Lower Injury Risk Research Articles

Brainstem Toxicity in Pediatric Patients Treated with Protons Using a Single-vault Synchrocyclotron System

PurposeCranial radiation therapy remains an integral component of curative treatment for pediatric patients with brain tumors. Proton beam radiation therapy (PBT) can limit collateral radiation dose to surrounding normal tissue, thus reducing off-target exposure while maintaining appropriate tumor coverage. While PBT offers significant advantages over photon therapy for pediatric patients with intracranial malignancies, cases of brainstem necrosis after PBT have raised concerns that PBT may pose an increased risk of necrosis over photon therapy. We investigated the incidence of brainstem necrosis at our institution in children treated with PBT for intracranial malignancies.Patients and MethodsPatients with pediatric brain tumor treated with passively scattered PBT, using a gantry-mounted, synchrocyclotron single-vault system between 2013 and 2018, were retrospectively reviewed. Inclusion criteria included patients 21 years of age or younger who received a minimum 0.1 cm3 maximum brainstem dose of 50 Gray relative biological effectiveness (GyRBE). Patients were assessed for “central nervous system necrosis” in the brainstem per the Common Terminology Criteria for Adverse Events (CTCAE), version 5.0 (US National Cancer Institute, Bethesda, Maryland) criteria.ResultsFifty-eight patients were included for analysis. The median age was 10.3 years. Twenty-one (36.2%) patients received craniospinal irradiation. Thirty-four (58.6%) patients received chemotherapy. The median prescription radiation dose was 54 GyRBE. Regarding published dosimetric constraints used at 3 separate proton centers, the goal brainstem D50% <52 GyRBE was exceeded in 23 (40%) patients, but the brainstem Dmax <58 GyRBE was not exceeded in any patients. No patient experienced grade ≥2 brainstem injury. One patient demonstrated radiographic changes consistent with grade 1 toxicity. This patient had myeloablative chemotherapy with tandem stem cell rescue before PBT.ConclusionOur data demonstrates a low risk of any brainstem injury in children treated with passively scattered PBT using a single-vault synchrocyclotron.

The Relationship Between Relative External Training Load and Sports Injury in Collegiate Football Players

PURPOSE: This study aimed to investigate the relationship between relative training load and non-contact injuries in collegiate football players.METHODS: Eleven players were enrolled in this study. During sports competitions, data were collected using global positioning system (GPS) units (10 Hz), and information on sport-related injuries of the lower extremities was recorded. The acute-to-chronic workload ratio (ACWR) of total distance covered, high-intensity distance (≥18 km/hours), sprint distance (≥21 km/hours) and bouts, work-torest ratio, and acceleration-deceleration bouts were calculated. Data were evenly split into quartiles, with the lowest ACWR range used as a reference group. Odds ratios were calculated to determine the injury risk at a given ACWR of each GPS variable, using a logistic regression analysis.RESULTS: Six players experienced nine injuries, yielding an incidence of 132.93 injuries per 1,000 athlete exposures. Based on ACWR values, the highest risk of injury was most associated with total distance covered, followed by high-intensity distance, and sprint bouts. The lowest risk of injury was associated with sprint distance, which yielded a lower injury risk than that in the reference group.CONCLUSIONS: Our study shows the need for continued monitoring of in-game athlete performance in preventing non-contact sportrelated injuries in football players.

Observed Injury Rates Did Not Follow Theoretically Predicted Injury Risk Patterns in Professional Human Circus Artists.

Identifying which types of athletes have increased injury risk (ie, predictive risk factors) should help develop cost-effective selective injury prevention strategies. Our objective was to compare a theoretical injury risk classification system developed by coaches and rehabilitation therapists, with observed injury rates in human circus acts across dimensions of physical stressors, acrobatic complexity, qualifications, and residual risks. Descriptive epidemiological study. professional circus company. Human circus artists performing in routine roles between 2007 and 2017. Characteristics of circus acts categorized according to 4 different dimensions. Medical attention injury rates (injury requiring a visit to the therapist), time-loss injury rates (TL-1; injury resulting in at least one missed performance), and time-loss 15 injury rates (TL-15; injury resulting in at least 15 missed performances). Among 962 artists with 1 373 572 performances, 89.4% (860/962) incurred at least one medical attention injury, 74.2% (714/962) incurred at least one TL-1 injury, and 50.8% (489/962) incurred at least one TL-15 injury. There were important inconsistencies between theoretical and observed injury risk patterns in each of the 4 dimensions for all injury definitions (medical attention, TL-1, and TL-15). Although theoretical classifications are the only option when no data are available, observed risk patterns based on injury surveillance programs can help identify artists who have a high (or low) theoretical risk but are nonetheless actually at low (or high) risk of injury, given their current roles. This will help develop more cost-effective selective injury prevention programs.

Rapid Exclusion of Acute Myocardial Injury and Infarction With a Single High-Sensitivity Cardiac Troponin T in the Emergency Department: A Multicenter United States Evaluation.

There are good data to support using a single high-sensitivity cardiac troponin T (hs-cTnT) below the limit of detection of 5 ng/L to exclude acute myocardial infarction. Per the US Food and Drug Administration, hs-cTnT can only report to the limit of quantitation of 6 ng/L, a threshold for which there are limited data. Our goal was to determine whether a single hs-cTnT below the limit of quantitation of 6 ng/L is a safe strategy to identify patients at low risk for acute myocardial injury and infarction. The efficacy (proportion identified as low risk based on baseline hs-cTnT<6 ng/L) of identifying low-risk patients was examined in a multicenter (n=22 sites) US cohort study of emergency department patients undergoing at least 1 hs-cTnT (CV Data Mart Biomarker cohort). We then determined the performance of a single hs-cTnT<6 ng/L (biomarker alone) to exclude acute myocardial injury (subsequent hs-cTnT >99th percentile in those with an initial hs-cTnT<6 ng/L). The clinically intended rule-out strategy combining a nonischemic ECG with a baseline hs-cTnT<6 ng/L was subsequently tested in an adjudicated cohort in which the diagnostic performance for ruling out acute myocardial infarction and safety (myocardial infarction or death at 30 days) were evaluated. A total of 85 610 patients were evaluated in the CV Data Mart Biomarker cohort, among which 24 646 (29%) had a baseline hs-cTnT<6 ng/L. Women were more likely than men to have hs-cTnT<6 ng/L (38% versus 20%, P<0.0001). Among 11 962 patients with baseline hs-cTnT<6 ng/L and serial measurements, only 1.2% developed acute myocardial injury, resulting in a negative predictive value of 98.8% (95% CI, 98.6-99.0) and sensitivity of 99.6% (95% CI, 99.5-99.6). In the adjudicated cohort, a nonischemic ECG with hs-cTnT<6 ng/L identified 33% of patients (610/1849) as low risk and resulted in a negative predictive value and sensitivity of 100% and a 30-day rate of 0.2% for myocardial infarction or death. A single hs-cTnT below the limit of quantitation of 6 ng/L is a safe and rapid method to identify a substantial number of patients at very low risk for acute myocardial injury and infarction.

Safely reducing abdominal/pelvic computed tomography imaging in pediatric trauma: a quality improvement initiative.

Intra-abdominal injury occurs in less than 15% of pediatric trauma activations but can be life-threatening. Computed tomography (CT) imaging is commonly ordered in pediatric trauma, even when intra-abdominal injury risk is low. We aimed to reduce abdominal/pelvic CT rates in children at very low risk for intra-abdominal injury requiring trauma activation at our pediatric trauma centre. We implemented a quality improvement initiative using the Model for Improvement in children 0-15.99years of age who activated a trauma response and were evaluated for intra-abdominal injury. Interventions included clinical decision support, institutional education, and individual audit and feedback. Our primary outcome was abdominal/pelvic CT rate in patients at very low risk for intra-abdominal injury. Balancing measures included CT scans ordered within 24h of emergency department (ED) assessment and return to ED or hospitalization within 72h for missed intra-abdominal injury. Statistical process control was used to evaluate rates over time. The baseline period (April 1, 2016 - November 30, 2017) included 359 trauma patients with a CT rate of 26.8% (95% CI 20.5-33.8%) in those at low risk for intra-abdominal injury. The intervention period (Dec 1, 2017-Dec 31, 2019) included 445 patients with a CT rate in low-risk patients of 6.8% (95% CI 3.2-12.6%), demonstrating an absolute reduction of 20.0% (95% CI 12.2-27.7%, p < 0.05). Interventions resulted in a significant decrease in abdominal/pelvic CT imaging corresponding with special cause variation. No clinically significant intra-abdominal injuries were missed. This quality improvement initiative reduced abdominal/pelvic CT rates in pediatric trauma patients at low risk for intra-abdominal injury without any missed cases of significant injury. Leveraging standardized decision tools to reduce unnecessary CT imaging can be successfully accomplished without compromising care.

MIRACLE2 Score and SCAI Grade to Identify Patients With Out-of-Hospital Cardiac Arrest for Immediate CoronaryAngiography.

The purpose of this study was to evaluate the impact of performing immediate coronary angiography (CAG) after out-of-hospital cardiac arrest (OHCA) with stratification of predicted neurologic injury and cardiogenic shock on arrival to a center. The role of immediate CAG for patients with OHCA is unclear, which may in part be explained by the majority of patients dying of hypoxic brain injury. Between May 2012 and July 2020, patients from 5 European centers were included in the EUCAR (European Cardiac Arrest Registry). Patients were retrospectively classified into low vs high neurologic risk (MIRACLE2 score 0-3 vs≥4) and degree of cardiogenic shock on arrival (Society for Cardiovascular Angiography and Interventions [SCAI] grade A vs B-E). A multivariable logistic regression analysis including immediate CAG was performed for the primary outcome of survival with good neurologic outcome (Cerebral Performance Category 1 or 2) at hospital discharge. Nine hundred twenty-six patients were included in the registry, with 405 (43.7%) in the low-risk group and 521 (56.3%) in the high-risk group. Immediate CAG was independently associated with improved survival with good neurologic outcome in the low MIRACLE2 risk group with ST-segment elevation myocardial infarction (OR: 11.80; 95%CI: 2.24-76.74; P=0.048) and with SCAI grade B to E shock (OR: 3.23; 95%CI: 1.10-9.50; P=0.031). No subgroups, including those with ST-segment elevation myocardial infarction and with SCAI grade B to E shock, achieved any benefit from early CAG in the high MIRACLE2 group. Combined classification of patients with OHCA with 12-lead electrocardiography, MIRACLE2 score 0 to 3, and SCAI grade B to E identifies a potential cohort of patients at low risk for neurologic injury who benefit most from immediate CAG.

C2 translaminar screw fixation in pediatric occipitocervical fusion

PurposeRigid occipitocervical (O-C) instrumentation can reduce the anterior pathology and has a high fusion rate in children with craniovertebral instability. Typically, axis (C2) screw fixation utilizes C1–C2 transarticular screws or C2 pars screws. However, anatomic variation may preclude these screw types due to the size of fixation elements or by placing the vertebral artery at risk for injury. Pediatric C2 translaminar screw fixation has low risk of vertebral artery injury and may be used when the anatomy is otherwise unsuitable for C1–C2 transarticular screws or C2 pars screws.MethodsWe retrospectively reviewed a neurosurgical database at UCSF Benioff Children’s Hospital Oakland for patients who had undergone a cervical spinal fusion that utilized translaminar screws for occipitocervical instrumentation between 2002 and 2020. We then reviewed the operative records to determine the parameters of C2 screw fixations performed. Demographic and all other relevant clinical data were then recorded.ResultsTwenty-five patients ranging from 2 to 18 years of age underwent O-C fusion, with a total of 43 translaminar screws at C2 placed. Twenty-three patients were fused (92%) after initial surgery with a mean follow-up of 43 months. Two patients, both with Down syndrome, had a nonunion. Another 2 patients had a superficial wound dehiscence that required wound revision. One patient died of unknown cause 7 months after surgery. One patient developed an adjacent-level kyphosis.ConclusionWhen performing occipitocervical instrumentation in the pediatric population, C2 translaminar screw fixation is an effective option to other methods of C2 screw fixation dependent on anatomic feasibility.

Effects of walking in individuals with prehypertension and stage 1 hypertension in India: a randomised controlled trial

Background/Aims Physical activity, such as walking, is a cheap approach with a low risk of injury that can be used in daily life. The aim of this study was to determine the effects of low impact aerobic exercise training on resting blood pressure in patients with prehypertension and stage 1 hypertension specifically for people in India. Methods A total of 63 sedentary adults with prehypertension and stage 1 hypertension participated in the study. All sedentary adults were randomly allocated to either the study group (aerobic training) (n=30) or the control group (n=33). Those in the study group walked for 30 minutes, three times a week for 8 weeks at an intensity of 60–75% of their target heart rate. The control group received no training but followed their usual prescribed medication and diet. The primary outcomes of systolic blood pressure and diastolic blood pressure were measured at the end of every 2 weeks for 8 weeks. Secondary outcomes of pulse pressure, mean arterial pressure and pulse rate were calculated. Results Significant changes in various outcome measures in the study group were noted (systolic blood pressure=7.30 mmHg (95% confidence interval [CI] 2.14 to 3.00; P=0.001); diastolic blood pressure=6.50 mmHg (95% CI 1.23 to 4.04; pulse pressure=0.000; mean arterial pressure=6.77 mmHg (95% CI 1.46 to 3.84; P=0.000) and pulse rate=6.90 bpm (95% CI 1.73 to 3.43; P=0.000) when compared with those in the control group, who had non-significant changes. Conclusions The findings of the present study concluded that aerobic exercise training improves blood pressure.

Car-Based External Airbag for Bicyclist Protection in Side Impacts

&lt;div class="section abstract"&gt;&lt;div class="htmlview paragraph"&gt;Cyclist injuries and fatalities are a world-wide concern and often a consequence of interaction with cars. The MICA2 Project (Modelling of Interactions between Cyclists and Automobiles) is aimed at protecting bicyclists from getting injured by a passing car. This study addresses the need for new protective safety systems through the development and testing of a novel external car airbag. The airbag was designed to add protection to the center side part of the car, in the B-pillar area, to protect the head of a bicyclist impacting a car in this area. Two methods were used to evaluate performance of the system. For full system tests, a Hybrid III 50&lt;sup&gt;th&lt;/sup&gt; percentile male dummy was seated on a city bike and projected into the side of a car at either 30°, 60° or 90° to the car side. In additional component tests an adult pedestrian headform was launched towards the roof rail or B-pillar structure of the car. The highest injury risk was found in a perpendicular (90 degree) impact between the bicycle and car. In oblique crashes the bicycle slid along the side of the car and that decreased the linear accelerations in the head. Glancing collisions (30 degree) resulted in low injury risk as there was no direct head impact. The airbag was very effective in reducing the HIC for the dummy or headform, by about 30%, in the 90 degree impact case with dummy and more than that with the headform.&lt;/div&gt;&lt;/div&gt;

Nine-Year Experience With the Arterial Switch Operation With Closed Coronary Transfer

BackgroundCoronary artery transfer is a critical step of the arterial switch operation (ASO) for transposition of the great arteries (TGA). Strategies for coronary transfer include open transfer before neoaortic anastomosis and closed transfer after neoaortic anastomosis. This study reports outcomes of ASO with closed coronary transfer at a single institution. MethodsA retrospective analysis was performed of patients undergoing ASO for TGA from November 2006 to September 2015. Closed coronary transfer was universally employed. Patients were assigned to simple vs complex coronary anatomy groups. The primary outcome was overall survival. Secondary outcomes included reoperation-free survival, coronary reintervention, and aortic insufficiency. ResultsNinety-six consecutive patients underwent ASO for TGA. Median follow-up was 5.8 years. Thirty-five (36%) patients had complex coronary anatomy, which was associated with significantly longer cardiopulmonary bypass and aortic cross-clamp time. Overall survival was 97.4%, and reoperation-free survival was 83.6%. There was no difference in survival or reoperation-free survival of patients with simple vs complex coronary anatomy. Hispanic ethnicity, side-by-side great arteries, and urgent or emergent operation were significantly associated with the composite outcome of reoperation or mortality. There were no coronary interventions after ASO, and the incidence of moderate or greater aortic insufficiency was 2.1% at hospital discharge and 1.5% in follow-up. ConclusionsClosed coronary transfer during ASO has excellent short-term and midterm results. Despite variable and often complex coronary anatomy, coronary ischemic events after ASO are avoidable. Closed coronary transfer has a low risk of aortic valve injury or insufficiency.

Race-Level Reporting of Incidents during Two Seasons (2015/16 to 2016/17) of Harness Racing in New Zealand.

Simple SummaryThe objective of this study was to describe the incident reporting of harness racing in New Zealand. Retrospective stipendiary stewards’ reports of race day events during the 2015/16 to 2016/17 racing season were examined to describe the reasons and outcomes for race day veterinary examinations of Standardbred horses in New Zealand. The primary reason for examination of horses after a race was due to poor performance. Poor performance was considered if a horse’s performance in the race was lower than its previous race, or lower than expected as reflected by the odds at the tote (reflecting the amount of money placed/gambled on the horse via the official betting agency). The lack of fatalities and injuries reported indicates a low risk profile in harness racing and highlights the stewards’ role in maintaining racing integrity and animal welfare.The objective of this study was to describe the incident and non-incident reporting of harness racing in New Zealand, the primary injury and reporting outcomes, and to examine horse- and race-level variables associated with the odds of these outcomes. Retrospective stipendiary stewards’ reports of race day events during the 2015/16 to 2016/17 racing seasons were examined. The number of incident and non-incident events and binomial exact 95% confidence intervals (CI) were calculated per 1000 horse starts. Most reports were for non-incidents and an examination was requested for poor performance (11.06 per 1000 starts (95% CI = 10.23–11.89). Races with more than eight participants were 1.9 (95% CI = 1.13–3.4) times more likely to have an incident than races with eight or less participants. The low incidence of significant injuries such as fractures (0.13 per 1000 starts (95% CI = 0.03–0.23) reflects the lower risk of injury in harness racing compared to Thoroughbred racing. The high incidence of poor performance reports highlights the steward’s role in maintaining animal welfare to a high standard.

Adult occupant injury risk in rear impact and frontal impact: Effect of impact conditions and occupant-related factors

Objectives The objectives of this study were to compare the adult occupant injury risk on specific body regions in frontal and rear impact and to investigate the effect of those crash conditions and occupant-related factors on the injury risk. Method Data from the NASS-CDS and Crash Investigation Sampling System were studied for crashes during 2000 to 2019 involving model year 2000 to 2020 motor vehicles, including frontal collisions and rear-end collisions. The injury risk by specific body regions were compared by descriptive statistics, and logistic regression models were developed to examine the effects of various factors on injury risk by specific body regions, controlling for crash type (frontal impact and rear impact), vehicle impact speed, vehicle impact location, vehicle model year, and occupant gender, age, belt use, and seating position. Results After controlling for the confounding factors, the occupants in frontal impact had higher overall injury risk than in rear impact (at Maximum Abbreviated Injury Scale [MAIS] 3+; odds ratio [OR] = 6.23; 95% confidence interval [CI] [6.06–6.40]), except for lower neck/spine injury risk at MAIS 1+ (OR = 0.47; 95% CI [0.46–0.47]). The impact speed (at MAIS 3+; OR = 1.10; 95% CI [1.10–1.10]) and aging (at MAIS 3+; OR = 1.05; 95% CI [1.05–1.05]) increase overall injury risk, and the unbelted occupants had higher overall injury risk than belted occupants not only in frontal impact (at MAIS 3+; OR = 4.04; 95% CI [3.98–4.10]), but also in rear impact (at MAIS 3+; OR = 28.4; 95% CI [26.4–30.5]). Females had higher overall injury risk than males in frontal impact (at MAIS 3+; OR = 2.01; 95% CI [1.99–2.04]) but not in rear impact (at MAIS 3+; OR = 0.77; 95% CI [0.73–0.81]). Conclusions Occupants in rear impact had lower injury risk than in frontal impact at MAIS 1+ to MAIS 3+, except for neck/spine at MAIS 1+. The belt restraint was effective not only in frontal impact but also in rear impact. This study provided injury risk references for current vehicles that may provide insight to the potential injury risk of rear-facing occupants in future vehicle configurations.

Can we reduce CT scan and hospital costs in children with blunt trauma using four parameters?

BackgroundBlunt trauma is one of the most common causes of admission to the emergency service in childhood. Children with trauma are generally evaluated in emergency services where pediatric and adult patients are together, and difficulties are experienced in managing children exposed to trauma. CT is preferred for quick detection and grading of toracoabdominal, skeleton, and neurological injury in high energy trauma. The present study aims to determine the severity of trauma and whether CT exposure can be reduced and patient cost using four parameters.This study was conducted with 586 pediatric patients exposed to blunt abdominal trauma. The clinical prediction rule consisted of four parameters, including abdominal pain, physical examination findings, aspartate aminotransferase (AST), and chest x-ray (CXR, which was used to predict intraabdominal injury in patients with blunt trauma. Patients with no parameters of the clinical decision rule were considered very low risk, and those with one or more parameters were considered at risk. The hospital cost of the patients with and without clinical decision rule was calculated and compared.ResultsIn our study, according to the four-variable clinical prediction rule, 88.1% of the patients had a very low risk of intraabdominal injury and 11.9% of them were at risk. The sensitivity was 97.3%, specificity 98.2%, and accuracy was 97.4% in very low-risk patients with four variables clinical prediction rule. In the very low-risk patients, the abnormal CT rate was 0.3% and conservative treatment was performed. With the use of four variables, 0.17% of solid organ injuries may be overlooked. In the risk of patients, 2.9% of these patients were abnormal CT findings, while tube thoracostomy was performed in four patients with pneumothorax, conservative treatment was performed in other patients.It was determined that routine computed tomography scan increased the patient cost by 5.5 times.ConclusionPatients exposed to blunt trauma with a very low risk of intra-abdominal injury can be identified with a four-variable clinical prediction rule. According to the four-variable clinical prediction rule, very low-risk patients do not require immediate CT. The hospital costs can be reduced by reducing the CT scan. However, it should be kept in mind that a small proportion of intra-abdominal injuries may be overlooked.

Exploring effects of cryotherapy modalities on pain, muscle strength and joint position sense in healthy participants with induced knee pain

Keywords: Cryotherapy; Compression; Rehabilitation Purpose: In the current guidelines for acute injury management ‘optimal loading’ has been introduced to facilitate early activity to optimise recovery. Although studies have identified potential adverse effects on muscle performance and knee joint repositioning following ice, evidence supports the use of cryotherapy to provide short-term pain relief. Cryotherapy interventions which can provide short-term pain relief, yet minimise adverse effects, would allow early activity with a lower risk of injury. This study utilised a targeted compressive-cryotherapy approach on experimentally induced knee pain in healthy participants and explored the effects on muscle strength and joint position sense. Methods: 10 healthy participants (7 females, 3 males; 32.9 ± 11.6 years) were induced with experimental knee pain using capsaicin cream (0.075%). Topical capsaicin is a common experimental pain method and was applied to the participant's skin on the medial aspect of the non-dominant knee. A randomised crossover design was adopted, exploring two 20-minute cryotherapy interventions, (1) ice (wetted: 400 g cubed ice, 400 ml water) and (2) Swellaway (10 °C, 50 mmHg compression), during separate testing sessions. Four outcome measures were explored: (i) participant-reported numerical pain rating scale (NPRS), (ii) pressure pain threshold (PPT), (iii) quadriceps muscle strength and (iv) joint position sense (JPS). These outcomes were recorded at four time points: pre-capsaicin cream application (T1), post-capsaicin (T2), post-cooling intervention (T3) and 20-minutes post-cooling (T4). Repeated measures ANOVAs (3 × 2) with post-hoc pairwise comparisons were used to assess change in outcomes between time points. Results: Complete pain relief (≥93% pain reduction) was achieved immediately post-cooling in 7 participants for Swellaway and in 4 participants for ice. Participant NPRS was reduced by 100% (Swellaway) and 91% (ice) 20-minutes post-cooling. No statistically significant differences were found in short-term pain relief between interventions. Significant increases in PPT were found between post-capsaicin and post-cooling (27% increase) and between post-capsaicin and 20-minutes post-cooling (20% increase) following Swellaway. No significant differences were found in PPT between any time points following ice. Ice reduced quadriceps strength by 13% immediately post-cooling. Swellaway had a negligible effect on muscle strength immediately post-cooling (+0.3%). The strength deficit post ice was almost double the percentage reduction (6%) associated with clinically important functional deficits in people with knee osteoarthritis. Significant increases were found in range of motion (ROM) in the coronal plane following ice, which indicates increased instability (adduction/abduction). Despite not being statistically significant, a trend of increased instability (14%) in the transverse plane ROM 20-minutes post-cooling was most apparent following the ice (P = 0.053). Conclusion(s): Targeted compressive-cryotherapy has the potential to achieve short-term pain relief, as demonstrated on healthy participants with experimentally induced knee pain. The results suggest a targeted approach can also minimise the negative effects on muscle strength, dynamic stability and knee joint repositioning, which may traditionally have discouraged early optimal loading post cryotherapy. This would allow individuals to return to weight-bearing rehabilitation exercises earlier, at a lower risk of re-injury post-intervention. Impact: Clinicians could consider utilising targeted compressive-cryotherapy to provide a short-term pain relief and minimise the reported adverse effects following cryotherapy, facilitating early weight-bearing rehabilitation. Funding acknowledgements: This research was carried out as part of a Knowledge Transfer Partnership between Manchester Metropolitan University, University of Central Lancashire and Swellaway.

External validation of a pediatric decision rule for blunt abdominal trauma.

IntroductionBlunt traumatic injuries are a leading cause of morbidity and mortality in the pediatric population. Contrast‐enhanced multidetector computed tomography is the best imaging tool for screening patients at risk of blunt abdominal injury. The Pediatric Emergency Care Applied Research Network (PECARN) abdominal rule was derived to identify patients at low risk for significant abdominal injury who do not require imaging.MethodsWe conducted a retrospective review of pediatric patients with blunt trauma to validate the PECARN rule in a non‐pediatric specialized hospital from February 3, 2013, through December 31, 2019. We excluded those with penetrating or mild isolated head injury. The PECARN decision rule was retrospectively applied for the presence of a therapeutic intervention, defined as a laparotomy, angiographic embolization, blood transfusion, or administration of intravenous fluids for pancreatic or gastrointestinal injury. Sensitivity and specificity analysis were conducted along with the negative and positive predictive values.ResultsA total of 794 patients were included in the final analysis; 23 patients met the primary outcome for an acute intervention. The PECARN clinical decision rule (CDR) had a sensitivity of 91.3%, a negative predictive value of 99.5, and a negative likelihood ration of 0.16.ConclusionIn a non‐pediatric specialty hospital, the PECARN blunt abdominal CDR performed with comparable sensitivity and negative predictive value to the derivation and external validation study performed at specialized children's hospitals.

Comparison of PECARN clinical decision rule and clinician suspicion in predicting intra-abdominal injury in children with blunt torso trauma in the emergency department.

The Pediatric Emergency Care Applied Research Network (PECARN) developed a clinical decision rule to identify children at low risk for intra-abdominal injury requiring acute intervention (IAI-I) for reducing unnecessary radiation exposure of ab-dominal computed tomography (CT) after blunt torso trauma. This study aimed to compare the PECARN decision rule with clinician suspicion in identifying children at low risk of intra-abdominal injuries that an abdominal CT scan can be safely avoided. This study is a retrospective review of children with blunt torso trauma in an academic emergency department (ED) between 2011 and 2019. Patients were considered positive for the PECARN rule if they exhibited any of the variables. Clinician suspi-cion was defined as actual CT ordering of the treating physician. The primary outcome was IAI-I detected by imaging or surgery within 1 month after the trauma, and the secondary outcome was any intra-abdominal injury (IAI) presence. Among the 768 children included, 48 (6.25%) had intra-abdominal injuries and 21 (2.73%) of whom underwent acute in-tervention. Four hundred and fifty-three (59%) children underwent abdominal CT scanning. If the PECARN rule had been applied, 232 patients would have undergone abdominal CT. The rule revealed 90.48% (95% CI=68.17-98.33%) sensitivity for IAI-I and 81.25% (95% CI=66.9-90.56%) for IAI. Clinician suspicion revealed sensitivities of 100% (95% CI=80.76-00%) and 93.75% (95% CI=81.79-98.37%) for IAI-I and IAI, respectively. Sensitivities of the rule and clinician suspicion were statistically similar for both IAI-I (p=0.5) and IAI (p=0.146). In this study, the PECARN abdominal rule and clinician suspicion performed similarly in identifying intra-abdominal injuries in children with blunt torso trauma. However, our study supports the use of PECARN abdominal rule in addition to clinical judgment to limit unnecessary abdominal CT use in pediatric patients with blunt torso trauma in the ED.

Бестроакарная Timesh-лигатурная кольпопексия у пациенток репродуктивного возраста с опущением передней стенки влагалища

This article presents the results of surgical treatment of 3 patients aged between 35 and 42 years with stage II anterior vaginal wall prolapse who underwent a trocar-less transobturator correction of anterior prolapse with titanium mesh implants of individual sizes according to a newly developed technique using titanium fixators. The efficacy and safety of the new trocar-less surgical technique for correcting stage II anterior vaginal wall prolapse in patients of reproductive age using titanium implants and fixators were demonstrated. Conclusion. The trocar-less fixation of titanium implants of individual sizes using 4 titanium fixators, their combination with non-absorbable ligatures into a single functional unit, and multifocal fixation of implants contribute to the normalization of anatomic position of pelvic organs, relief of anterior prolapse symptoms, lower risk of injuries to obturator vessels and nerves, and lower incidence of mesh-related complications. Key words: pelvic organ prolapse, TiMesh-ligature colpopexy, trocar-less transobturator correction, titanium fixators

Water fetcher's lumbar load analysis while carrying heavy loads

The aim of this research exploration is to develop a computational model based on the availabilityoftherural water fetcher's work environment and investigate the water fetcher's workplace with the help of CATIA V5 software. The investigation is carried out on a total of 65 water fetchers, which yields an ordinary model with the following characteristics: 160 cm height and 62 kg weight. Digital human builder is constructed with the help of CATIA V5 software and analysis is performed using the anthropometric and work environment data of a water fetcher, as well as ergonomic design and analysis, water carrying analysis, biomechanics analysis, and rapid upper limb assessment(RULA). The results indicate that improved posture of the water fetcher in L4-L5 position, torque is reduced due to decrease in compression force on the L4-L5 from 3480 N to 278 N and RULA score is diminished from 7 to 3 which is acceptable for the water fetching work place. Based on ergonomic analysis, it is observed that the suggested technique will result in a lower risk of injury, a lower risk of sickness, less tiredness, higher safety and less energy while fetching of water. The proposed technique of water fetching helps to reduce manual work of rural water fetcher’s.

Temporal Bone Landmarks of the Transversesigmoid Sinus Junction: An Anatomical Study in Dried Human Skulls

Objective: To investigate the accuracy in localization of the anterosuperior margin of TSSJ by using the intersection point between the squamosal and parietomastoid sutures (A point) and the intersection of the squamosal suture and supramastoid crest (B point) as bony landmarks.Materials and Methods: The A and B points were marked on the inner surface of a skull by using the transillumination technique. The anatomical relationship between the projected A point, B point, and groove of TSSJ was investigated in 60 dried Thai human skulls (120 sides).Results: Of the 120 sides, the projected A points were located exactly on the anterosuperior margin of the TSSJ in 38 (31.7%) instances and adjacent (above and below) the anterosuperior margin in 82 (68.3%) cases. Of the 118 sides with identifiable supramastoid crests, the projected B points were located precisely on the anterosuperior margin of TSSJ in 60 (50.8%) cases and above the anterosuperior margin of the TSSJ in 57 (48.3%) cases. Hence, the projected B point was a more reliable bony landmark for localizing the anterosuperior margin of the TSSJ when compared with the projected A point (p = 0.003, OR 2.2, and 95% CI =1.3-3.8).Conclusion: The B point is a more reliable temporal bone landmark for localization of the TSSJ than the A point. In temporal craniotomy, an initial burr hole at the B point is relatively safe and carries a very low risk of inadvertent venous sinus injury.

Optimal relative workload for managing low-injury risk in lower extremities of female field hockey players: A retrospective observational study.

Our study aimed to investigate the relative workload that is related to the injury in lower extremities of female field hockey players and to identify the optimal ratio of acute to chronic workloads (ACWR) depending on the playing position to manage low risk of sports-related injuries.Data were collected using a global positioning systems unit on a full-time basis and during competition among 52 players who were enrolled in Korea National Team. The ACWR was calculated by dividing the most recent 1 week workload by the prior 4 weeks workload. Injury risk was calculated for each category from very low to very high based on a z-score.In striker and midfielder, the injury risk was the lowest in the moderate-low category of total distance covered, meters per minute (MpM), repeated high-intensity effort bouts, and acceleration bouts, and the moderate-high category of high-intensity running distance (HID). The injury risk of a defender was the lowest in the moderate-low category of HID and MpM.The ACWR in total distance covered, MpM, repeated high-intensity effort bouts, and acceleration bouts should stay within the moderate-low category in striker and midfielder positions and HID and MpM in defender positions in order to manage low-risk of non-contact and soft tissue injuries in female field hockey players.