.000 liposuctions were performed. Apart from aesthetic indications, liposuction also is suitable for treatment of benign adipose tissue diseases. This intervention is not a simple procedure but requires extensive knowledge and experience to prevent irreversible medical or aesthetic complications. Severe complications including necrotizing fasciitis, toxic shock syndrome, hemorrhage, perforation of inner organs und pulmonary embolism - some even with lethal outcome - occasionally have been reported. These complications were mostly due to inadequate hygiene measures, inappropriate patient selection, use of excessive local anesthesia during mega-liposuction (tumescent technique) and inadequate post-operative surveillance. The complication rate usually reflects a lack of medical experience as well as technical inadequacies.

Objectives: To summarize existing knowledge regarding the prevalence of complications associated with temporary percutaneous central venous catheters placed in critically ill children, and to review evolving strategies to minimize the prevalence of these complications., Data Sources: Literature review was performed: PubMed and EBSCOhost were searched using the terms central venous catheter, children, ultrasound, infection, thrombosis, and thromboembolism in various combinations. Citations of interest from identified articles were also reviewed., Study Selection: The review focused primarily on pediatric literature relevant to the topic of interest., Data Extraction and Synthesis: Randomized clinical trials and other prospective studies were discussed in greater detail than retrospective, single-center investigations., Conclusions: Complications during percutaneous central venous catheter placement in children are not rare and may be in part attributable to abnormalities in vascular anatomy. Thromboses in children with central venous catheters are increasingly recognized as an important problem for which evidence-based preventive measures are lacking. Catheter-associated bloodstream infection rates in critically ill children have markedly decreased over the last decade, associated with an increased emphasis on staff education and the use of insertion and maintenance bundles. Available evidence tends to support the use of two-dimensional ultrasound to augment the landmark technique for catheter placement, but more studies are needed.

The number of neck injuries has increased during the war in Afghanistan, and they have become an appreciable source of mortality and long-term morbidity for UK servicemen. A three-dimensional numerical model of the neck is necessary to allow simulation of penetrating injury from explosive fragments so that the design of body armour can be optimal, and a framework is required to validate and describe the individual components of this program. An interdisciplinary consensus group consisting of military maxillofacial surgeons, and biomedical, physical, and material scientists was convened to generate the components of the framework, and as a result it incorporates the following components: analysis of deaths and long-term morbidity, assessment of critical cervical structures for incorporation into the model, characterisation of explosive fragments, evaluation of the material of which the body armour is made, and mapping of the entry sites of fragments. The resulting numerical model will simulate the wound tract produced by fragments of differing masses and velocities, and illustrate the effects of temporary cavities on cervical neurovascular structures. Using this framework, a new shirt to be worn under body armour that incorporates ballistic cervical protection has been developed for use in Afghanistan. New designs of the collar validated by human factors and assessment of coverage are currently being incorporated into early versions of the numerical model. The aim of this paper is to describe this developmental framework and provide an update on the current progress of its individual components., (Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.)

Aim: To determine military-specific cervical neurovascular and external anthropometric data to scale future numerical injury models of the neck and improve body armour design with a view to prevention or mitigation of combat neck injury., Materials and Methods: Contrast-enhanced computed tomography (CT) angiograms of 50 UK servicemen were analysed. Mean diameters and distances from the skin surface were determined for the carotid artery (CA), internal jugular vein (IJV), vertebral artery (VA) and spinal cord (SC) at the three surgical neck zones. Horizontal neck circumference at C6 and three potential vertical cervical anthropometric measurements were analysed to determine which had the least variability between subjects., Results: The diameters of cervical vascular structures are greater and the vessels more superficial as the anatomical plane moves caudally. The SC and VA are better protected than the IJV and CA due to their greater depth and bony coverage, except for the VA in zone 1., Conclusion: Future cervical anthropometric assessments should use the vertical angle of mandible to mid-claviclular distance in combination with the horizontal neck circumference as these demonstrated the least variability. Cervical neurovascular structures are least vulnerable posterosuperiorly and therefore extending the posterior aspect of a ballistic helmet inferiorly or adding a nape protector would appear to be less justified. Cervical vessels are most vulnerable in zone 1 and a circumferential collar of ballistic material at least 75 mm high would cover this area in 95% of this population., (Copyright © 2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Aim: This study investigated the characteristics and contexts of unintentional cutting or piercing injuries at home amongst young and middle-aged adults., Methods: We conducted a population-based study of individuals aged 20-64 years who were admitted to hospital in the Auckland, Waikato and Otago regions of New Zealand following an unintentional cutting or piercing injury sustained at home. Participants were interviewed using a structured questionnaire covering a range of factors including demographic information, circumstances of the injury, and personal factors such as medication, alcohol and recreational drug use., Results: Of 340 eligible cases, 267(78.5%) were interviewed. The overall age-specific hospitalisation rate for cutting or piercing injuries was 30.7 per 100,000 (95% CI 27.4-33.9). The highest hospitalisation rates occurred amongst males aged 20-24 and 60-64 years. Common mechanisms of injury were: contact with sharp glass (30.0%), contact with a powered hand tool or household machinery (29.7%), contact with knife (10.8%), and contact with non-powered hand tool (10.8%). The mechanism of injury varied significantly by gender, age, and ethnicity., Conclusion: Prevention strategies aimed at reducing the burden of cutting or piercing injuries occurring at home should focus on those most at risk including males aged 20-24 years, from injury by sharp glass, and those aged 40-64 years, from powered lawnmower, hand tool or household machinery-related injuries., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Due to the infrequent occurrence of large animal-related injury (LARI) in many areas, their significance as a public health problem could be overlooked. The purpose of this study was to examine the demographics and injury disparities associated with LARI., Methods: The Healthcare Cost and Utilization Project Nationwide Inpatient Survey from 2001 was used to construct a cohort of patients admitted after LARI. Patients were stratified by age, gender, race, and median household income of patient's zip code. Where available total hospital charges were converted to cost using the hospital's cost-to-charge ratio. To determine variables associated with injury type, univariable and multivariable logistic regression analysis were used., Results: 2424 LARI admissions were identified within the database. The largest proportion of admitted patients were female (53.8%), Caucasian (64.6%), and from areas with median income >$45,000 (41.8%). Average hospital cost was $5062. Overall, the most common injuries were rib fractures (15.2%), vertebral fractures (11.6%) and haemo-pneumothorax (9%). Multivariable logistic regression analysis revealed that age disparities with older patients receiving more rib fractures, haemo-pneumothorax, vertebral fractures, and pelvic fractures. Skull fractures and head injuries are disproportionately seen in younger patients. Gender disparities were also present, with females more likely to have vertebral fractures but less likely to have rib fractures and heart and lung injuries., Conclusions: Disparities based on age and gender are associated with hospital admission for LARI in the United States. These admissions have a significant impact on the healthcare system with nationwide cost estimates of nearly $60 million. These findings represent potential areas for targeted prevention efforts., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Purpose: To prospectively study the incidence, mechanism, distribution of injury, and outcome of patients admitted to Al-Ain Hospital with camel bite injuries in Al-Ain, United Arab Emirates., Methodology: All patients admitted to Al-Ain Hospital with a camel bite were prospectively studied during the period of October 2001-October 2007. Patient's demography, mechanism of injury including behaviour of the camel, distribution and severity of injury, and outcome were studied., Results: 33 patients were studied having a median (range) age of 27 (10-58), all were males. 97% were from the Indian subcontinent. A majority of injuries (73%) occurred during the camel rutting season (November-March). Twenty-five patients were camel caregivers whilst five were camel jockeys. All camel jockeys were children. Seven patients were raised up by the camel's mouth and thrown to the ground whilst 26 patients were only bitten. Most injuries were in the upper limb (64%) and head and face (15%). 48% of upper limb injuries had associated fractures. Two patients who were bitten at the neck were admitted to the ICU. One of these died due to massive left-brain infarction and the other had complete quadriplegia due to spinal cord injury. The median hospital stay was 6 days. There was only one death (3%)., Conclusion: The behaviour of the camel is occasionally unpredictable, especially during the rutting season. The mechanism of camel bite injuries, which are usually severe, are complex including penetrating and crushing injuries by the camel jaw and blunt injuries when patients are picked up and thrown away. Care should be taken when handling camels, particularly in the rut., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: The general guidelines on the management of ingested foreign bodies (FBs) do not address specific aspects raised by psychiatric patients, particularly in patients with borderline personality disorders (BPD) who repeatedly ingest FBs. The aim of this survey was to collect data on experience and opinions on the management of FBs in psychiatric patients with BPD and to review the relevant literature., Methods: A survey focusing on the indication and the timing of endoscopy for sharp FB removal in patients with BPD was e-mailed to 215 gastroenterologists, psychiatrists, and surgeons in Switzerland, Germany and Austria, discussing this clinical problem using a specific case vignette., Results: Responses were received from 63 of 215 (29%) contacted physicians. Two-thirds of the respondents knew patients with BPD who had swallowed FBs repeatedly; 86% recommended removing sharp FBs endoscopically even in the case of repeated FB ingestion and 14% of respondents argued against emergent endoscopic FB removal in the case of repeated ingestions. Different specialities expressed partially divergent opinions regarding the management of these patients., Conclusion: Repeated FB ingestions can be a problem in patients with BPD. Although published data show that the perforation risk of unremoved FBs is low, most clinicians support repeated endoscopies also in the case of repeated FB ingestions. Nevertheless, in selected cases, repeated endoscopies need to be discussed and an interdisciplinary consensus and/or the involvement of an ethical committee is advised.

Unintentional dural puncture is a source of significant morbidity in obstetric patients undergoing neuraxial anesthesia. In this focused review, we discuss the use of a prophylactic epidural blood patch to prevent postdural puncture headache, particularly as it relates to the obstetric population. Although epidural blood patch is thought to be an effective treatment for postdural puncture headache, there is insufficient evidence to support its use as a prophylactic procedure.

Aim: The aim of this paper was to assess the incidence of injuries in the general population caused by participation in the sport of target archery or bowhunting., Methods: Descriptive analysis of a national probability sample of hospital based treatments for archery-related injuries, over a 10-year period., Results: The leading injuries were lacerations (62±2%), which most often occurred through mishandling hunting arrows. Puncture wounds accounted for 8±1% and foreign bodies 6±1%, arising from feathers or vanes embedding in the hand, falling onto an arrow, or a rupturing arrow shaft. Contusions and abrasions, often caused by the bowstring hitting the arm, accounted for 6±1% of injuries. Nearly all (99±0.4%) of cases were treated and released. The overall injury rate is 4.4/10000 participants age 6 and over., Conclusion: Contrary to the prevailing perception that archery is inherently dangerous, the evidence shows that recreational archery is a very safe sport ‑ safer than popular field sports where people risk collisions or falls, such as soccer, basketball or baseball. The injury rate from lacerations could be significantly reduced if bow hunter education courses emphasized safe handling of broadhead arrows. The data suggest that nearly all acute injuries in target archery can be prevented through participation in an accredited training program and the use of basic protective gear (arm guards and shooting gloves). All archery education programs should focus on proper archery stance and joint strengthening to minimize chronic shoulder and back injuries.

Objective: This study assessed the safety of direct trocar insertion (DTI) versus Veress needle followed by primary trocar insertion (VN)., Methods: Ovid MEDLINE(®), Cochrane Library, Google Scholar, Scopus, and the reference lists of published articles were searched up to September 2011 to identify randomized clinical trials comparing DTI with VN. This meta-analysis was restricted to randomized studies comparing the safety of these two laparoscopic entry techniques., Results: Seven randomized studies consisting of 2940 women (VN, n=1525; DTI, n=1415) were identified. The data on the safety of two entry techniques were abstracted, integrated, and analyzed with the meta-analysis method and are presented as pooled relative risk (RR) with 95% confidence intervals (CI). There were 4 cases of a major complication in the VN group in contrast to none in the DTI group. Pooled results failed to show a statistically significant difference in the risk of major complications between the two groups. A significantly higher risk of minor complications was detected in the VN group (RR [95% CI]=10.78 [6.27-18.51]). Among minor complications, preperitoneal injuries (46.73 [11.55-189.10]) and omental injuries (4.51 [2.12-9.62]) were the two most common complications in the VN group. There were significantly increased risks of multiple insertions (more than two attempts) (2.99 [2.11-4.23]) and failed entry (2.21[1.07-4.56]) in the VN group., Conclusion: This meta-analysis suggests that the commonly used VN entry technique carries a significantly increased risk of minor complications. In addition, the likelihood of multiple insertions and failed entry are significantly higher in the VN group.

Objective: The purpose of this study was to evaluate the image quality and diagnostic accuracy of postgadolinium complex of diethylenetriaminepentaacetic acid (GD-DTPA)-enhanced magnetic resonance cholangiography (MRC) in donor selection., Materials and Methods: Donors (n=228) with both preoperative MRC and intraoperative cholangiography (IOC) were enrolled in this study. MRC pre- and post-GD-DTPA enhancement were performed using 1.5-T magnetic resonance imaging. The signal-to-noise ratio (SNR) of liver parenchyma and contrast-to-noise ratio of bile duct, as well as the contrast between bile duct and liver parenchyma, were calculated. The biliary anatomy correlation with the IOC during hepatectomy and patient prognosis were also evaluated., Results: Quantitative results of the SNR of the liver parenchyma post-GD-DTPA were statistically significantly lower than preenhanced MRC (2.69 times reduced from the preenhanced MRC). The contrast of the bile duct and liver parenchyma in post-GD-DTPA were significantly higher than the preenhancement MRC. The anatomic diagnostic accuracy rate of post-GD-DTPA MRC was 92.9%. The sensitivity and specificity of GD-PTPA MRC were 85% and 96%, respectively. GD-DTPA-enhanced MRC has higher accuracy than the preenhanced MRC (92.9% vs 75%). The concurrence between GD-DTPA-enhanced MRC and IOC were commendable (kappa=0.9). The posttransplant biliary complication rate was 5.5%, and the 3-year survival rate was 91.2% in the recipients., Conclusion: GD-DTPA, a paramagnetic metal, can shorten the T1 and T2 relaxation values of surrounding protons. This decreases the signal of the liver parenchyma and brightens the biliary anatomy. It can improve the image quality of MRC and increase the diagnostic accuracy of the biliary tract classification. It is mandatory in the "donor and recipient surgery during the LDLT"., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Accidents or violence can result in penetrating trauma in the adult population. Contaminated penetrating foreign bodies introduced at the time of wounding cause infection, especially high velocity projectiles, which result in cavitation. Surgical debridement reduces potential infection; however, perioperative antibiotics are usually indicated owing to studies demonstrating high rates of sepsis in the pre-antibiotic era. Trauma-associated pathogens include Gram-positive, Gram-negative and anaerobic pathogens. Antibiotic resistance is increasing, and several recent panels have sought to develop guidelines for perioperative prevention and empiric treatment of infection to limit usage and reduce selective pressure for resistance. We review infections of the CNS, thorax, abdomen and extremities following penetrating trauma injury, as well as the data supporting a reasonable antimicrobial approach.