Severity Of Initial Injury Research Articles

Acute Phase Proteins in Cerebrospinal Fluid from Dogs with Naturally-Occurring Spinal Cord Injury.

Spinal cord injury (SCI) affects thousands of people each year and there are no treatments that dramatically improve clinical outcome. Canine intervertebral disc herniation is a naturally-occurring SCI that has similarities to human injury and can be used as a translational model for evaluating therapeutic interventions. Here, we characterized cerebrospinal fluid (CSF) acute phase proteins (APPs) that have altered expression across a spectrum of neurological disorders, using this canine model system. The concentrations of C-reactive protein (CRP), haptoglobin (Hp), alpha-1-glycoprotein, and serum amyloid A were determined in the CSF of 42 acutely injured dogs, compared with 21 healthy control dogs. Concentrations of APPs also were examined with respect to initial injury severity and motor outcome 42 d post-injury. Hp concentration was significantly higher (p<0.0001) in the CSF of affected dogs, compared with healthy control dogs. Additionally, the concentrations of CRP and Hp were significantly (p=0.0001 and p=0.0079, respectively) and positively associated with CSF total protein concentration. The concentrations of CRP and Hp were significantly higher (p=0.0071 and p=0.0197, respectively) in dogs with severe injury, compared with those with mild-to-moderate SCI, but there was no significant correlation between assessed CSF APP concentrations and 42 d motor outcome. This study demonstrated that CSF APPs were dysregulated in dogs with naturally-occurring SCI and could be used as markers for SCI severity. As Hp was increased following severe SCI and is neuroprotective across a number of model systems, it may represent a viable therapeutic target.

Cerebrospinal Fluid Markers of Macrophage and Lymphocyte Activation After Traumatic Brain Injury in Children.

The magnitude and role of the cellular immune response following pediatric traumatic brain injury remains unknown. We tested the hypothesis that macrophage/microglia and T-cell activation occurs following pediatric traumatic brain injury by measuring cerebrospinal fluid levels of soluble cluster of differentiation 163 and ferritin and soluble interleukin-2 receptor α, respectively, and determined whether these biomarkers were associated with relevant clinical variables and outcome. Retrospective analysis of samples from an established, single-center cerebrospinal fluid bank. PICU in a tertiary children's hospital. Sixty-six pediatric patients after severe traumatic brain injury (Glasgow Coma Scale score < 8) who were 1 month to 16 years old and 17 control patients who were 1 month to 14 years old. None. Cerebrospinal fluid levels of soluble cluster of differentiation 163, ferritin, and soluble interleukin-2 receptor α were determined by enzyme-linked immunosorbent assay at two time points (t1 = 17 ± 10 hr; t2 = 72 ± 15 hr) for each traumatic brain injury patient. Cerebrospinal fluid levels of soluble cluster of differentiation 163, ferritin, and soluble interleukin-2 receptor α after traumatic brain injury were compared with controls and analyzed for associations with age, patient sex, initial Glasgow Coma Scale score, diagnosis of abusive head trauma, the presence of hemorrhage on CT scan, and Glasgow Outcome Scale score. Cerebrospinal fluid level of soluble cluster of differentiation 163 was increased in traumatic brain injury patients at t2 versus t1 and controls (median, 95.4 ng/mL [interquartile range, 21.8-134.0 ng/mL] vs 31.0 ng/mL [5.7-77.7 ng/mL] and 27.8 ng/mL [19.1-43.1 ng/mL], respectively; p < 0.05). Cerebrospinal fluid level of ferritin was increased in traumatic brain injury patients at t2 and t1 versus controls (8.3 ng/mL [<7.5-19.8 ng/mL] and 8.9 ng/mL [<7.5-26.7 ng/mL] vs <7.5 ng/mL below lower limit of detection, respectively; p < 0.05). Cerebrospinal fluid levels of soluble interleukin-2 receptor α in traumatic brain injury patients at t2 and t1 were not different versus controls. Multivariate regression revealed associations between high ferritin and age 4 years or younger, lower Glasgow Coma Scale score, abusive head trauma, and unfavorable Glasgow Outcome Scale score. Children with traumatic brain injury demonstrate evidence for macrophage activation after traumatic brain injury, and in terms of cerebrospinal fluid ferritin, this appears more prominent with young age, initial injury severity, abusive head trauma, and unfavorable outcome. Further study is needed to determine whether biomarkers of macrophage activation may be used to discriminate between aberrant and adaptive immune responses and whether inflammation represents a therapeutic target after traumatic brain injury.

Factors Associated with Word Memory Test Performance in Persons with Medically Documented Traumatic Brain Injury

Objectives: (1) To examine the rate of poor performance validity in a large, multicenter, prospectively accrued cohort of community dwelling persons with medically documented traumatic brain injury (TBI), (2) to identify factors associated with Word Memory Test (WMT) performance in persons with TBI. Method: This was a prospective cohort, observational study of 491 persons with medically documented TBI. Participants were administered a battery of cognitive tests, questionnaires on emotional distress and post-concussive symptoms, and a performance validity test (WMT). Additional data were collected by interview and review of medical records. Results: One hundred and seventeen participants showed poor performance validity using the standard cutoff. Variable cluster analysis was conducted as a data reduction strategy. Findings revealed that the 10 cognitive tests and questionnaires could be summarized as 4 indices of emotional distress, speed of cognitive processing, verbal memory, and verbal fluency. Regression models revealed that verbal memory, emotional distress, age, and injury severity (time to follow commands) made unique contribution to prediction of poor performance validity. Conclusions: Poor performance validity was common in a research sample of persons with medically documented TBI who were not evaluated in conjunction with litigation, compensation claims, or current report of symptoms. Poor performance validity was associated with poor performance on cognitive tests, greater emotional distress, lower injury severity, and greater age. Many participants expected to have residual deficits based on initial injury severity showed poor performance validity.

The matricellular protein CCN1 promotes mucosal healing in murine colitis through IL-6.

The matricellular protein CCN1 (CYR61) is known to function in wound healing and is upregulated in colons of patients with Crohn’s disease and ulcerative colitis, yet its specific role in colitis is unknown. Here we have used Ccn1dm/dm knockin mice expressing a CCN1 mutant unable to bind integrins α6β1 and αMβ2 as a model to probe CCN1 function in dextran sodium sulfate (DSS)-induced colitis. Ccn1dm/dm mice exhibited high mortality, impaired mucosal healing, and diminished IL-6 expression during the repair phase of DSS-induced colitis compared to wild type mice, despite having comparable severity of initial inflammation and tissue injury. CCN1 induced IL-6 expression in macrophages through integrin αMβ2 and in fibroblasts through α6β1, and IL-6 promoted intestinal epithelial cell (IEC) proliferation. Administration of purified CCN1 protein fully rescued Ccn1dm/dm mice from DSS-induced mortality, restored IEC proliferation and enhanced mucosal healing, whereas delivery of IL-6 partially rectified these defects. CCN1 therapy accelerated mucosal healing and recovery from DSS-induced colitis even in wild type mice. These findings reveal a critical role for CCN1 in restoring mucosal homeostasis after intestinal injury in part through integrin-mediated induction of IL-6 expression, and suggest a therapeutic potential for activating the CCN1/IL-6 axis for treating inflammatory bowel disease.

Prognostic Factors of Survival From Intractable Oronasal Bleeding After Successful Transarterial Embolization

To evaluate the prognostic factors that influence the survival of patients with traumatic intractable oronasal bleeding treated by transarterial embolization (TAE). Patients who received TAE for intractable oronasal bleeding in the National Taiwan University Hospital from 2002 through 2013 were included in the study. Retrospective reviews were undertaken to collect relevant clinical and neuroradiologic data that might be correlated with patients' survival. The Wilcoxon rank-sum test or Fisher exact test was adopted to analyze differences between the survival group and the mortality group. Odds ratios were estimated by univariate logistic regression. TAE successfully controlled the bleeding in 24 of 26 patients (92.3%) who had severe craniofacial injury in the 12-year period. Of the 24 patients with successful TAE, 13 patients were discharged alive from the hospital. The overall survival rate was 50% (13 of 26). Significantly higher initial Glasgow Coma Scale (GCS) score (P= .01) and lower Injury Severity Score (ISS; P < .01) were present in the survival group than in the mortality group by the Wilcoxon rank-sum test. Moreover, patients with an ISS of at least 30, a GCS score lower than 9, initial hemoglobin level lower than 10 g/dL, and computed tomographic (CT) findings of a brain midline shift had statistically higher odds ratios predicting mortality than their counterparts as estimated by univariate logistic regression. The results of this study showed that the combination of diagnostic angiography and therapeutic embolization is effective treatment for intractable oronasal bleeding in patients with severe craniofacial injury. The prognosis in patients who were rescued with successful TAE was statistically correlated with the severity of trauma and concomitant brain injury. An ISS of at least 30, a GCS score lower than 9, an initial hemoglobin level lower than 10, and CT findings of a brain midline shift were strong predictors for mortality.

Association between early airway damage-associated molecular patterns and subsequent bacterial infection in patients with inhalational and burn injury.

Bacterial infection is a major cause of morbidity affecting outcome following burn and inhalation injury. While experimental burn and inhalation injury animal models have suggested that mediators of cell damage and inflammation increase the risk of infection, few studies have been done on humans. This is a prospective, observational study of patients admitted to the North Carolina Jaycee Burn Center at the University of North Carolina who were intubated and on mechanical ventilation for treatment of burn and inhalational injury. Subjects were enrolled over a 2-yr period and followed till discharge or death. Serial bronchial washings from clinically indicated bronchoscopies were collected and analyzed for markers of tissue injury and inflammation. These include damage-associated molecular patterns (DAMPs) such as hyaluronic acid (HA), double-stranded DNA (dsDNA), heat-shock protein 70 (HSP-70), and high-mobility group protein B-1 (HMGB-1). The study population was comprised of 72 patients who had bacterial cultures obtained for clinical indications. Elevated HA, dsDNA, and IL-10 levels in bronchial washings obtained early (the first 72 h after injury) were significantly associated with positive bacterial respiratory cultures obtained during the first 14 days postinjury. Independent of initial inhalation injury severity and extent of surface burn, elevated levels of HA dsDNA and IL-10 in the central airways obtained early after injury are associated with subsequent positive bacterial respiratory cultures in patients intubated after acute burn/inhalation injury.

The effect of vertebral fracture on the early neurologic recovery in patients with central cord syndrome.

To compare early changes in the ASIA Motor Score (AMS) between patients with central cord syndrome (CCS) from an acute fracture to patients without a fracture. Patients with CCS were identified and stratified based on the presence of a fracture. The AMS through the first week of the patients' hospitalization was obtained. Initial injury severity as well as early neurologic recovery was measured using the AMS. Analysis of variance was performed to determine if age, gender, rectal tone at presentation, congenital stenosis, or surgery within 24h significantly effected the change in AMS. A strong trend (p=0.0504) towards a more severe initial neurologic injury in patients with a fracture (AMS 59.7) than in patients without a fracture (AMS 70.2) was identified. However, in the week after injury, patients with a fracture had an improvement in their neurologic function (ΔAMS +4.8) while patients without a fracture demonstrated neurologic decline (ΔAMS -5.9). The change in AMS between patients with and without a fracture was nearly significant (p=0.06). Patients with central cord syndrome present with similar symptoms, but injuries with and without a fracture may be associated with a different early neurologic recovery. Patients with a fracture have a more severe injury at initial presentation, but tend to have neurologic improvement in the first week; conversely patients without a fracture have a less severe initial neurologic injury, but tend to have a slight decline in neurologic function over the first week.

Preinjury warfarin, but not antiplatelet medications, increases mortality in elderly traumatic brain injury patients.

Previous studies of traumatic brain injury (TBI) outcomes in elderly patients on oral antithrombotic (OAT) therapies have yielded conflicting results. Our objective was to examine the effect of premorbid OAT medications on outcomes among elderly TBI patients with intracranial hemorrhage. We performed a retrospective analysis of elderly TBI patients (≥65 years) with closed head injury and evidence of brain hemorrhage on computed tomography scan from 2006 to 2010. Patient demographics, injury severity, clinical course, hospital and intensive care unit length of stay, and disposition were collected. Comparison of patients stratified by premorbid OAT use was performed using nonparametric Kruskal-Wallis and Fisher's exact tests. Multivariable logistic regression was used to compare groups and identify predictors of primary outcomes, including mortality, neurosurgical intervention, hemorrhage progression, complications, and infection. A total of 1,552 patients were identified: 543 on aspirin only, 97 on clopidogrel only, 218 on warfarin only, 193 on clopidogrel and aspirin, and 501 on no antithrombotic agent. Blood products were administered to reverse coagulopathy in 77.3% of patients on antithrombotic medications. After adjusting for covariates, including medication reversal, OAT use was associated with increased mortality (p = 0.04). Warfarin use was identified as a key predictor (odds ratio, 2.27; p = 0.05), in contrast to the preinjury use of antiplatelet medications, which was not associated with increased risk of in-hospital death. Rates of neurosurgical intervention differed between groups, with patients on warfarin undergoing intervention more frequently. Survivor subset analysis demonstrated that hemorrhage progression was not associated with preinjury antithrombotic therapy, nor were rates of complication or infection, hospital and intensive care unit lengths of stay, or ventilator days. Preinjury use of warfarin, but not antiplatelet medications, influences survival and need for neurosurgical intervention in elderly TBI patients with intracranial hemorrhage; hemorrhage progression and morbidity are not affected. The importance of antithrombotic therapy may lie in its impact on initial injury severity. Epidemiologic study, level III.

Hospital-acquired pneumonia is an independent predictor of poor global outcome in severe traumatic brain injury up to 5 years after discharge.

Long-term outcomes following traumatic brain injury (TBI) correlate with initial head injury severity and other acute factors. Hospital-acquired pneumonia (HAP) is a common complication in TBI. Limited information exists regarding the significance of infectious complications on long-term outcomes after TBI. We sought to characterize risks associated with HAP on outcomes 5 years after TBI. This study involved data from the merger of an institutional trauma registry and the Traumatic Brain Injury Model Systems outcome data. Individuals with severe head injuries (Abbreviated Injury Scale [AIS] score ≥ 4) who survived to rehabilitation were analyzed. Primary outcome was Glasgow Outcome Scale-Extended (GOSE) at 1, 2, and 5 years. GOSE was dichotomized into low (GOSE score < 6) and high (GOSE score ≥ 6). Logistic regression was used to determine adjusted odds of low GOSE score associated with HAP after controlling for age, sex, head and overall injury severity, cranial surgery, Glasgow Coma Scale (GCS) score, ventilation days, and other important confounders. A general estimating equation model was used to analyze all outcome observations simultaneously while controlling for within-patient correlation. A total of 141 individuals met inclusion criteria, with a 30% incidence of HAP. Individuals with and without HAP had similar demographic profiles, presenting vitals, head injury severity, and prevalence of cranial surgery. Individuals with HAP had lower presenting GCS score. Logistic regression demonstrated that HAP was independently associated with low GOSE scores at follow-up (1 year: odds ratio [OR], 6.39; 95% confidence interval [CI], 1.76-23.14; p = 0.005) (2 years: OR, 7.30; 95% CI, 1.87-27.89; p = 0.004) (5-years: OR, 6.89; 95% CI, 1.42-33.39; p = 0.017). Stratifying by GCS score of 8 or lower and early intubation, HAP remained a significant independent predictor of low GOSE score in all strata. In the general estimating equation model, HAP continued to be an independent predictor of low GOSE score (OR, 4.59; 95% CI, 1.82-11.60; p = 0.001). HAP is independently associated with poor outcomes in severe TBI extending 5 years after injury. This suggests that precautions should be taken to reduce the risk of HAP in individuals with severe TBI. Prognostic study, level III.

Evaluation of occupational traumatic injuries in rural sectors of turkey

AIM: Traumatic injuries related to agricultural production can lead to serious disability and even mortality. Inappropriate use of farm machinery increases the risk for accidents. The objective of this study was to describe the characteristics of pat-patmachine- related work injuries cases treated at the emergency department and to assess injury severity and hospital admissions in the West Black Sea Region of Turkey. METHODS: All cases related to injuries caused by work with a pat between June 2003 and June 2010 were included. Information was collected concerning the demographic features of patients, and injury sites, injury types, initial injury severity scores at admission, and clinical features were evaluated. RESULTS: Thirty-nine (73.6%) of the cases were male and 14 (26.4%) were female. The ages of the cases were 5-76 years with a mean age of 38.8 ± 18.3 years. Approximately 19% of the cases were considered slight injuries, 30.2% moderate, and 50.9% severe. In terms of age, a plurality of injuries 24 (45.3 %) occurred among those aged 19-45. The Glasgow Outcome Scale score for 37 patients was five; it was four for 14 patients, and it was three for two patients. CONCLUSIONS: Our findings suggest that the pat-pat is one of the most dangerous agricultural machines, particularly for adults. In rural areas of Turkey, agricultural machines cause serious injuries that require hospitalization. KEYWORDS: Agricultural machine, Injury, Pat-pat machine Language: en

Ecological validity of the Dysexecutive Questionnaire: Results from the PariS-TBI study

The Dysexecutive Questionnaire (DEX; Wilson, Pettigrew, & Teasdale, 1998) has been designed to assess executive dysfunctions in daily life. However, its relationships with cognitive testing, mood, and the ability to fulfil daily life demands, have not yet been systematically addressed. The objective of this study was to address these issues in a prospective four-year follow-up study of patients with severe traumatic brain injury (TBI) (PariS-TBI study). One hundred and forty seven patients were included. The DEX (self-version) showed a good internal consistency. The total DEX score was significantly inversely correlated with years of education, but did not significantly correlate with any initial injury severity measure. The DEX was significantly and positively related to cognitive deficits, as assessed with the Neurobehavioral Rating Scale–Revised (NRS-R); with mood disorders, as assessed with the Hospital Anxiety and Depression Scale (HADS); with dependency in elementary and extended activities of daily living; and with non-return to work. In multivariate analyses, cognitive and mood impairments were significantly and independently related to the total DEX score. These results suggest that the DEX is a multidetermined sensitive questionnaire to detect everyday life difficulties in patients with severe TBI at a chronic stage.

Tenascin-C is a possible mediator between initial brain injury and vasospasm-related and -unrelated delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

Tenascin-C (TNC), a matricellular protein, exerts diverse functions, including tissue remodeling and apoptosis, and is induced in cerebrospinal fluid (CSF) after aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study was to examine the relationships among CSF TNC levels, initial brain injury, delayed cerebral ischemia (DCI), and vasospasm after SAH. CSF TNC levels were measured in 30 patients with aneurysmal SAH of Fisher computed tomography (CT) group III who were treated microsurgically or endovascularly with CSF drainage within 24 h of SAH. Admission World Federation of Neurosurgical Societies (WFNS) grade was supposed to indicate the severity of initial brain injury. Cerebral vasospasm was defined as narrowed (≥ 25 %) cerebral arteries demonstrated by angiography. DCI was defined as any neurological deterioration presumed related to ischemia that persisted for ≥ 1 h. Higher CSF TNC levels were correlated with worse admission WFNS grades. Vasospasm was aggravated with higher TNC levels. DCI occurred regardless of the degree of vasospasm but was associated with TNC induction. Multivariate analyses showed that higher TNC levels and vasospasm were independent predictors of DCI occurrence. SAH (initial brain injury) that is more severe induces more TNC, which may cause the subsequent development of both vasospasm and vasospasm-unrelated secondary brain injury, leading to DCI.

163 Brain Tissue Oxygenation and 3- and 6-month Neurological Outcome in Severe Traumatic Brain Injury

INTRODUCTION: Brain tissue oxygenation (PbtO2) monitoring has been utilized in the severe traumatic brain injury (sTBI) population as an in vivo tool to detect oxygenation changes in the acute injury phase. It has been previously reported that the longer a patient experiences a PbtO2 of = 15 torr, the greater the likelihood of death. The purpose of this study is to assess PbtO2 values and its relationship to 3- and 6-month outcome in adult sTBI. METHODS: Under an approved Internal Review Board protocol, PbtO2 data were prospectively collected on sTBI patients (Glasgow Coma Scale [GCS] score <9) during the acute 5 days following injury. Intensive care unit management included intracranial pressure (ICP) management per Guidelines of sTBI Management; however, PbtO2 was not treated, just monitored. Glasgow Outcome Scale (GOS) score, a measurement of neurologic outcome, was assessed at 3- and 6-months from injury and dichotomized into poor (GOS 1-3) and favorable outcome (GOS 4-5). Statistical analyses were performed using a logistic regression model controlling for age and initial severity of injury. RESULTS: Two hundred fifty-eight adult, sTBI patients with 3- and 6-month outcome were included. The mean age was 38 ± 17 years, with 69% male and a median GCS of 6. Post-trauma day (PTD) 2 PbtO2 data was chosen for analysis to avoid insertional microtrauma and minimize variability of values seen within the first 24 hours of monitoring. Logistic regression resulted in cut-off values of minimum PbtO2 <16.03 and maximum PbtO2 >37.15 being significant for poor 3-month neurological outcome (odds ratio, [OR] 2.46; 95% confidence interval [CI], 1.29-4.68; P = .004; and OR, 2.71; 95% CI, 1.37-5.33; P = .006, respectively). There was no residual significance for 6-month neurological outcome at these same cutoffs; however, PTD2 PbtO2 values in combination for minimum <18.3 and maximum >37.2 were significant predictors of poor outcome (OR, 2.02; 95% CI, 1.11-3.67; P = .02). CONCLUSION: Monitoring of PbtO2 in the adult sTBI population may be predictive of 3-month neurological outcome and provide a target cohort for early rehabilitation efforts. Additional studies are needed to assess the effectiveness of treating PbtO2 values.

Minimizing errors in acute traumatic spinal cord injury trials by acknowledging the heterogeneity of spinal cord anatomy and injury severity: an observational Canadian cohort analysis.

Clinical trials of therapies for acute traumatic spinal cord injury (tSCI) have failed to convincingly demonstrate efficacy in improving neurologic function. Failing to acknowledge the heterogeneity of these injuries and under-appreciating the impact of the most important baseline prognostic variables likely contributes to this translational failure. Our hypothesis was that neurological level and severity of initial injury (measured by the American Spinal Injury Association Impairment Scale [AIS]) act jointly and are the major determinants of motor recovery. Our objective was to quantify the influence of these variables when considered together on early motor score recovery following acute tSCI. Eight hundred thirty-six participants from the Rick Hansen Spinal Cord Injury Registry were analyzed for motor score improvement from baseline to follow-up. In AIS A, B, and C patients, cervical and thoracic injuries displayed significantly different motor score recovery. AIS A patients with thoracic (T2-T10) and thoracolumbar (T11-L2) injuries had significantly different motor improvement. High (C1-C4) and low (C5-T1) cervical injuries demonstrated differences in upper extremity motor recovery in AIS B, C, and D. A hypothetical clinical trial example demonstrated the benefits of stratifying on neurological level and severity of injury. Clinically meaningful motor score recovery is predictably related to the neurological level of injury and the severity of the baseline neurological impairment. Stratifying clinical trial cohorts using a joint distribution of these two variables will enhance a study's chance of identifying a true treatment effect and minimize the risk of misattributed treatment effects. Clinical studies should stratify participants based on these factors and record the number of participants and their mean baseline motor scores for each category of this joint distribution as part of the reporting of participant characteristics. Improved clinical trial design is a high priority as new therapies and interventions for tSCI emerge.

Conventional (continuous) EEG monitoring in the NICU.

Conventional EEG is being used more frequently in NICUs in the U.S. with the advent of therapeutic hypothermia and the growth of neurocritical care intensivists & units. Historical applications have included assessing encephalopathy, seizure evaluation and prognosis. Past reluctance or limitation of the use in the NICU are receding with the digitization of EEG recordings and increasing interest in the neonatal brain. Continuous EEG monitoring is expanding the potential for its application as a brain monitoring tool to stratify initial injury severity, monitor seizure response to treatment, and detect sentinel neurologic events in the NICU, in addition to guiding neurotherapeutic options. The progression of the EEG background after an acute insult can also increase its prognostic specificity and provide another immediate marker of NICU neurologic outcome. The future of EEG monitoring in the NICU holds many possibilities and may greatly advance the new field of neuroprotection in the NICU.

THE PREVENTIVE EFFECT OF THE NORDIC HAMSTRING EXERCISE ON HAMSTRING INJURIES IN AMATEUR SOCCER PLAYERS: A RANDOMIZED CONTROLLED TRIAL

BackgroundHamstring injuries are the most common muscle injuries in male amateur soccer. Eccentric strength of the hamstrings is recognized as an important modifiable risk factor, leading to the development of...

Initial injury severity and social factors determine ability to deploy after combat-related amputation

ObjectiveWhile many recent publications have examined the ability of amputees to return to active duty, it remains largely unknown why few amputees deploy after amputation and many amputees do not. The purpose of this study is to examine what predictor(s) exist for whether or not an amputee will deploy after sustaining a combat-related amputation. MethodsAll U.S. Service members who sustained major extremity amputations from September 2001 through July 2011 were analysed. Amputation level(s), mechanism of injury, time interval to amputation, age, rank, Physical Evaluation Board (PEB) disposition and ability to deploy after amputation were determined. ResultsDeployment information after amputation was obtained for 953 amputees. There were 47 (5%) amputees who deployed. There were no significant differences amongst service branches for the deployment of amputees (p>0.2). Amputees who underwent their amputation on the same day of their injury were significantly less likely to deploy after amputation than those who had their amputation on the day of injury (p=.01). Deployed amputees had significantly lower Injury Severity Scores than amputees who did not deploy (15.98 vs 20.87, p<0.01) and officers were significantly (p<.01) more likely to deploy and the average age of amputees who deployed was significantly higher than those who did not (27.5 vs 25.1, p<.01). Lastly, those amputees who sustained a transtibial amputation were significantly more likely to deploy than all other amputation levels (p<.01). Nine out of 19 (47%) Special Forces amputees were able to deploy. DiscussionThe vast majority of amputees do not able to deploy after undergoing amputation. The main predictors of deploying after sustaining a combat-related amputation appear to be: sustaining a transtibial amputation, being of senior rank or age and being a member of the Special Forces. Many of these factors appear to be non-treatment related and highlight the importance that individual and social factors play in the recovery of severe injuries.

Prognosis of Outcome in Adult Survivors of Road Accidents in France: One-Year Follow-Up in the ESPARR Cohort

Objective: The consequences of road crashes are various, and few studies have dealt with the multidimensionality of outcomes. The aim of the present study was to assess the multidimensional nature of outcomes one year after a crash and to determine predictive factors that could help in adapting medical and social care to prevent such consequences to improve road crash victims’ prognosis. Methods: The study population was the 886 respondents to the one-year follow-up from the ESPARR (Etude et Suivi d'une Population d'Accidentés de la Route du Rhône) cohort, aged ≥ 16 years; the analysis was carried out only on the 616 subjects who fully completed a self-report questionnaire on health, social, emotional, and financial status one year after a crash. Multiple correspondence analysis and hierarchical clustering was implemented to produce homogeneous groups according to differences in outcome. Groups were compared using the World Health Organization Quality of Life Assessment (WHOQOL-BREF, a standard instrument of quality of life, assessing physical health, psychological health, social relationships, and environment) and the Injury Impairment Scale (IIS), a tool to predict road crash sequelae. Baseline predictive factors for group attribution were analyzed by weighted multinomial logistic regression models. Results: Three hundred seventeen of the 616 subjects (60.1%) were men. Mean age was 36.9 years (SD = 16.5). Five victim groups were identified in terms of consequences at one year: one group (206 subjects, 33.4%) with few problems, one with essentially physical sequelae, one with problems that were essentially both physical and social, and 2 groups with a wider range of problems (one including psychological problems but fewer environmental problems; the last one reported negative physical, psychological, social, and environmental impact; notably, all had post-concussion syndrome [PCS]). There were significant differences between groups in terms of family status, injury severity, and certain types of injury (thorax, spine, lower limbs). Comparison on the WHOQOL-BREF confirmed that groups reporting more adverse outcomes had a lower quality of life. Description of the 5 groups by IIS indicators showed that IIS underestimated physical consequences one year after the crash. In addition to the known prognostic factors such as age, initial injury severity, and injury type, socioeconomic fragility and having a relative involved in the accident emerged as predictive of poor outcome at one year. Conclusions: One year after the crash, victims may still be experiencing multiple problems in terms of not only physical health but also of mental health, social life, and environment. Poor outcome may be predicted from both accident-related factors and socioeconomic fragility. Our results are useful in catching the attention of both clinicians and the public administration regarding victims at risk of suffering from important consequences after an accident. If those suffering head injuries are recognized, it would be very important to better consider and treat posttraumatic stress disorder (PTSD) or PCS. Furthermore, subjects from lower socioeconomic backgrounds, with or without lower limb injuries, have numerous difficulties after an accident, notably for returning to work. An objective would be to provide them with more specific support. Supplemental materials are available for this article. Go to the publisher's online edition of Traffic Injury Prevention to view the supplemental file.

Early neuropsychological tests as correlates of return to driving after traumatic brain injury

Objective: To assess the ability of neuropsychometric tests administered during inpatient rehabilitation to predict return to driving after traumatic brain injury (TBI).Design: Retrospective, matched case-controlled study.Methods: Sixty-seven participants with TBI, drawn from an existing database, completed a questionnaire that assessed return to driving post-TBI, as measured by reinstatement of the driver’s license. Drivers were individually case-matched to non-drivers on age, Glasgow Coma Scale (GCS), Disability Rating Scale (DRS) and the rehabilitation admission interval (RAI). Scores on four neuropsychological tests (Trail-Making A, Trail Making B, Digit Span–forward and Digit Span–backward), administered during the rehabilitation stay, were compared between case-matched drivers and non-drivers.Outcome measure: Return to driving, as defined by reinstatement of the driver’s license.Results: Participants who had returned to driving were comparable to those who had not returned to driving with respect to demographic variables, initial injury severity and baseline functioning. Scores on two neuropsychological assessments were significantly better in participants who had returned to driving than in those who had not: Trail-making A (p < 0.01) and Trail-making B (p < 0.01).Conclusions: The results suggest that neuropsychological measures of processing speed and cognitive flexibility may predict return to driving after TBI.

The preventive effect of the Nordic hamstring exercise on hamstring injuries in amateur soccer players: study protocol for a randomised controlled trial

BackgroundHamstring injuries are the most common muscle injury in male amateur soccer players and have a high rate of recurrence, often despite extensive treatment and long rehabilitation periods. Eccentric strength...