Initial Injury Research Articles

Identification of clinical risk factors and optimal inflammatory marker cutoffs for the diagnosis of septic nonunion at time of presentation.

The diagnosis of septic nonunion is difficult due to the risk of occult presentation. The purpose of this study is to identify risk factors for infection prior to nonunion surgery. This retrospective cohort study was completed at a single tertiary referral level one trauma center. Patients were included if they had surgery to repair a nonunion of the femur, tibia, or humerus after operative initial management. Predictors for septic nonunion were determined based on clinical, laboratory, and radiographic findings. 122 Patients met inclusion criteria. 28 Patients (23.0%) were diagnosed with septic nonunion. Clinical risk factors for septic nonunion diagnosis on multivariate regression included nonunion surgery performed at an outside hospital prior to referral (p=0.003) and early infection requiring debridement within 60days of initial injury (p=0.01). Ideal inflammatory marker cutoffs based on ROC curves included WBC>8.1×109/L (p=0.001) and CRP>14.1mg/L (p=0.001). This study demonstrates additional clinical risk factors and re-defines cutoff values for laboratory biomarkers as predictors for diagnosis of septic nonunion. These data may help providers better identify cases of septic nonunion prior to nonunion surgery.

Is Excretory Phase Computerized Tomography Important for Evaluation of Pediatric High-Grade Renal Trauma?

Is Excretory Phase Computerized Tomography Important for Evaluation of Pediatric High-Grade Renal Trauma?

Neuroprotection by Anti-Oxidative Stress Response After Severe Traumatic Brain Injury – Do Extracellular Vesicles Count?

Severe traumatic brain injury (sTBI) is a serious and potentially life-threatening brain injury typically caused by a severe blow or impact to the head. The clinical manifestation can vary greatly and include loss of consciousness, cognitive impairment, memory problems, and sensory, motor, and behavioural disturbances. sTBI requires emergent treatment because the initial injury can be further aggravated by hypoxia, hypotension, and raised intracranial pressure. Acute management is therefore focused on preventing and/or mitigating additional damage to the brain by relying on macrophysiological parameters. However, a deeper understanding of the cellular and molecular pathophysiology of sTBI might offer additional insight into underlying processes in the brain and contribute to medical decision-making. Here we provide an overview of the main TBI features, including treatment in the acute phase. We describe the molecular pathophysiology with emphasis on oxidative stress as one of the major detrimental events in acute sTBI. Furthermore, we discuss if the anti-oxidative response after sTBI might be mediated by extracellular vesicles, nano-sized particles secreted by cells into body fluids including cerebrospinal fluid (CSF). EVs were attributed different roles in oxidative stress, and as carriers of various macromolecules, CSF-EVs might further combat oxidative stress in sTBI. Taken together, sTBI has a complex and dynamic pathophysiology with oxidative stress playing a significant part. Newly discovered mediators of anti-oxidative response are EVs which are present in CSF and can reveal ongoing processes in the brain. Further studies are required to determine if and how CSF-EVs participate in anti-oxidative response in sTBI.

Return to Vocal Performance After Vocal Fold Hemorrhage.

Although vocal fold hemorrhage (VFH) is a common injury among vocal performers, no evidence exists to guide safe return to performance (RTP). This study assesses VFH recurrence following RTP. Retrospective cohort. Academic institution. Adult vocal performers with clearly documented dates of VFH and of RTP were retrospectively studied. Clinicodemographics, interventions, and recurrence of VFH within 30 days of RTP were noted. Cohorts with and without recurrence were compared. Thirty-two patients (median age: 36 years, 49% female, 76% musical theater performers) with 33 unique occurrences of VFH were included. Most hemorrhages (31; 94%) were unilateral. Twelve patients (36%) had varices, all of which were ipsilateral to the hemorrhage. Overall, median time from initial VFH to RTP was 12.0 days (range 3-29). Two patients (6%) had a recurrence within 30 days of RTP. Median time to RTP was 10 days for those with recurrence and 12 days for those without recurrence (P = .6398). There were no differences in age (37 vs 34 years; P = .8206), sex (0 vs 16 [49%] female; P = .4848), extent of hemorrhage (P = .1728), or presence of associated varices (1 [50%] vs 11 [35.5%]; P > .9999) between groups. Rate of VFH recurrence following RTP at a median of 12 days after initial injury was 6%, regardless of age, sex, hemorrhage extent, or associated varices. Although the interval between VFH and RTP was shorter in patients with recurrence, this was not statistically significant. These findings guide counseling and set expectations among vocal performers faced with VFH. IV.

Type IV Tibial Tubercle Fractures in Adolescents-Is Operative Treatment Necessary?

Tibial tubercle fractures (TTF) in adolescents can be treated operatively or nonoperatively depending on fracture configuration and displacement. In the modified Ogden classification, the type IV fracture is extra-articular and exits through the posterior physis or metaphysis. No previous publications have reviewed a series of these injuries and compared clinical and radiographic outcomes of operative and nonoperative treatment. Patients under the age of 18 with Ogden type IV TTFs treated at a single institution between 2013 and 2023 were evaluated. Mechanism of injury, weight percentile, concern for compartment syndrome, time to full weight bearing, time to return to sport/activity, method of treatment, follow-up time, and complications were collected from the electronic medical record (EMR). Posterior tibial slope angle (PTSA), medial proximal tibial angle (MPTA), and anterior fracture gap were measured from the initial injury, postreduction, and final follow-up radiographs. A total of 36 limbs in 33 patients were followed for an average of 182 days, 18 of which were treated nonoperatively and 18 operatively. The mean pretreatment PTSA was 22.4° in the nonoperative and 25.0° in the operative group (P=0.25). The mean final follow-up PTSA was 15.1° in the nonoperative and 14.3° in the operative group (P=0.54). The mean pretreatment MPTA was 84.7° for both groups (P=0.99). The final follow-up mean MPTA was 84.2° in the nonoperative and 85.5° in the operative group (P=0.08). There were no significant differences noted in time to full weight bearing, return to sport/activity, or total follow-up. There were 7 cases with complications, 4 in the nonoperative and 3 in the operative group. The present study suggests that nonoperative and operative treatment for type IV TTFs are equivalent in terms of radiographic and clinical outcomes. Given that joint incongruity is not an issue in these fractures, closed reduction can be attempted unless contraindicated by impending compartment syndrome. Operative management should be performed for failure of closed reduction. Level IV.

CT Utilisation in Emergency Department (ED) Assessment of Patients With Suspected Polytrauma: Impact of a Dedicated Trauma Surgical Team.

We aimed to assess the impact of introduction of a dedicated trauma surgical unit (TSU) on CT utilisation for polytrauma in the Emergency Department (ED). Single centre retrospective cohort study comparing adult patients undergoing CT for polytrauma following TSU introduction (Intervention group, n = 617) to a historical Baseline group (n = 257) over a matched time period. Patient impact, including initial clinical assessment, injuries, radiation exposure, incidental findings, ED disposition, and impact on radiology services were compared with Mann-Whitney and Fisher's exact tests. Intervention patients were more likely to be examined by ED physicians (96.7% vs. 91.1%, p = 0.001) prior to CT. There was greater documented clinical suspicion for chest and abdominal injuries, with increased WBCT utilisation for Intervention (Baseline 17.1% vs. 47.8%, p < 0.05), with no significant increase in positive scans by region. More CT chest (Intervention 38.4% vs. Baseline 14.8%, p < 0.05), CT abdomen (42.6% vs. 12.6%, p < 0.005) and CT pelvis (46.1% vs. 16%, p < 0.001) was performed even with low documented clinical suspicion, with no significant increase in positive findings. The intervention group returned for more additional scans (12.48% vs. Baseline 5.45%), had more incidental findings (23.66% vs. 15.18%), and were more likely to be admitted for observation (21.7% vs. 14%), all p < 0.05. Time to scan and total CT reporting time were significantly longer for Intervention. Introduction of a TSU was associated in a shift towards increased CT utilisation, with no increase in scan yield, increased incidental findings and impacts on Radiology workflow.

The Effect of Residential Distance from Inpatient Setting on Outcomes of Rehabilitation Following Acquired Brain Injury

The Effect of Residential Distance from Inpatient Setting on Outcomes of Rehabilitation Following Acquired Brain Injury

Short-term disruption of TGFβ signaling in adult mice renders the aorta vulnerable to hypertension-induced dissection.

Hypertension and transient increases in blood pressure from extreme exertion are risk factors for aortic dissection in patients with age-related vascular degeneration or inherited connective tissue disorders. Yet, a common experimental model of angiotensin II-induced aortopathy in mice appears independent of high blood pressure as lesions do not occur in response to an alternative vasoconstrictor, norepinephrine, and are not prevented by co-treatment with a vasodilator, hydralazine. We investigated vasoconstrictor administration to adult mice following 1 week of disrupted TGFβ signaling in smooth muscle cells (SMCs). Norepinephrine increased blood pressure and induced aortic dissection by 7 days and even within 30 minutes (as did angiotensin II) that was prevented by hydralazine. Initial medial injury manifested as blood extravasation among SMCs and fibrillar matrix, progressive delamination from accumulation of blood, and stretched or ruptured SMCs with persistent attachments to elastic fibers. Altered regulatory contractile molecule expression was not of pathological importance. Rather, reduced synthesis of extracellular matrix yielded a vulnerable aortic phenotype by decreasing medial collagen, most dynamically basement membrane-associated multiplexin collagen, and impairing cell-matrix adhesion. We conclude that transient and sustained increases in blood pressure can cause dissection in aortas rendered vulnerable by inhibition of TGFβ-driven extracellular matrix production by SMCs.

Cast Wedging in Pediatric Forearm and Tibia Fractures-A Safe Way to Avoid Surgery.

Cast wedging is an established technique used to improve the alignment of pediatric fractures. The purpose of this study was to review the effectiveness of cast wedging to treat malaligned pediatric fractures and report the incidence of complications and failure associated with cast wedging. A retrospective review of a level one pediatric trauma center was performed. Children aged 3 to 18 who underwent cast wedging following a forearm shaft, distal radius, or tibia shaft fracture (January 2005 to January 2021) were reviewed. A total of 294 patients were identified for analysis. Coronal and sagittal angles were measured throughout the course of fracture management. Improved radiologic correction was defined as at least a 50% correction of malalignment in the plane of maximum deformity. Complications associated with cast wedging were recorded, and wedging failure was defined as patients who underwent a secondary procedure. Multivariable logistic regression analysis was used to identify variables affecting outcomes and odds ratios (ORs) with 95% CIs were estimated for final model effects. Cast wedging generated a median 56% correction in angulation, with 74% of the cohort (217/294) achieving at least 50% correction. Twenty-two patients (7%) failed wedging treatment, with half undergoing a repeat closed reduction (12/22, 55%). Eighteen patients (6%) experienced at least 1 complication. Nine patients (3%) sustained a refracture after wedging an average of 8.9 months from the initial injury. Multivariable analysis identified older patients and those who did not achieve 50% radiologic correction after wedging to have increased odds of repeat surgery (OR=1.17; P=0.04 and OR=11.1; P=0.001, respectively). Cast wedging is a safe and effective method to correct malaligned pediatric fractures with a low incidence of complications and refracture. Cast wedging remains an important skill for orthopaedic surgeons managing pediatric fractures. Level IV.

Endocrinological Complications of Traumatic Brain Injury: A Comprehensive Narrative Review

INTRODUCTION Traumatic brain injury (TBI) is a major cause of neuroendocrine dysfunction, primarily affecting the hypothalamic-pituitary axis. Hypopituitarism, particularly involving growth hormone, gonadotropins, ACTH, and TSH deficiencies, is frequently observed in TBI survivors. The underlying pathophysiology includes direct mechanical damage, vascular compromise, and neuroinflammatory processes that impair hormone secretion. Despite its significant impact on metabolism, cognition, and overall recovery, endocrine dysfunction remains underdiagnosed due to its nonspecific presentation and overlap with other post-TBI sequelae. OBJETIVE To comprehensively analyze the prevalence, pathophysiology, clinical manifestations, diagnostic challenges, and management strategies of endocrine dysfunction in patients with traumatic brain injury. METHODS This is a narrative review which included studies in the MEDLINE – PubMed (National Library of Medicine, National Institutes of Health), COCHRANE, EMBASE and Google Scholar databases, using as descriptors: “Traumatic Brain Injury” OR “Endocrine Dysfunction” OR “Hypopituitarism” OR “Neuroinflammation” OR “Hormonal Deficiencies” in the last years. RESULTS AND DISCUSSION Neuroimaging studies have revealed structural pituitary abnormalities in some patients, although functional impairments may occur even in the absence of detectable changes. Laboratory testing remains essential for diagnosis, with dynamic hormone stimulation tests playing a crucial role in detecting deficiencies. Growth hormone deficiency is one of the most common post-TBI endocrinopathies, contributing to metabolic disturbances, muscle wasting, and reduced quality of life. Hypogonadism, adrenal insufficiency, and thyroid dysfunction further complicate the clinical course, necessitating early detection and appropriate management. Emerging research suggests that neuroinflammatory mechanisms, genetic predispositions, and autoimmunity may play roles in the pathogenesis of post-TBI endocrine dysfunction. CONCLUSION Long-term follow-up and endocrine screening are essential for optimizing patient outcomes, as some deficiencies manifest years after the initial injury. Hormonal replacement therapy has shown benefits in restoring metabolic balance and improving neurocognitive function. Future research should focus on refining diagnostic protocols, identifying predictive biomarkers, and developing targeted neuroprotective strategies. A multidisciplinary approach, integrating neurology, endocrinology, and rehabilitation medicine, is critical for improving the long-term prognosis of TBI survivors with endocrine dysfunction.

The Metabolic Profile of Plasma During Epileptogenesis in a Rat Model of Lithium-Pilocarpine-Induced Temporal Lobe Epilepsy.

Temporal lobe epilepsy (TLE) arises mostly because of an initial injury. Certain stimuli can make a normal brain prone to repeated, spontaneous seizures via a process called epileptogenesis. This study examined the plasma metabolomics profile in rats with the induced TLE to identify feasible biomarkers that can distinguish progression of epileptogenesis in three different time points and reveal the underlying mechanisms of epileptogenesis. Status epilepticus (SE) was induced by repetitive intraperitoneal injections of low-dose lithium chloride-pilocarpine hydrocholoride. Blood samples were collected 48h, 1week, and 6weeks after SE, respectively. Plasma metabolites were analyzed by nuclear magnetic resonance (NMR) spectrometry. Statistical analysis was performed using MetaboAnalyst 6.0. An orthogonal partial least squares discriminant analysis (OPLS-DA) model was employed to represent variations between the TLE model groups and respective controls. Volcano plot analysis was used to identify key features, applying a fold-change criterion of 1.5 and a t-test threshold of 0.05. 48h after SE, dimethyl sulfone (DMSO2) and creatinine levels were decreased, whereas glycine and creatine levels were increased. The only metabolite that changed 1week after SE was pyruvic acid, which was increased compared to its control level. Lactic acid, pyruvic acid, and succinic acid levels were increased 6weeks after SE. The identified metabolites were especially related to the tricarboxylic acid cycle and glycine, serine, and threonine metabolism. The results illustrate that distinct plasma metabolites can function as phase-specific biomarkers in TLE and reveal new insights into the mechanisms underlying SE.

Chronic Kidney Disease Following Cardiac Arrest Manifesting as Dyspnoea and Peripheral Oedema in Cardiovascular Multimorbidity: Case Analysis and Brief Literature Review.

Chronic kidney disease (CKD) contributes significantly to morbidity, mortality, and healthcare costs. CKD is not only an independent risk factor for cardiovascular disease (CVD) but also a severe complication for patients with CVD, impacting substantially their prognosis and quality of life. A 79-year-old male with a complex medical history, including asthma, hypertension, myocardial infarction, ischaemic heart disease, and recent atrial fibrillation, presented with new-onset exertional breathlessness and peripheral oedema following cardiac arrest and pacemaker insertion. Investigations, including medication reviews conducted shortly after in an outpatient setting, revealed severe renal impairment with creatinine levels at 250 μmol/l (reference range for adult males: 59-104), representing an initial acute kidney injury (AKI) that did not resolve and resulted in the diagnosis of stage 4 CKD (eGFR 25 ml/min/1.73 m2). The patient was treated with furosemide, dapagliflozin, and adjusted doses of ramipril and edoxaban. Following treatment, the patient's symptoms ameliorated and renal function slightly improved (eGFR 27 ml/min/1.73 m2). This case highlights the importance of individualised treatment for patients with CKD alongside complex cardiovascular multi-morbidity. The administration of dapagliflozin and furosemide, together with careful adjustments to ramipril, were instrumental in stabilising the patient's renal function and alleviating symptoms. This case demonstrates how a multifaceted approach, continuous monitoring, and patient education are essential for achieving optimal outcomes in patients with CKD and cardiovascular comorbidities.

Incidence and Risk Factors for Posttraumatic Osteoarthritis After Primary ACL Reconstruction in Pediatric Patients: A National Database Study.

The development of posttraumatic osteoarthritis (PTOA) of the knee after anterior cruciate ligament (ACL) reconstruction (ACLR) leads to additional morbidity in adults. To determine the 5-year incidence of and risk factors for PTOA diagnoses after primary ACLR in pediatric patients. Case control study, Level of evidence, 3. A United States-based insurance database was used to identify patients aged ≤16 years who underwent primary ACLR from 2010 to 2019 and had at least 5 years of follow-up data. Patients with multiligament knee injuries, tibial eminence avulsion fractures, congenital/syndromic ACL absence syndrome, juvenile idiopathic arthritis, previous knee osteoarthritis or PTOA diagnoses, or previous knee injuries/surgeries were excluded. Demographic factors and concomitant meniscal and cartilage procedures at the time of primary ACLR were recorded. Delayed ACLR was defined as ≥3 months between initial ACL injury diagnosis and ACLR. We also recorded the presence of subsequent motion restoration reoperations, including lysis of adhesions and/or manipulation under anesthesia, after primary ACLR but before PTOA diagnosis. Risk factors for PTOA were evaluated using multivariable logistic regression. Included were 16,935 patients (mean age at surgery, 15.1 ± 1.2 years; 62% women). PTOA was diagnosed in 267 patients (1.6%) within 5 years after ACLR; 148 of these patients (55.4%) were diagnosed within 2 years after ACLR. Independent risk factors associated with PTOA diagnosis included subsequent motion restoration procedures (odds ratio [OR], 5.03 [95% CI, 3.31-8.25]; P < .001), age ≥12 years at the time of ACLR (OR, 4.82 [95% CI, 1.54-29.20]; P = .027), delayed ACLR (OR, 1.87 [95% CI, 1.43-2.43]; P < .001), obesity (OR, 1.40 [95% CI, 1.01-1.94]; P = .046), and male sex (OR, 1.36 [95% CI, 1.06-1.74]; P = .015). Performing concomitant partial meniscectomy, meniscus repair, and cartilage restoration at the time of ACLR was not significantly associated with PTOA. The incidence of PTOA diagnoses was low within 5 years after primary ACLR in patients ≤16 years old with no subsequent cartilage, meniscus, and/or revision ligament procedures. The need for subsequent motion restoration procedures, age ≥12 years at the time of ACLR, delayed ACLR, obesity, and male sex were significant risk factors associated with a PTOA diagnosis.

Prehospital Trauma Compendium: Prehospital Administration of Antibiotics in Trauma Patients – an NAEMSP Resource Document

Prehospital Trauma Compendium: Prehospital Administration of Antibiotics in Trauma Patients – an NAEMSP Resource Document

More than just a broken limb: Unmasking CRPS in Pakistan.

Madam, Complex Regional Pain Syndrome (CRPS) is a debilitating pain disorder, usually affecting one limb, and occurring after a trauma. It is marked by intense pain out of proportion to the severity of the initial injury. Because CRPS is a rare condition, its pathophysiology, diagnosis, and treatment are not completely understood. The pathophysiology might involve an interplay between inflammation, genetics, nervous system changes, and psychological influences1. Despite the challenges in diagnosis, the currently accepted diagnostic criteria is the Budapest Criteria, established after revising the previous IASP Criteria which led to overdiagnosis.2 Once CRPS is identified, therapy can be just as complicated. The UK Royal College of Physicians outlines a multidisciplinary approach based on each patient’s individual needs.3 This involves patient education, utilizing intervention and medications for the pain, physical rehabilitation, and psychological intervention. Each of these elements is equally important for recovery. Older studies indicate a significant delay in CRPS diagnosis, with patients waiting an average of 4 years.4 The lack of knowledge among physicians, unnecessary surgeries, and the belief that patients might be exaggerating about their pain, all contribute to a delayed diagnosis. This leads to a further decline in limb function, muscle wasting, difficulty in performing everyday activities, and eventually, social isolation. To improve the understanding of CRPS in low-resource settings with limited patient data, Lewis et al. presented a global series from 9 different countries, including Pakistan.5 Despite being the world’s 5th most populous country, Pakistan lacks sufficient CRPS prevalence and presentation data. Out of the identified patients, only 16% were diagnosed according to the globally recognized Budapest criteria, and for 65% of patients, only pharmacological intervention was used. The essential multidisciplinary approach was rarely used. This highlights several issues that need to be resolved. This letter calls for localized research to help refine management protocols tailored to the Pakistani population. By raising awareness about the clinical features of CRPS and the consequences of neglect towards patients, we can promote timely diagnoses and avoid long-term complications. Physicians need to build trust with their patients and make them feel heard. CRPS is a complicated condition, so a culture of strict adherence to standardized diagnostic and management approaches must be created. Integration of said protocols into the healthcare curriculum is also essential. This comprehensive approach requires immediate implementation to improve quality of life and reduce unnecessary suffering.

Sex Differences in Neurological Outcome at 6 and 12 Months Following Severe Traumatic Brain Injury. An Observational Analysis of the OXY-TC Trial.

The effect of sex in outcomes after severe traumatic brain injury (TBI) remains uncertain. We explored whether outcomes differed between women and men after standardized care management during the first 5 days in the intensive care unit (ICU). This study was an observational analysis of the OXY-TC multicenter randomized clinical trial between June 15, 2016 and April 17, 2021. Recruited patients had a pre-hospital Glasgow Coma Scale (GCS) score of 3-8, mechanical ventilation, and intracranial pressure (ICP) with or without brain tissue oxygen pressure (PbtO2) monitoring. Objectives were to maintain ICP at 20 mmHg or below and PbtO2 above 20 mmHg at all times. The primary end-point was the proportion of women and men with poor outcomes at 6 months, corresponding to an extended Glasgow Outcome Scale (GOSE) score of 1-4 (death to upper severe disability). Of 318 randomized patients, 200 men and 71 women were analyzed. They were comparable in age, comorbidities, and initial injury severity scores. However, women had larger doses of ICP as the proportion of monitoring time of ICP above 20 mmHg 8% (3-18; median, interquartile range) versus 3% (1-10), respectively (p = 0.002). They required more often at least one tier-3 treatment, i.e., barbiturate coma and therapeutic hypothermia, for refractory intracranial hypertension during the first 5 days in the ICU: 33/68 (48%) versus 60/193 (31%), respectively (p = 0.012). At 6 months, the proportion of women with GOSE 1-4 was significantly higher than men: 48/71 (68%) versus 94/200 (47%), respectively (odds ratio 2.35 [1.33-4.16]; p = 0.003]. Similar differences were found using Disability Rating Scale and Functional Independence Measure at 6 and 12 months, and GOSE at 12 months. Sex differences in neurological outcomes persisted after adjustment for other determinants of outcome such as age, initial GCS score, and dose of ICP during the 5-day monitoring. In conclusion, women sustained more severe ICP and required more active treatment, both of which would explain a worse outcome after severe TBI. Prospective research is required to confirm these findings and identify possible mechanisms. Trial registration: ClinicalTrials.gov Identifier NCT02754063 (April 28, 2016).

Tolerance of Cotton to Herbicide-Coated Fertilizers

Abstract Cotton producers need residual herbicides that can safely and practically be applied postemergence (POST). Herbicide-coated fertilizers could allow for simultaneous application of residual herbicides and a bulk fertilizer blend. Therefore, a study was conducted in 2022 and 2023 in Fayetteville, AR, to evaluate cotton tolerance to 12 herbicide treatments coated onto a fertilizer blend and applied over cotton. Herbicides and rates evaluated included: diuron at 840 g ai ha-1, florpyrauxifen-benzyl at 29 g ai ha-1, flumioxazin at 105 g ai ha-1, flumioxazin plus pyroxasulfone at 70 + 90 g ai ha-1, fluridone at 168 g ai ha-1, fluometuron at 840 g ai ha-1, fomesafen at 280 g ai ha-1, pyroxasulfone at 128 g ai ha-1, saflufenacil at 66 g ai ha-1, saflufenacil plus dimethenamid-P at 25 + 219 g ai ha-1, saflufenacil plus pyroxasulfone at 44 + 91 g ai ha-1, and S-metolachlor at 1388 g ai ha-1. In both years, fluridone, fluometuron, diuron, and S-metolachlor caused less than 10% injury at 7 d after treatment (DAT). Higher injury levels were observed in 2022 (19 to 30%) compared to 2023 (4 to 12%) for flumioxazin, fomesafen, saflufenacil, saflufenacil plus dimethenamid-P, and saflufenacil plus pyroxasulfone. The elevated injury in one of two years was attributed to the presence of dew when the herbicide-coated fertilizer was applied. The initial injury was transient, as the cotton generally had recovered by 28 DAT for all herbicides. No differences in seed cotton yield or groundcover among the herbicide treatments occurred either year. These results highlight the potential of using several POST-applied, residual herbicides coated on fertilizer that are not currently registered for over-the-top use in cotton.

Return to sports after pediatric traumatic brain injury: An expert panel survey.

Return to sports after pediatric traumatic brain injury: An expert panel survey.

Erroneous Classification and Coding as a Limitation for Big Data Analyses: Causes and Impacts Illustrated by the Diagnosis of Clavicle Injuries.

Background/Objectives: Clavicle injuries are common and seem to be frequently subject to diagnostic misclassification. The accurate identification of clavicle fractures is essential, particularly for registry and Big Data analyses. This study aims to assess the frequency of diagnostic errors in clavicle injury classifications. Methods: This retrospective study analyzed patient data from two Level 1 trauma centers, covering the period from 2008 to 2019. Included were cases with ICD-coded diagnoses of medial, midshaft, and lateral clavicle fractures, as well as sternoclavicular and acromioclavicular joint dislocations. Radiological images were re-evaluated, and discharge summaries, radiological reports, and billing codes were examined for diagnostic accuracy. Results: A total of 1503 patients were included, accounting for 1855 initial injury diagnoses. In contrast, 1846 were detected upon review. Initially, 14.4% of cases were coded as medial clavicle fractures, whereas only 5.2% were confirmed. The misclassification rate was 82.8% for initial medial fractures (p < 0.001), 42.5% for midshaft fractures (p < 0.001), and 34.2% for lateral fractures (p < 0.001). Billing codes and discharge summaries were the most error-prone categories, with error rates of 64% and 36% of all misclassified cases, respectively. Over three-quarters of the cases with discharge summary errors also exhibited errors in other categories, while billing errors co-occurred with other category errors in just over half of the cases (p < 0.001). The likelihood of radiological diagnostic error increased with the number of imaging modalities used, from 19.7% with a single modality to 30.5% with two and 40.7% with three. Conclusions: Our findings indicate that diagnostic misclassification of clavicle fractures is common, particularly between medial and midshaft fractures, often resulting from errors in multiple categories. Further prospective studies are needed, as accurate classification is foundational for the reliable application of Big Data and AI-based analyses in clinical research.

Shifting trends in outpatient hand trauma care: a 16-year analysis at a major center in northern Germany

BackgroundHand injuries are a leading cause of emergency department visits. Recent trends in hand trauma management reflect a shift toward outpatient care, driven by factors such as a shortage of skilled personnel or increasing cost pressures. This study analyzed these trends to propose updated management strategies for hand injuries.Materials and methodsThis retrospective cohort study included 14,414 patients treated at a certified major hand surgical trauma center between 2007 and 2022. Patients were divided into two groups: the earlier cohort (EC, 2007–2014) and the current cohort (CC, 2015–2022). Trends in inpatient and outpatient care, as well as hospitalization durations, were analyzed.ResultsDuring the study period, approximately one-third of all patients required inpatient treatment, with one-third of hospitalized patients staying at least one week, one-fifth staying two weeks, and one-tenth staying three or more weeks. Inpatient treatment rates decreased annually by 7%, while outpatient care increased by 5.3% annually. A significant shift toward outpatient management was noted for various injuries, including fractures, burns, lacerations, dislocations, complex injuries, and infections. Despite declining hospitalization rates, patients in the CC group had significantly longer hospital stays, reflecting the increasing complexity and severity of cases requiring admission (p < 0.001).ConclusionsThis study reveals a growing trend toward outpatient care for hand injuries, reflecting improved efficiency without compromising quality. Although fewer patients are hospitalized, those admitted require more intensive care, highlighting a shift toward ambulatory management for moderately severe cases. These findings emphasize the importance of initial injury management and underscore the need for expanding outpatient hand surgical care to meet growing demand in a rapidly changing healthcare landscape.Level of evidenceIII.