Acute Traumatic Injury Research Articles

Within-person relationships between catastrophizing and pain intensity during a mind-body intervention to prevent persistent pain and disability after acute traumatic orthopedic injury

Interventions aimed at preventing chronic pain after acute traumatic injury have significant potential to reduce healthcare expenditures and improve quality of life for millions of individuals. Given recent development of such interventions, limited research has examined mechanisms of change using repeated measures (e.g., session-by-session assessments). This study examines within-person relationships between pain catastrophizing and intensity during and after a four-session mind-body intervention for individuals with acute traumatic orthopedic injury (N = 76, T = 445). Random intercept cross-lagged panel models were used to examine within-person autoregressive, contemporaneous, and cross-lagged effects between pain catastrophizing and pain intensity, after accounting for stable between-person differences. Our primary hypothesis that improvements in catastrophizing would be associated with subsequent reductions in pain intensity was partially supported by a significant within-person cross-lagged effect between catastrophizing at post-test and pain with activity reported at three-month follow-up (β = 0.421, SE = 0.099, p < .001). Improvement in catastrophizing was also associated with same-session improvement in pain intensity midway through the intervention. Importantly, bidirectional within-person analyses allowed us to rule out the possibility that improvements in pain were responsible for subsequent improvements in catastrophizing, but not vice versa. Together, these findings suggest improvements in catastrophizing during psychosocial intervention may prevent transition from acute to chronic pain after injury. Future research with larger between-person sample sizes, more frequent within-person assessment, and comparable control group data is necessary to facilitate greater understanding of psychosocial mechanisms for preventing chronic pain after injury. PerspectiveThis study examines within-person relationships between pain catastrophizing and intensity during and after a four-session mind-body intervention to prevent persistent pain after acute traumatic orthopedic injury. Improved catastrophizing at post-test was associated with reduced pain with activity at three-month follow-up. Within-person analyses enhance understanding of psychosocial mechanisms for preventing chronic pain after injury.

Diagnostic Value of Serum Clara Cell Secretory Protein Level in an Experimental Blunt Chest Trauma Model

Objective: Blunt chest trauma is a significant clinical problem leading to injury of the lungs that may be fatal. Experimental blunt chest trauma is well established in animal models. This study aimed to investigate whether Clara cell secretory protein (CC16) can be a biomarker in an experimentally created blunt chest trauma model. Material and Methods: A total of 30 rabbits were used in our study. A modified bilateral blunt thoracic trauma model was used to produce different levels of lung contusion. We divided the rabbits into four groups according to the energy level at which blunt thoracic trauma was applied. Blood samples were taken from the control and trauma groups to evaluate CC16 levels at 0, 12, and 24 hours. Results: The CC16 levels measured at the start of the experiment were significantly lower in the control and low-energy groups compared to the medium- and high-energy groups (p =.002). While there was a significant difference in CC16 levels measured at the 12th hour (p =.004), no significant difference was found among the groups at the 24th hour. Upon analyzing the change in CC16 levels over time within the groups, we observed that CC16 levels decreased from 0–12 hours and subsequently increased after the 12th hour. Histopathologically, we observed that the level of contusion increased in proportion to the severity of trauma across the different groups. Conclusion: With the designed platform, we created a reproducible experimental model of pulmonary contusion from blunt thoracic trauma in rabbits. Increased levels of CC16 following a lung contusion could serve as a foundation for clinical decision-making. Thus, CC16 has the potential to serve as a rapid and simple biochemical indicator for acute traumatic lung injury.

A-090 Performance of GFAP and UCH-L1 Biomarkers for Traumatic Brain Injury in the ARCHITECT i1000SR TBI Test

Abstract Background Traumatic Brain Injury (TBI) has been recognized as an important cause of death and disability and is a growing public health problem. An estimated 69 million people globally experience a TBI annually. The vast majority (80%) of patients evaluated for TBI in the Emergency Department will receive head CT scans, however less than 10% will have findings of acute traumatic abnormalities. This highlights the need for objective, rapid, accurate tools to help clinicians evaluate and triage patients with suspected TBI and reduce unnecessary radiation exposure. Blood based biomarkers such as glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase L1 (UCH-L1) have shown utility to predict acute traumatic intracranial injury on CT scan after TBI. Methods The ARCHITECT TBI test is a panel of in vitro diagnostic chemiluminescent microparticle immunoassays for the measurement of GFAP and UCH-L1 in plasma and serum. A method comparison study was performed to compare the GFAP and UCH-L1 assays on ARCHITECT i1000SR to the FDA cleared Alinity i assays. Performance characteristics such as detection limits, imprecision, linearity, and measuring interval were established following CLSI guidance. Results The analytical measuring interval (AMI) extends from the limit of quantitation (LoQ) to the upper LoQ and is determined by the range that demonstrates acceptable performance for linearity, imprecision, and bias. The AMI is 6.1 to 42,000 pg/mL for GFAP and 26.3 to 25,000 pg/mL for UCH-L1. Within-laboratory imprecision ranged from 2.2 to 6.2% CV for GFAP and 2.2 to 4.5% CV for UCH-L1. The Overall Reproducibility (includes repeatability, between-run, between-day, between-instrument variance components) results ranged from 2.7 to 6.8% CV for GFAP and 2.4 to 3.9 %CV for UCH-L1. The method comparison study evaluated 123 specimens across the range of 6.5-32,548.6 pg/mL for GFAP, and 51.5-24,127.7 for UCH-L1. The correlation coefficients were 1.0, with a slope of 1.03 and 1.06, an intercept of -0.6 and -6.0, for GFAP and UCH-L1, respectively. The results support use of the established GFAP and UCH-L1 cutoffs and clinical performance findings in a multi-site pivotal study which enrolled 1899 mild TBI (Glasgow Coma Scale score 13 to 15) subjects. 116 of the 120 specimens with a positive CT scan had a positive TBI interpretation (Sensitivity 96.7%). Of the 1779 subjects with negative CT scan results, 713 had a negative TBI interpretation (Specificity 40.1%). The negative predictive value (NPV) of the test was 99.4% (713/717). Conclusions The ARCHITECT TBI test performance was evaluated compared to the Alinity i TBI test across a broad concentration range of GFAP and UCH-L1. The results support equivalence of the ARCHITECT TBI test to the Alinity i TBI test. The established cutoffs were evaluated in a prospective cohort of mild TBI subjects and demonstrated high sensitivity and NPV relative to head CT scan results, supporting the utility to rule out the need for CT scan in mild TBI subjects presenting to the emergency department. Funding This work is in collaboration with the US Army Medical Materiel Development Activity, US Army Medical Research and Development Command CRADA 20-1266-CRA.

Cerebral physiologic insult burden in acute traumatic neural injury: a Canadian High Resolution-TBI (CAHR-TBI) descriptive analysis

BackgroundOver the recent decades, continuous multi-modal monitoring of cerebral physiology has gained increasing interest for its potential to help minimize secondary brain injury following moderate-to-severe acute traumatic neural injury (also termed traumatic brain injury; TBI). Despite this heightened interest, there has yet to be a comprehensive evaluation of the effects of derangements in multimodal cerebral physiology on global cerebral physiologic insult burden. In this study, we offer a multi-center descriptive analysis of the associations between deranged cerebral physiology and cerebral physiologic insult burden.MethodsUsing data from the Canadian High-Resolution TBI (CAHR-TBI) Research Collaborative, a total of 369 complete patient datasets were acquired for the purposes of this study. For various cerebral physiologic metrics, patients were trichotomized into low, intermediate, and high cohorts based on mean values. Jonckheere–Terpstra testing was then used to assess for directional relationships between these cerebral physiologic metrics and various measures of cerebral physiologic insult burden. Contour plots were then created to illustrate the impact of preserved vs impaired cerebrovascular reactivity on these relationships.ResultsIt was found that elevated intracranial pressure (ICP) was associated with more time spent with cerebral perfusion pressure (CPP) < 60 mmHg and more time with impaired cerebrovascular reactivity. Low CPP was associated with more time spent with ICP > 20 or 22 mmHg and more time spent with impaired cerebrovascular reactivity. Elevated cerebrovascular reactivity indices were associated with more time spent with CPP < 60 mmHg as well as ICP > 20 or 22 mmHg. Low brain tissue oxygenation (PbtO2) only demonstrated a significant association with more time spent with CPP < 60 mmHg. Low regional oxygen saturation (rSO2) failed to produce a statistically significant association with any particular measure of cerebral physiologic insult burden.ConclusionsMean ICP, CPP and, cerebrovascular reactivity values demonstrate statistically significant associations with global cerebral physiologic insult burden; however, it is uncertain whether measures of oxygen delivery provide any significant insight into such insult burden.

Osteochondritis Dissecans of the Knee: A Case Report

Osteochondritis dissecans (OCD) is a focal, idiopathic alteration of subchondral bone with the potential for instability and disruption of adjacent articular cartilage causing pain or discomfort in the knee and, if left untreated, may cause increasing disability and progressive arthritic change of the joint. This article presents a case study of a 16-year-old female who presented with intermittent right lateral knee pain for several years with no acute traumatic injury. Diagnostic imaging demonstrated subchondral changes of the lateral femoral condyle consistent with osteochondritis dissecans. The patient was diagnosed with an unstable OCD of the right knee and underwent surgical treatment. Following treatment, the patient attended formal physical therapy two times per week and began a gradual return to sport protocol at 4 months post-operatively. This case study will demonstrate the complexities surrounding the clinical presentation, diagnostic workup, and treatment options for this challenging diagnosis. The importance of accurate imaging and aggressive treatment of unstable OCD lesions will be highlighted.

Predictive factors for size change of aorta in patients with acute blunt traumatic aortic injury.

We aimed to investigate the changes in aorta size, the factors affecting size changes in patients with acute blunt traumatic aortic injury and to evaluate the adequacy of the current 120% thoracic endovascular aortic repair graft oversizing policy. This retrospective review study was conducted using the prospectively collected medical records of 45 patients (mean age: 53.5years, male: 39 patients) with blunt traumatic aortic injury treated at a level 1 trauma center between 2012 and 2021. Aortic diameter was measured by computed tomography angiographic images at four different levels [ascending aorta (A), isthmus (B), descending thoracic aorta (C), and infrarenal aorta (D)] on arrival and follow-up (median time interval, 13days). Associated factors including patient characteristics and hemodynamic parameters on arrival and follow-up were collected to determine their influence on changes in the aorta. The mean diameter of all four aortic levels increased on follow-up computed tomography compared to initial computed tomography (A: + 11.77%, B: + 10.19%, C: + 7.71%, D: + 12.04%). Patient age and injury severity score influenced changes in the diameter of the ascending aorta (P < 0.05). Patient age and blunt traumatic aortic injury grade were significantly associated with changes in the infrarenal aortic diameter (P < 0.05). Three cases of type 1 endoleak were observed at follow-up but all were spontaneously resolved without further intervention at next computed tomography follow-up. In patients with acute blunt traumatic aortic injury, aortic diameter is significantly smaller by about 10% under shock and is not considered a basis for oversizing the currently implemented 120% thoracic endovascular aortic repair graft sizing. However, in young patients under the age of 40, the change is significantly large and subsequent computed tomography follow-up is required.

Splinting of Low-Risk Pediatric Fractures.

This review covers common orthopedic injuries seen after acute traumatic injury. A thorough physical examination and radiographic review of these injuries are key to ensuring appropriate management. Although many injuries may require urgent or emergent orthopedic consultation and management, this review focuses on injuries that are low-risk and amenable to splinting with outpatient orthopedic follow-up. This review covers key physical examination features, radiographic findings that help providers assess injuries, as well as reviewing splinting application to help facilitate rapid management of these injuries in the acute care setting.

A Brief Mind-body Intervention Is Feasible and May Prevent Persistent Pain After Acute Orthopaedic Traumas: A Randomized Controlled Trial.

Approximately 20% to 50% of patients develop persistent pain after traumatic orthopaedic injuries. Psychosocial factors are an important predictor of persistent pain; however, there are no evidence-based, mind-body interventions to prevent persistent pain for this patient population. (1) Does the Toolkit for Optimal Recovery after Injury (TOR) achieve a priori feasibility benchmarks in a multisite randomized control trial (RCT)? (2) Does TOR demonstrate a preliminary effect in improving pain, as well as physical and emotional function? This pilot RCT of TOR versus a minimally enhanced usual care comparison group (MEUC) was conducted among 195 adults with an acute orthopaedic traumatic injury at risk for persistent pain at four geographically diverse Level 1 trauma centers between October 2021 to August 2023. Fifty percent (97 of 195) of participants were randomized to TOR (mean age 43 ± 17 years; 67% [65 of 97] women) and 50% (98) to MEUC (mean age 45 ± 16 years; 67% [66 of 98] women). In TOR, 24% (23 of 97) of patients were lost to follow-up, whereas in the MEUC, 17% (17 of 98) were lost. At 4 weeks, 78% (76 of 97) of patients in TOR and 95% (93 of 98) in the MEUC completed the assessments; by 12 weeks, 76% (74 of 97) of patients in TOR and 83% (81 of 98) in the MEUC completed the assessments (all participants were still included in the analysis consistent with an intention-to-treat approach). The TOR has four weekly video-administered sessions that teach pain coping skills. The MEUC is an educational pamphlet. Both were delivered in addition to usual care. Primary outcomes were feasibility of recruitment (the percentage of patients who met study criteria and enrolled) and data collection, appropriateness of treatment (the percent of participants in TOR who score above the midpoint on the Credibility and Expectancy Scale), acceptability (the percentage of patients in TOR who attend at least three of four sessions), and treatment satisfaction (the percent of participants in TOR who score above the midpoint on the Client Satisfaction Scale). Secondary outcomes included additional feasibility (including collecting data on narcotics and rescue medications and adverse events), fidelity (whether the intervention was delivered as planned) and acceptability metrics (patients and staff), pain (numeric rating scale), physical function (Short Musculoskeletal Function Assessment questionnaire [SMFA], PROMIS), emotional function (PTSD [PTSD Checklist], depression [Center for Epidemiologic Study of Depression]), and intervention targets (pain catastrophizing, pain anxiety, coping, and mindfulness). Assessments occurred at baseline, 4 and 12 weeks. Several outcomes exceeded a priori benchmarks: feasibility of recruitment (89% [210 of 235] of eligible participants consented), appropriateness (TOR: 73% [66 of 90] scored > midpoint on the Credibility and Expectancy Scale), data collection (79% [154 of 195] completed all surveys), satisfaction (TOR: 99% [75 of 76] > midpoint on the Client Satisfaction Scale), and acceptability (TOR: 73% [71 of 97] attended all four sessions). Participation in TOR, compared with the MEUC, was associated with improvement from baseline to postintervention and from baseline to follow-up in physical function (SMFA, baseline to post: -7 [95% CI -11 to -4]; p < 0.001; baseline to follow-up: -6 [95% CI -11 to -1]; p = 0.02), PROMIS (PROMIS-PF, baseline to follow-up: 2 [95% CI 0 to 4]; p = 0.045), pain at rest (baseline to post: -1.2 [95% CI -1.7 to -0.6]; p < 0.001; baseline to follow-up: -1 [95% CI -1.7 to -0.3]; p = 0.003), activity (baseline to post: -0.7 [95% CI -1.3 to -0.1]; p = 0.03; baseline to follow-up: -0.8 [95% CI -1.6 to -0.1]; p = 0.04), depressive symptoms (baseline to post: -6 [95% CI -9 to -3]; p < 0.001; baseline to follow-up: -5 [95% CI -9 to -2]; p < 0.002), and posttraumatic symptoms (baseline to post: -4 [95% CI -7 to 0]; p = 0.03; baseline to follow-up: -5 [95% CI -9 to -1]; p = 0.01). Improvements were generally clinically important and sustained or continued through the 3 months of follow-up (that is, above the minimum clinically important different [MCID] of 7 for the SMFA, the MCID of 3.6 for PROMIS, the MCID of 2 for pain at rest and pain during activity, the MCID of more than 10% change in depressive symptoms, and the MCID of 10 for posttraumatic symptoms). There were treatment-dependent improvements in pain catastrophizing, pain anxiety, coping, and mindfulness. TOR was feasible and potentially efficacious in preventing persistent pain among patients with an acute orthopaedic traumatic injury. Using TOR in clinical practice may prevent persistent pain after orthopaedic traumatic injury. Level I, therapeutic study.

Treatment of Knee Chondral Defects in Athletes.

Cartilage lesions of the knee are a challenging problem, especially for active individuals and athletes who desire a return to high-load activities. They occur both through chronic repetitive loading of the knee joint or through acute traumatic injury and represent a major cause of pain and time lost from sport. They can arise as isolated lesions or in association with concomitant knee pathology. Management of these defects ultimately requires a sound understanding of their pathophysiologic underpinnings to help guide treatment. Team physicians should maintain a high index of suspicion for underlying cartilage lesions in any patient presenting with a knee effusion, whether painful or not. A thorough workup should include a complete history and physical examination. MRI is the most sensitive and specific imaging modality to assess these lesions and can provide intricate detail not only of the structure and composition of cartilage, but also of the surrounding physiological environment in the joint. Treatment of these lesions consists of both conservative or supportive measures, as well as surgical interventions designed to restore or regenerate healthy cartilage. Because of the poor inherent capacity for healing associated with hyaline cartilage, the vast majority of symptomatic lesions will ultimately require surgery. Surgical treatment options range from simple arthroscopic debridement to large osteochondral reconstructions. Operative decision-making is based on numerous patient- and defect-related factors and requires open lines of communication between the athlete, the surgeon, and the rest of the treatment team. Ultimately, a positive outcome is based on the creation of a durable, resistant repair that allows the athlete to return to pain-free sporting activities.

Comparative evaluation of postoperative outcomes and expenditure between robotic and conventional single-level lumbar fusion surgery: a comprehensive analysis of nationwide inpatient sample data

IntroductionIn this study, we investigate the evolution of lumbar fusion surgery with robotic assistance, specifically focusing on the impact of robotic technology on pedicle screw placement and fixation. Utilizing data from the Nationwide Inpatient Sample (NIS) covering 2016 to 2019, we conduct a comprehensive analysis of postoperative outcomes and costs for single-level lumbar fusion surgery. Traditionally, freehand techniques for pedicle screw placement posed risks, leading to the development of robotic-assisted techniques with advantages such as reduced misplacement, increased precision, smaller incisions, and decreased surgeon fatigue. However, conflicting study results regarding the efficacy of robotic assistance in comparison to conventional techniques have prompted the need for a thorough evaluation. With a dataset of 461,965 patients, our aim is to provide insights into the impact of robotic assistance on patient care and healthcare resource utilization. Our primary goal is to contribute to the ongoing discourse on the efficacy of robotic technology in lumbar fusion procedures, offering meaningful insights for optimizing patient-centered care and healthcare resource allocation.MethodsThis study employed data from the Nationwide Inpatient Sample (NIS) spanning the years 2016 to 2019 from USA, 461,965 patients underwent one-level lumbar fusion surgery, with 5770 of them having the surgery with the assistance of robotic technology. The study focused primarily on one-level lumbar fusion surgery and excluded non-elective cases and those with prior surgeries. The analysis encompassed the identification of comorbidities, surgical etiologies, and complications using specific ICD-10 codes. Throughout the study, a constant comparison was made between robotic and non-robotic lumbar fusion procedures. Various statistical methods were applied, with a p value threshold of < 0.05, to determine statistical significance.ResultsRobotic-assisted lumbar fusion surgeries demonstrated a significant increase from 2016 to 2019, comprising 1.25% of cases. Both groups exhibited similar patient demographics, with minor differences in payment methods, favoring Medicare in non-robotic surgery and more private payer usage in robotic surgery. A comparison of comorbid conditions revealed differences in the prevalence of hypertension, dyslipidemia, and sleep apnea diagnoses—In terms of hospitalization outcomes and costs, there was a slight shorter hospital stay of 3.06 days, compared to 3.13 days in non-robotic surgery, showcasing a statistically significant difference (p = 0.042). Robotic surgery has higher charges, with a mean charge of $154,673, whereas non-robotic surgery had a mean charge of $125,467 (p < 0.0001). Robotic surgery demonstrated lower rates of heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury compared to non-robotic surgery, with statistically significant differences (p < 0.05). Conversely, robotic surgery demonstrated increased post-surgery anemia and blood transfusion requirements compared to non-robotic patients (p < 0.0001). Renal disease prevalence was similar before surgery, but acute kidney injury was slightly higher in the robotic group post-surgery (p = 0.038).ConclusionThis is the first big data study on this matter, our study showed that Robotic-assisted lumbar fusion surgery has fewer post-operative complications such as heart failure, acute coronary artery disease, pulmonary edema, venous thromboembolism, and traumatic spinal injury in comparison to conventional methods. Conversely, robotic surgery demonstrated increased post-surgery anemia, blood transfusion and acute kidney injury. Robotic surgery has higher charges compared to non-robotic surgery.

Associations Between Intracranial Pressure Extremes and Continuous Metrics of Cerebrovascular Pressure Reactivity in Acute Traumatic Neural Injury: A Scoping Review.

Cerebrovascular pressure reactivity plays a key role in maintaining constant cerebral blood flow. Unfortunately, this mechanism is often impaired in acute traumatic neural injury states, exposing the already injured brain to further pressure-passive insults. While there has been much work on the association between impaired cerebrovascular reactivity following moderate/severe traumatic brain injury (TBI) and worse long-term outcomes, there is yet to be a comprehensive review on the association between cerebrovascular pressure reactivity and intracranial pressure (ICP) extremes. Therefore, we conducted a systematic review of the literature for all studies presenting a quantifiable statistical association between a continuous measure of cerebrovascular pressure reactivity and ICP in a human TBI cohort. The methodology described in the Cochrane Handbook for Systematic Reviews was used. BIOSIS, Cochrane Library, EMBASE, Global Health, MEDLINE, and SCOPUS were all searched from their inceptions to March of 2023 for relevant articles. Full-length original works with a sample size of ≥10 patients with moderate/severe TBI were included in this review. Data were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A total of 16 articles were included in this review. Studies varied in population characteristics and statistical tests used. Five studies looked at transcranial Doppler-based indices and 13 looked at ICP-based indices. All but two studies were able to present a statistically significant association between cerebrovascular pressure reactivity and ICP. Based on the findings of this review, impaired reactivity seems to be associated with elevated ICP and reduced ICP waveform complexity. This relationship may allow for the calculation of patient-specific ICP thresholds, past which cerebrovascular reactivity becomes persistently deranged. However, further work is required to better understand this relationship and improve algorithmic derivation of such individualized ICP thresholds.

Association Between Clinical Measures of Depth of Sedation and Multimodal Cerebral Physiology in Acute Traumatic Neural Injury.

Neurointensive care primarily focuses on secondary injury reduction, utilizing a variety of guideline-based approaches (including administration of high-dose sedation) to reduce the injured state. However, titration of sedation is currently based on the Richmond Agitation Sedation Scale (RASS), a subjective clinical grading score of a patient's response to external physical stimuli, and not an objective measure. Therefore, it is likely that there exists substantial variation in objective sedation depth for a given clinical grade in these patients, leading to undesired sedation depths and cerebral physiological consequences. Improper sedation can impede cerebral autoregulation, emphasizing the critical need for optimal sedation in traumatic brain injury (TBI) patients. This study evaluates the relationship between RASS to an objective measure of depth of sedation (bispectral index, BIS) and cerebral physiological measures. Fifty-nine patients were assessed using Jonckheere-Terpstra testing to compare various key physiologies with RASS. RASS (-5 through 0 categories) showed no statistically significant relationship between BIS and cerebral physiological parameters, after adjusting for multiple comparisons. Furthermore, it is crucial to note that within each RASS value, the distribution of the physiological measures all had high variability. As an exemplar, for RASS values of -5 and -4, BIS ranged from near 0 (burst suppression levels) up to over 80 (near awake states). BIS and other cerebral physiologies displayed substantial variation across each RASS category. This suggests that RASS as a means to titrate sedative medication for the goal of neuroprotection is insufficient. More momentary, individualized determination of sedation depth is required for TBI patients.

Color discrimination in fixed saturation level of patients with acute traumatic injury.

Traumatic brain injury (TBI) is an important public health concern and that may lead to severe neural sequels, such as color vision deficits. We evaluated the color vision of 10 TBI patients with normal cognitive function using a color discrimination test in a fixed saturation level. We also analyzed computerized tomography scans to identify the local of the brain damages. Four TBI patients that had lesions in brain areas of the ventral visual streams, five TBI patients had lesions inferred in brain areas of the dorsal visual stream, and one TBI patient had lesion in the occipital area. All the patients had cognitive and color vision screened and they had characterized the chromatic discrimination at high and low saturation. All participants had no significant cognitive impairment in the moment of the color vision test. Additionally, they had perfect performance for discrimination of chromatic stimulus at high saturation and similar to controls (n = 37 age-matched participants). Three of four TBI patients with lesions in the ventral brain and one patient with lesion in the occipital area had impairment of the chromatic discrimination at low saturation. All TBI patients with lesions in the dorsal brain had performance similar or slightly worse than the controls. Chromatic discrimination at low saturation was associated to visual damage in the ventral region of the brain and is a potential tool for functional evaluation of brain damage in TBI patients.

The Role of Language Barriers on Hospital Outcomes in Culturally and Linguistically Diverse Patients following Trauma Admission

(1) Background: Patients who experience acute traumatic injury requiring hospitalisation represent a vulnerable population. The trauma patient often experiences multi-system injuries and complex physiology. Additionally, there are complex socio-ecological issues that impact the care and outcomes of trauma patients. Of interest, culturally and linguistically diverse populations with language barriers experience worse outcomes in trauma settings. This scoping review evaluates the current evidence on language barriers in this population and the influences on outcomes for trauma patients. (2) Methods: A scoping review was performed following a computer-assisted search of the Medline, Embase and Cochrane Central databases. Papers that evaluated the impact of the language barrier in culturally and linguistically diverse populations and outcomes in acute trauma settings were included. (3) Results: A literature search identified eight articles that were eligible for inclusion. Overall, there was no robust evidence to suggest that such populations were disadvantaged in terms of length of hospital stay and overall mortality. However, studies did identify that these populations were at higher risk of disability and poor mental health outcomes, experienced communication barriers more often and had lower social functioning. (4) Conclusions: This scoping review demonstrates that individuals admitted due to trauma who are from culturally and linguistically diverse backgrounds experience more significant disadvantages concerning psychological and functional outcomes. It is posited this is due to their inability to communicate their complex needs in trauma, however more robust and rigorous research is required to better characterise this effect.

Near-Infrared Spectroscopy Regional Oxygen Saturation Based Cerebrovascular Reactivity Assessments in Chronic Traumatic Neural Injury versus in Health: A Prospective Cohort Study.

Near-infrared spectroscopy (NIRS) regional cerebral oxygen saturation (rSO2)-based cerebrovascular reactivity (CVR) monitoring has enabled entirely non-invasive, continuous monitoring during both acute and long-term phases of care. To date, long-term post-injury CVR has not been properly characterized after acute traumatic neural injury, also known as traumatic brain injury (TBI). This study aims to compare CVR in those recovering from moderate-to-severe TBI with a healthy control group. A total of 101 heathy subjects were recruited for this study, along with 29 TBI patients. In the healthy cohort, the arterial blood pressure variant of the cerebral oxygen index (COx_a) was not statistically different between males and females or in the dominant and non-dominant hemispheres. In the TBI cohort, COx_a was not statistically different between the first and last available follow-up or by the side of cranial surgery. Surprisingly, CVR, as measured by COx_a, was statistically better in those recovering from TBI than those in the healthy cohort. In this prospective cohort study, CVR, as measured by NIRS-based methods, was found to be more active in those recovering from TBI than in the healthy cohort. This study may indicate that in individuals that survive TBI, CVR may be enhanced as a neuroprotective measure.

Prognostic value of near-infrared spectroscopy regional oxygen saturation and cerebrovascular reactivity index in acute traumatic neural injury: a CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Cohort Study

BackgroundNear-infrared spectroscopy regional cerebral oxygen saturation (rSO2) has gained interest as a raw parameter and as a basis for measuring cerebrovascular reactivity (CVR) due to its noninvasive nature and high spatial resolution. However, the prognostic utility of these parameters has not yet been determined. This study aimed to identify threshold values of rSO2 and rSO2-based CVR at which outcomes worsened following traumatic brain injury (TBI).MethodsA retrospective multi-institutional cohort study was performed. The cohort included TBI patients treated in four adult intensive care units (ICU). The cerebral oxygen indices, COx (using rSO2 and cerebral perfusion pressure) as well as COx_a (using rSO2 and arterial blood pressure) were calculated for each patient. Grand mean thresholds along with exposure-based thresholds were determined utilizing sequential chi-squared analysis and univariate logistic regression, respectively.ResultsIn the cohort of 129 patients, there was no identifiable threshold for raw rSO2 at which outcomes were found to worsen. For both COx and COx_a, an optimal grand mean threshold value of 0.2 was identified for both survival and favorable outcomes, while percent time above − 0.05 was uniformly found to have the best discriminative value.ConclusionsIn this multi-institutional cohort study, raw rSO2was found to contain no significant prognostic information. However, rSO2-based indices of CVR, COx and COx_a, were found to have a uniform grand mean threshold of 0.2 and exposure-based threshold of − 0.05, above which clinical outcomes markedly worsened. This study lays the groundwork to transition to less invasive means of continuously measuring CVR.

Association of RAP Compensatory Reserve Index with Continuous Multimodal Monitoring Cerebral Physiology, Neuroimaging, and Patient Outcome in Adult Acute Traumatic Neural Injury: A Scoping Review.

Acute traumatic neural injury, known as traumatic brain injury (TBI), stands as a significant contributor to global mortality and disability. Ideally, continuously monitoring cerebral compliance/cerebral compensatory reserve would enable timely interventions and avert further substantial deterioration in TBI cases. RAP, defined as the moving Pearson's correlation between intracranial pressure (ICP) pulse amplitude waveform and ICP, has been proposed as a continuously updating index in this context. However, the literature remains scattered and difficult to navigate. Thus, the goal of this scoping review was to comprehensively characterize the literature regarding RAP and its association with (1) other multimodal cerebral physiological monitoring, (2) neuroimaging features, and (3) long-term patient outcomes. We subsequently conducted a systematic scoping review of the human literature to highlight the association of RAP with continuous multimodal monitoring of cerebral physiology, neuroimaging, and patient outcomes in the context of adult TBI patients. Our review encompassed 21 studies focusing on these topics. The primary findings involve meticulous analysis of studies, categorizing findings into three states of RAP to clearly understand its relation to cerebral physiology and clinical outcomes. State 1 signifies a healthy condition with a small positive value near zero (RAP <0.5). Conversely, state 2, a predominant characterization of TBI patients, indicates compromised compensatory reserve, featuring a large positive RAP value (RAP > 0.4). State 3 emerges in worsened conditions, showcasing further compromised compensatory reserve, exhausted cerebrovascular reactivity, and disturbed cerebral autoregulation. A substantial number of patients with fatal outcomes was found in state 3, marked by a notable occurrence of decreasing and, in some instances, negative RAP. The significance of this review lies in establishing a platform for future research directions to enhance the precision and clinical implications of RAP in TBI care, ultimately aiming to prevent the transition from state 2 to state 3 and mitigate fatal outcomes.

Re-thinking the value of cross-sectional torso imaging for ground-level fall patients with altered mental status: Outcomes from a level 1 trauma center

IntroductionPatients with altered mental status (AMS) are often excluded from studies evaluating the utility of computed tomography of the torso (CTT) after ground level falls (GLF). It is not known whether CTT identifies otherwise undetectable injuries in patients with AMS after GLF. We sought to describe the value of performing CTT in patients with AMS after GLF, and hypothesized that CTT would not identify new, clinically significant injuries in patients with a normal torso physical exam (PE) and normal chest and pelvic radiographs (CXR/PXR). MethodsSingle-institution retrospective cohort study of GLF patients (≤1 m) with and without AMS (GCS <15, blood alcohol level >150 mg/dL, intubation prior to hospital evaluation), 2015–2019. Traumatic injury identification on CTT was evaluated in the context of normal/abnormal torso PE (based on provider documentation) and normal CXR/PXR. Results1195 patients met inclusion criteria; 344 had AMS, of which 129 (37.5 %) underwent CTT. A further 851 patients had normal mental status, of which 180 (21.2 %) underwent CTT. Patients with a normal PE with AMS (N = 79) and without AMS (N = 38) had a similar rate of new injury discovery on CTT (6.3% vs. 7.9 %, p = 1.00). Negative PE had a negative predictive value (NPV) for identification of a new, acute traumatic injury of 92.4 % (95 % CI: 0.84–0.96) in patients with AMS while normal PE, CXR, and PXR had a NPV of 96.0 % (95 % CI: 0.80–0.99). Among patients with CTT, patients with AMS had a significantly lower rate of acute traumatic injury on CTT compared to alert patients (26.4 % vs. 48.9 %, p < 0.001). On multivariate analysis, AMS was not positively associated with likelihood of identifying acute traumatic injury on CTT. ConclusionsIn patients sustaining GLFs who present with AMS and who otherwise have a negative PE, CXR, and PXR, CTT is very unlikely to identify new traumatic injuries. Strong consideration should be given to forego cross-sectional imaging in this patient population.

LOCAL AND SYSTEMIC MEDIATORS OF SKELETAL MUSCLE WASTING IN HUMANS FOLLOWING ACUTE TRAUMA

AbstractIntroductionSkeletal muscle wasting is an important clinical issue following acute traumatic injury, and can delay recovery and cause permanent functional disability particularly in the elderly. However, the fundamental mechanisms involved in trauma-induced muscle wasting remain poorly defined and therapeutic interventions are limited.ObjectivesTo characterise local and systemic mediators of skeletal muscle wasting in elderly patients following acute trauma.MethodsExperiments were approved by a local NHS Research Ethics Committee and all participants provided written informed consent. Vastus lateralis biopsies and serum samples were taken from human male and female patients shortly after acute trauma injury in lower limbs (n=6; mean age 78.7±4.4 y) and compared to age-matched controls (n=6; mean age 72.6±6.3 y). Atrogenes and upstream regulators (MuRF1; MAFbx; IL6, TNFα, PGC-1α) mRNA expression was assessed in muscle samples via RT-qPCR. Serum profiling of inflammatory markers (e.g. IL6, TNFα, IL1β) was further performed via multiplex assays. To determine whether systemic factors induced by trauma directly affect muscle phenotype, differentiated primary human myotubes were treated in vitro with serum from controls or trauma patients (pooled; n=3 each) in the final 24 hours of differentiation. Cells were then fixed, stained for myogenin and imaged to determine minimum ferret diameter. Statistical significance was determined at P&lt;0.05.ResultsThere was an increase in skeletal muscle mRNA expression for E3 ligase MAFbx and inflammatory cytokine IL-6 (4.6 and 21.5-fold respectively; P&lt;0.05) in trauma patients compared to controls. Expression of myogenic determination factor MyoD and regulator of mitochondrial biogenesis PGC-1α was lower in muscle of trauma patients vs controls (0.5 and 0.39-fold respectively; P&lt;0.05). In serum, trauma patients showed increased concentrations of circulating pro-inflammatory cytokines IL-6 (14.5 vs. 0.3 pg/ml; P&lt;0.05) and IL-16 (182.7 vs. 85.2 pg/ml; P&lt;0.05) compared to controls. Primary myotube experiments revealed serum from trauma patients induced atrophy (32% decrease in diameter) compared to control serum-treated cells (P&lt;0.001).ConclusionSkeletal muscle from patients following acute trauma injury showed greater expression of atrophy and inflammatory markers. Trauma patient serum exhibited higher circulating pro-inflammatory cytokine concentrations. Primary human myotubes treated with serum from trauma patients showed significant atrophy compared to healthy serum-treated controls. We speculate a mechanism(s) acting via circulating factors may contribute to skeletal muscle pathology following acute trauma.Declaration of Interest(b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Race and Ethnicity and Prehospital Use of Opioid or Ketamine Analgesia in Acute Traumatic Injury

Racial and ethnic disparities in pain management have been characterized in many hospital-based settings. Painful traumatic injuries are a common reason for 911 activations of the EMS (emergency medical services) system. To evaluate whether, among patients treated by EMS with traumatic injuries, race and ethnicity are associated with either disparate recording of pain scores or disparate administration of analgesia when a high pain score is recorded. This cohort study included interactions from 2019 to 2021 for US patients ages 14 to 99 years who had experienced painful acute traumatic injuries and were treated and transported by an advanced life support unit following the activation of the 911 EMS system. The data were analyzed in January 2023. Acute painful traumatic injuries including burns. Outcomes were the recording of a pain score and the administration of a nonoral opioid or ketamine. The study cohort included 4 781 396 EMS activations for acute traumatic injury, with a median (IQR) patient age of 59 (35-78) years (2 497 053 female [52.2%]; 31 266 American Indian or Alaskan Native [0.7%]; 59 713 Asian [1.2%]; 742 931 Black [15.5%], 411 934 Hispanic or Latino [8.6%], 10 747 Native Hawaiian or other Pacific Islander [0.2%]; 2 764 499 White [57.8%]; 16 161 multiple races [0.3%]). The analysis showed that race and ethnicity was associated with the likelihood of having a pain score recorded. Compared with White patients, American Indian and Alaskan Native patients had the lowest adjusted odds ratio (AOR) of having a pain score recorded (AOR, 0.74; 95% CI, 0.71-0.76). Among patients for whom a high pain score was recorded (between 7 and 10 out of 10), Black patients were about half as likely to receive opioid or ketamine analgesia as White patients (AOR, 0.53; 95% CI, 0.52-0.54) despite having a pain score recorded almost as frequently as White patients. In this nationwide study of patients treated by EMS for acute traumatic injuries, patients from racial or ethnic minority groups were less likely to have a pain score recorded, with Native American and Alaskan Natives the least likely to have a pain score recorded. Among patients with a high pain score, patients from racial and ethnic minority groups were also significantly less likely to receive opioid or ketamine analgesia treatment, with Black patients having the lowest adjusted odds of receiving these treatments.