Definition Of Injury Research Articles

The effect of different definitions of hepatic injury on incidence and mortality rates in the ICU patient population with secondary hepatic injury

The effect of different definitions of hepatic injury on incidence and mortality rates in the ICU patient population with secondary hepatic injury

Moral Injury: A Theme in Search of Definition

Moral injury refers to a complex psychological condition that is assumed to emerge following exposure to distressing events that challenge the moral values or ethical beliefs of individuals by direct commission, omission, observation, or betrayal by a trusted leader. Moral injury can be found across various occupational domains, such as military, healthcare, and law enforcement. Symptoms of moral injury can include guilt, a sense of moral disorientation, struggle with spiritual or existential issues, and more. This paper aims to summarize current debates on the definition, symptomatology, and assessment of moral injury. Furthermore, it discusses the conceptual and psychological overlap and differences between moral injury and Post-Traumatic Stress Disorder (PTSD) and addresses current therapeutic approaches for treating patients with moral injury.

Moral Injury Among Youth: Historical Accounts, Current Research and Future Directions

AbstractThis manuscript explores the definition and historical context of Moral Injury (MI), detailing its psychological and spiritual impact on individuals, including youth populations. Morals are our beliefs and understanding of what is right and wrong. They are often informed by cultural and social norms and typically encompass values and responsibilities that individuals use to judge whether an action is right or wrong. MI is a psychological phenomenon that can unfold when there is a loss of trust in these beliefs or others' ability to keep our shared moral agreements. Traditionally associated with military personnel, MI has evolved to include other populations, including youth and family systems. This piece explores moral development among youth populations and how injuries to moral codes are particularly salient in youth populations and family systems. Special attention is given to MI's unique manifestations and implications in childhood and adolescence. The manuscript concludes with a call to action for further research that prioritizes and integrates youths' own voices in understanding and addressing MI.

An Update on the Six Recommendations from the 2012 IADMS Standard Measures Initiative: Assessing and Reporting Dancer Capacities, Risk Factors, and Injuries.

In 2012, the Standard Measures Consensus Initiative (SMCI) of the International Association for Dance Medicine and Science (IADMS) presented 6 recommendations regarding dance injury surveillance, definitions of injury and exposure, dance-specific screening, risk reduction strategies, and collaborative data management. The aim was to standardize risk factor measurement and injury reporting by researchers in dance medicine and science. Since then, numerous reports on the recording and reporting of injury data in sport and performing arts have been published. IADMS commissioned SMCI to update the 2012 recommendations, a process that involved 3 stages: (1) current field experts were invited to join SMCI, (2) SMCI members reviewed recent and relevant sport and performing arts literature, then drafted, discussed, and revised section updates, (3) IADMS invited individuals representing diverse backgrounds in the IADMS community to critically review drafted updates. The final update serves as a bridge from the 6 recommendations in the 2012 report to the current state of evidence. We continue to encourage use of dance injury surveillance systems and support that surveillance protocols be fit-for-purpose, and that failure to use clear and consistent injury definitions perpetuates a lack of rigor in dance injury research. Based on new evidence, we recommend that some aspects of injury surveillance be self-reported, that the choice of dance exposure measures be dependent on the research question, contextual factors, and type of injury/health problem(s) of interest, and that studies using dance-specific screening articulate specific objectives, validity, and reliability of each protocol. Future studies should focus on the development, implementation, and evaluation of strategies to minimize injury risk to improve consistency and rigor in data collection and research reporting on the health and wellness of dancer populations, thus facilitating a future dance injury consensus statement similar to recent statements published for sports and circus arts.

Acute Kidney Injury after Isolated Coronary Bypass Surgery

AbstractAcute kidney injury (AKI) is among the most serious of the common postoperative complications of cardiac surgeries, which can increase the short- and long-term morbidity and mortality of patients. This study aimed to examine possible risk factors that lead to AKI. We sought to compare our AKI rates to national averages in coronary artery bypass grafting (CABG) reported by the Society of Thoracic Surgeons (STS). We reviewed our institution's data for renal failure in CABG procedures performed between January 1, 2020, and June 30, 2023. From the database, we identified 1,068 CABG patients and reviewed demographics, nonmodifiable conditions, and modifiable risk factors. The STS database uses the Risk, Injury, Failure, Loss, and End-stage renal disease definition for renal failure. Of our patient sample, 14 (1.3%) experienced renal failure. The national rate for AKI after isolated CABG was 1.9% in 2023. Chronic lung disease was a risk factor for AKI development. The mean perfusion, cross-clamp, ventilator times, and hospital stay increased in AKI patients. All patients who suffered from AKI had undergone perioperative blood transfusion. Our single-center experience with renal failure is slightly better than the national average. In our population, chronic lung disease and lower preoperative ejection fractions were associated with increased rates of AKI. Modifiable risk factors in our population included perioperative blood transfusion and increased perfusion/cross-clamp times. Lastly, AKI patients spent longer time on ventilators, increased lengths of stay, and increased postoperative mortality.

Severe acute liver disease in adults: Contemporary role of histopathology.

Liver biopsies have consistently contributed to our understanding of the pathogenesis and aetiologies of acute liver disease. As other diagnostic modalities have been developed and refined, the role of biopsy in the management of patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and acute hepatitis, including acute liver injury (ALI), has changed. Liver biopsy remains particularly valuable when first-line diagnostic algorithms fail to determine aetiology. Despite not being identified as a mandatory diagnostic tool in recent clinical guidelines for the management of ALF or ACLF, many centres continue to undertake biopsies given the relative safety of transjugular biopsy in this setting. Several studies have demonstrated that liver biopsy can provide prognostic information, particularly in the context of so-called indeterminate hepatitis, and is extremely useful in excluding conditions such as metastatic tumours that would preclude transplantation. In addition, its widespread use of percutaneous biopsies in cases of less severe acute liver injury, for example in the establishment of a diagnosis of acute presentation of autoimmune hepatitis or confirmation of a probable or definite drug-induced liver injury (DILI), has meant that many centres have seen a shift in the ratio of specimens they are receiving from patients with chronic to acute liver disease. Histopathologists therefore need to be equipped to deal with these challenging specimens. This overview provides an insight into the contemporary role of biopsies (as well as explant and autopsy material) in diagnosing acute liver disease. It outlines up-to-date clinical definitions of liver injury and considers recent recommendations for the diagnosis of AIH and drug-induced, autoimmune-like hepatitis (DI-AIH).

Sports Injury Surveillance Systems: A Scoping Review of Practice and Methodologies.

Background: Injury prevention/reduction strategies are driven by data collected through injury surveillance systems. The aim of this review was to describe injury surveillance systems that are used for ongoing surveillance in either a professional or amateur sporting environment. This was an update to a review done in 2015 to determine the gaps in injury surveillance. Methods: A systematic search process of five databases (MEDLINE, CINAHL, EMBASE, SCOPUS and ProQuest) was used to discover published research that presented methodological data about the injury surveillance systems implemented by clubs and organisations for ongoing surveillance. Inclusion criteria centred on the population under surveillance and the ongoing nature of that activity. Data extracted and summarised included the level of athlete under surveillance, the data collection mechanism and the personnel involved, the injury definitions applied and the date and country of origin to provide a comprehensive picture of the systems. Results: A total of 21 systems were documented as being used in ongoing injury surveillance, with 57% of these exclusively in the professional/elite landscapes and 33% at the amateur level. Surveillance systems cater for one sport per athlete entry so there is a gap in research for multi-sport athletes at the amateur level, especially where there is no early specialisation in a multi-sport participation environment. Conclusions: Research in this area will lead to a better understanding of subsequent injury risk for multi-sport athletes who have a higher athlete exposure than single-sport athletes.

Research progress on exercise-induced cardiac injury

Integrating recent domestic and international research on exercise-induced cardiac injury and combining it with the author's related work, this paper mainly discusses the definition, clinical manifestations, pathogenesis, early warning, and prevention and treatment of exercise-induced cardiac injury, in the hope of providing reference and insights for the early warning and prevention and treatment of exercise-induced cardiac injury in military training personnel.

Has the role of troponin as a biomarker of cardiac complications after non-cardiac surgery been fully understood?

Myocardial injury after non-cardiac surgery is a major issue with a rate of almost 20%, as suggested by the literature. Guidelines recommend screening patients undergoing non-cardiac surgery who have at least one cardiovascular risk factor. Clinical trials are characterized by a high degree of heterogeneity. Myocardial injury definitions vary among studies, and multiple troponin assays with different cut-offs are utilized. Myocardial injury has a poorly understood pathophysiology. While some studies only include troponin elevations that are thought to be caused by ischemia, others do not. Troponin elevation can be a result of patient-related factors and comorbidities, including age, chronic renal failure, and inflammatory status. Currently, there is no effective strategy to prevent perioperative myocardial injury, and there are no therapeutic options that significantly improve the outcome of patients with myocardial injury. We have focused on this topic and on perioperative myocardial injury to highlight the areas of research that remain unexplored.

The Levels of Biomarkers Interleukin 1 (IL-1) and Brain-Derived Neurotrophic Factor (BDNF) in Non-Invasive Conventional Rehabilitation and Robotic Rehabilitation Among Brain Injury Patients: A Narrative Review.

Acquired brain injury (ABI) is becoming increasingly common in Malaysia as a result of a rise in both strokes and accidents. The present review aims to explore the levels of serum inflammatory markers of interleukin-1 (IL-1) and brain-derived neurotrophic factor (BDNF) following conventional and robotic rehabilitation regimes among ABI patients and the association between serum biomarkers with the Medical Research Council (MRC) scale for muscle strength. Online databases, namely ScienceDirect, PubMed, and Google Scholar were utilized by using search terms such as 'Definition of brain injury', 'Epidemiology of brain injury', 'Interleukin-1 in stroke', 'BDNF in stroke', 'Interleukin-1 in traumatic brain injury', 'BDNF in traumatic brain injury', 'Interleukin-1 level and robotic rehabilitation', 'BDNF and robotic rehabilitation', 'Interleukin-1 level and neurorehabilitation', and 'BDNF and neurorehabilitation'. All types of articles with different levels of evidence were included along with other relevant review articles. Articles that were not in English and were not available in the full text were excluded. The review identifies similar and no significant improvement in the treatment between conventional rehabilitation and robotic rehabilitation concerning serum biomarkers IL-1and BDNF. This review also identifies that muscle strength and endurance training improved the levelof serum BDNF in brain injury patients. Therefore, this review provides evidence of the levels of IL-1 and BDNF in non-invasiveconventionalrehabilitation and robotic rehabilitation among brain injury patients, as well as their relation with the MRC scale, to give a good functional outcome that will enhance the quality of life of these groups of individuals.

“Working within broken systems”: Social workers bridge the fractures of U.S. healthcare: A qualitative inquiry on moral injury

Healthcare social workers (HSWs) in the United States are integral to interdisciplinary teams and health services. HSWs have a unique role in healthcare, as they care for their patients' psychosocial needs, through case management and clinical services. There is a gap in understanding how HSWs are impacted by their healthcare work. This study aims to understand the experience of moral injury, a marker of well-being, amongst HSWs in one state in the United States. Moral injury is the moral transgression (or boundary breaking) by oneself or someone in a position of power in high stakes situations and the negative outcomes of those experiences. Using a qualitative approach, semi-structured interviews were conducted with 24 HSWs in August of 2022. Thematic analysis was used to understand the lived experience of moral injury for HSWs. Three themes emerged: 1) HSWs’ definition and examples of moral injury; 2) HSWs situated in the “in-between” of policy and practice; and 3) upholding social work values within the medical model. These findings impact healthcare practice and policy, in delineating what falls within the bounds of social work, changing the workflow of health services, and creating further opportunities for interdisciplinary training, well-being initiatives, and systems-level changes. The findings from this work highlight the importance of understanding the moral impact of healthcare work on social workers, which should be further examined in depth not only amongst HSWs but also across the healthcare workforce.

Update: Delayed Onset Muscle Soreness (DOMS) – Muscle Biomechanics, Pathophysiology and Therapeutic Approaches

The term Delayed Onset Muscle Soreness (DOMS) refers to a complex injury entity which is based on ultrastructural injury patterns. The injury is usually harmless and heals within a few days without sequelae. However, at the time of the manifestation there are (sometimes considerable) performance limitations and the risk of possible secondary injuries is increased. Thus, prevention and treatment of DOMS, especially in high-performance sports, are of particular value. Insights into muscle biomechanics are necessary to understand the background and mechanisms of DOMS. The definition and classification of overload-related muscle injuries has not yet been uniformly determined. Fluid transitions between physiological, metabolic and neuromuscular fatigue as well as the actual occurrence of injuries with clinical symptoms make clear delineation difficult. The “Munich Classification” terms Delayed Onset Muscle Soreness (DOMS) as Type 1b muscle injury, “delayed onset muscle pain”. The central target of prevention of DOMS is to prevent or alleviate the onset of the initial damage, known as “Exercise Induced Muscle Damage” (EIMD). In case of manifest DOMS, the intention is both to relieve the attendant symptoms and to promote rapid restoration of muscle function. In clinical practice as in scientific research, diverse procedures and interventions have proven valuable, whereby especially physical therapy procedures like cryotherapy, heat therapy or compression therapy show promising study results.

Redefining urine output thresholds for acute kidney injury criteria in critically Ill patients: a derivation and validation study

IntroductionThe current definition of acute kidney injury (AKI) includes increased serum creatinine (sCr) concentration and decreased urinary output (UO). Recent studies suggest that the standard UO threshold of 0.5 ml/kg/h may be suboptimal. This study aimed to develop and validate a novel UO-based AKI classification system that improves mortality prediction and patient stratification.MethodsData were obtained from the MIMIC-IV and eICU databases. The development process included (1) evaluating UO as a continuous variable over 3-, 6-, 12-, and 24-h periods; (2) identifying 3 optimal UO cutoff points for each time window (stages 1, 2, and 3); (3) comparing sensitivity and specificity to develop a unified staging system; (4) assessing average versus persistent reduced UO hourly; (5) comparing the new UO-AKI system to the KDIGO UO-AKI system; (6) integrating sCr criteria with both systems and comparing them; and (7) validating the new classification with an independent cohort. In all these steps, the outcome was hospital mortality. Another analyzed outcome was 90-day mortality. The analyses included ROC curve analysis, net reclassification improvement (NRI), integrated discrimination improvement (IDI), and logistic and Cox regression analyses.ResultsFrom the MIMIC-IV database, 35,845 patients were included in the development cohort. After comparing the sensitivity and specificity of 12 different lowest UO thresholds across four time frames, 3 cutoff points were selected to compose the proposed UO-AKI classification: stage 1 (0.2–0.3 mL/kg/h), stage 2 (0.1–0.2 mL/kg/h), and stage 3 (< 0.1 mL/kg/h) over 6 h. The proposed classification had better discrimination when the average was used than when the persistent method was used. The adjusted odds ratio demonstrated a significant stepwise increase in hospital mortality with advancing UO-AKI stage. The proposed classification combined or not with the sCr criterion outperformed the KDIGO criteria in terms of predictive accuracy—AUC-ROC 0.75 (0.74–0.76) vs. 0.69 (0.68–0.70); NRI: 25.4% (95% CI: 23.3–27.6); and IDI: 4.0% (95% CI: 3.6–4.5). External validation with the eICU database confirmed the superior performance of the new classification system.ConclusionThe proposed UO-AKI classification enhances mortality prediction and patient stratification in critically ill patients, offering a more accurate and practical approach than the current KDIGO criteria.

Definition and management of right ventricular injury in adult patients receiving extracorporeal membrane oxygenation for respiratory support using the Delphi method: a PRORVnet study. Expert position statements.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is an integral part of the management algorithm of patients with severe respiratory failure refractory to evidence-based conventional treatments. Right ventricular injury (RVI) pertaining to abnormalities in the dimensions and/or function of the right ventricle (RV) in the context of VV-ECMO significantly influences mortality. However, in the absence of a universally accepted RVI definition and evidence-based guidance for the management of RVI in this very high-risk patient cohort, variations in clinical practice continue to exist. Following a systematic search of the literature, an international Steering Committee consisting of eight healthcare professionals involved in the management of patients receiving ECMO identified domains and knowledge gaps pertaining to RVI definition and management where the evidence is limited or ambiguous. Using a Delphi process, an international panel of 52 Experts developed Expert position statements in those areas. The process also conferred RV-centric overarching open questions for future research. Consensus was defined as achieved when 70% or more of the Experts agreed or disagreed on a Likert-scale statement or when 80% or more of the Experts agreed on a particular option in multiple-choice questions. The Delphi process was conducted through four rounds and consensus was achieved on 31 (89%) of 35 statements from which 24 Expert position statements were derived. Expert position statements provided recommendations for RVI nomenclature in the setting of VV-ECMO, a multi-modal diagnostic approach to RVI, the timing and parameters of diagnostic echocardiography, and VV-ECMO settings during RVI assessment and management. Consensus was not reached on RV-protective driving pressure thresholds or the effect of prone positioning on patient-centric outcomes. The proposed definition of RVI in the context of VV-ECMO needs to be validated through a systematic aggregation of data across studies. Until further evidence emerges, the Expert position statements can guide informed decision-making in the management of these patients.

The netball injury evidence base: a scoping review of methodologies and recommendations for future approaches

BackgroundNetball is a sport with a large participation base and a high risk of injuries. Effective injury prevention strategies are dependent upon a clear understanding of injury issues, aetiology and mechanisms, requiring robust research methodologies to ensure a reliable evidence base. This scoping review aims to identify the characteristics and range of netball injury research methodologies, to inform recommendations for future research.MethodsA systematic search of SPORTDiscus, MEDLINE, CINAHL and Academic Search Complete, PubMed, Scopus and Web of Science, from 1985 to May 2023 identified relevant studies. Inclusion criteria included peer-reviewed studies assessing injury incidence, aetiology and mechanisms in netball.ResultsFollowing screening, 65 studies were included (68% descriptive epidemiology, 32% analytic epidemiology). Descriptive epidemiology reported data from hospital/clinic and insurance databases (57%) and netball competitions (43%). Only two studies used ongoing, systematic injury surveillance in netball cohorts, and significant heterogeneity existed in study designs, data collection methods, injury definitions and injury incidence rates calculations. Studies assessed a limited number of risk factors (descriptive competition studies: median: n = 4; analytic studies median: n = 6), with 76% using a simplistic reductionist approach to determine causality. Basic descriptions and retrospective recall of injury mechanisms reduced accuracy. Only two studies conducted comprehensive assessments of injury mechanisms using video-based methods.ConclusionTo establish an accurate netball injury evidence base, future research should prioritise the development of reliable, continuous surveillance systems. The International Olympic Committee (IOC) consensus statement guidelines are recommended for accurate injury data collection and reporting. A multifactorial approach should be adopted to assess the complex interaction between multiple risk factors, player load and the injury inciting event. Comprehensive descriptions of injury mechanisms using video methods, alongside descriptions from medical staff are recommended. This information is crucial for developing targeted prevention strategies.

Childhood Health and Educational outcomes afteR perinatal Brain injury (CHERuB): protocol for a population-matched cohort study

IntroductionOver 3000 infants suffer a brain injury around the time of birth every year in England. Although these injuries can have important implications for children and their families, our understanding...

Epidemiological Features of Traumatic Spinal Cord Injury in Elderly in Ilam

Background: Spinal cord injuries are neurological disorders characterized by varying degrees of damage to the spinal cord. Objectives: Considering the increase in the elderly population, identifying the prevalence and factors affecting the development of spinal cord lesions in this group can provide valuable results for researchers. Therefore, this study aimed to determine the prevalence of spinal cord injuries in the elderly in Ilam city. Methods: In this retrospective study, patients who were hospitalized due to spinal cord trauma, as diagnosed by a doctor, were included. Information was collected using the results of radiography, radiology, and CT scans, along with patient files, demographic profile forms, and a researcher - made checklist. The definition of spinal cord injury included the cervical, thoracic, and lumbar regions. Results: The results showed that most of the patients were male, with a rate of 256 (67.6%). The number of patients with damage in each area was as follows: 43 in the cervical area, 61 in the thoracic area, and 54 in the lumbar area. Additionally, the study results showed that 17 (4.5%) of the patients had infections, 35 (9.2%) had hyponatremia, 32 (8.4%) had bedsores, 30 (7.9%) had urinary complications, 21 (5.5%) had thrombosis, and 15 (3.9%) had other complications. Conclusions: Considering the significant prevalence of spinal cord injuries among the elderly in Ilam city, it is necessary to implement interventions to prevent these injuries in this population.

Impact of differences between the Nuclear Law Act and the Vienna Convention on Civil Liability for Nuclear Damage on the Terms and Conditions of Nuclear Civil Liability Insurance2nd Part

This article is the second part of the publication with the same title, which appeared in the issue no. 4/2023 of the “Insurance Law”. The first part discussed selected differences in the regulation of civil liability of the operator of a nuclear installation for nuclear personal injury between the Nuclear Law Act and the Vienna Convention. Those included the definition of nuclear personal injury, the limitation period for claims for such injury and the rules for seeking compensation thereof. The Vienna Convention sets minimum protection standards in the event of nuclear damage, which has served as a benchmark for developing the principle of civil liability insurance of the operator of a nuclear installation for nuclear damage.The second part of the article deals with practical issues and provides a summary of the most crucial information concerning nuclear insurance market. It clarifies the notion of a nuclear insurer and their available insurance options. It also discusses the major elements of the civil liability protection for nuclear damage which differ from the rules of the insured’s civil liability specified by law. Finally, it addresses obstacles which may hinder the offering of this type of insurance as compulsory insurance under national legislation. This Article concerns solely the rules for civil liability for nuclear personal injury suffered as a result of operating the nuclear power plant. Insurance aspects related to the transport of nuclear material from nuclear facilities, the operation of research reactors and radioactive waste repositories have been omitted.

Overhead and Wheelchair Sport-related injuries in Para Athletes: Interplay between disability and sport specific factors.

With the increasing opportunities for people with disabilities to engage in competitive Para sports, it becomes imperative to understand the injury consequences that may impact both sports participation and daily life activities. This narrative review aims to examine the intrinsic and extrinsic risk factors inherent in overhead and wheelchair summer Para sports, while also exploring prospective avenues for implementing prevention strategies. By understanding the injury epidemiology in this cohort of Para athletes, this review aims to explore the intricate interplay between the athletes' underlying disability with sport-specific factors, such as how wheelchair use might amplify injury susceptibility. Specifically, we highlight the impact of impairment, daily activity, and workload or discipline-induced overuse on injury occurrence, as well as how surveillance methods can be tailored to this population. In this regard, we propose practical injury surveillance methods that encompass a sensitive injury definition, severity assessment, incidence rate calculation, and the recording of adaptive equipment (e.g., type of wheelchair) and workload monitoring. It is worth noting that studies of prospective injury surveillance systems coupled with workload monitoring within a dedicated Para sport web-based platform are scarce. To establish a comprehensive understanding of Para athlete health, the monitoring framework should incorporate regular athlete follow-ups and facilitate knowledge transfer.

Early Creatinine Changes After Aortic Valve Replacement and Late Survival, Heart Failure, and Chronic Kidney Disease in a National Registry

BackgroundThe impact of small increases in serum creatinine after surgical aortic valve replacement (SAVR) that fail to meet the acute kidney injury stage 1 criteria is unknown. The aim of this study was to investigate prognosis after primary SAVR in patients with small increases in postoperative serum creatinine. MethodsThis observational cohort study included all adult patients who underwent primary SAVR in Sweden from 2009 to 2022. The primary outcome was all-cause mortality. Secondary outcomes were chronic kidney disease and heart failure. Regression standardization addressed confounding. ResultsIn 16,766 patients, 4074 (24.2%) had no change in postoperative serum creatinine, 5764 (34.3%) had a small increase in postoperative serum creatinine (0.06 mg/dL ≤ Δserum creatinine <0.3 mg/dL), and 2753 (16.4%) fulfilled the Kidney Disease Improving Global Outcomes acute kidney injury stage 1 criteria. The mean age was 67 years, and 31% of patients were female. No significant difference in long-term all-cause mortality was observed in the no change group at 13 years compared with the small increase group (absolute survival difference, 2.3% [95% CI, 0%-4.6%]). A stepwise increase in the risk of 30-day mortality was observed with increasing changes in serum creatinine. At 13 years of follow-up, there was a significant difference in the risk of chronic kidney disease (absolute difference, 2.8% [95% CI, 1.0%-4.5%]) and heart failure (absolute difference, 3.5% [95% CI, 1.3%-5.7%]) between the no change and small increase groups. ConclusionsA small increase in postoperative serum creatinine after SAVR was associated with an increased risk of adverse outcomes. The acute kidney injury definition may benefit from including more reliable and specific biomarkers together with small creatinine increases to detect kidney injury.