Non-severe Injury Research Articles

POSTTRAUMATIC PSYCHOPATHOLOGICAL MANIFESTATIONS OF THE HEAD INJURY IN MEDICO-LEGAL PRACTICE

Neuropsychopathological problems are an intrinsic part of the clinical presentation of traumatic brain injury, its sequelae and outcomes, and require special attention when evaluating the degree of severity of harm to human health. The article discusses the issues of severe psychopathological sequalae after non-severe head injury in medicolegal practice. Objectives. To develop additional criteria of the medico-legal diagnostics and assessment of harm to health in cases of appearance of severe posttraumatic neuropsychiatric disorders after the mild traumatic brain injury. Material and methods. Materials of the Irkutsk Regional Bureau of Forensic Medical Examination were studied. We used common scientific research methods, an analysis of the literature on the research topic, a description and analysis of the expert case.Results. Existing conceptions and theories in understanding traumatic brain injury admit the possibility of the development of severe psychopathological manifestations lead to the neuropsychiatric disorder even in cases of mild traumatic brain injury. Practical medico-legal cases support this point.Conclusion. Additional criteria are defined for medico-legal diagnostics and assessment of harm to health in a case of severe neuropsychiatric outcomes of mild traumatic brain injury.

1914P - Investigating the link between burn injury and tumorigenesis

BackgroundRecent population studies have shown an increase in cancer rates in patients after burn injury over a 30-year follow-up period. This work aims to understand the mediators and mechanisms that lead to cancer susceptibility after acute burn. MethodsIn silico analytics with Watson for Drug Discovery were performed to interrogate networks and pathways in common between burn injury and cancer to better understand the possible mechanistic links. We then useda murine non-severe burn injury model (injury to ∼ 6% body surface area) with subsequent tumor susceptibility evaluation using B16 melanoma challenge 4 weeks after the burn injury. Primary tumor growth (n=10) and metastasis (n=11-13) were assessed compared to sham controls. ResultsNetwork analysis highlighted multiple overlapping pathways important in burn repair and in tumors. In particular, the evidence suggested links to pathways important in the immune response to burn injury (including well characterized pro-inflammatory genes such as IL-6 and TNF-α) and matrix remodeling (such as MMP9) to metastasis. In the murine model, at four weeks after burn injury, primary tumor growth was unaffected (mean volume 353.7mm3± 235.4 vs 256.8mm3± 122.6, burn injury and control respectively, p=0.32). However, mean number of metastases in burn injury mice was significantly increased (7.7± 4.1 compared with 2.6±1.8 for control mice (p=0.0015)), and there was a trend for increased metastatic tumor volume (mean volume 2.7±1.2 compared with 1.6 ±1.3cm3 respectively, p=0.08) after burn injury. ConclusionsThis work suggests burn injury increases cancer susceptibility, specifically through increased number and size of metastases. Further work to delineate the mechanism, potentially through modulation of in silico-identified immune system and metastasis pathways, may provide potential to improve long-term health outcomes for patients. Legal entity responsible for the studyFiona Woods Institute. FundingIBM Watson Health. DisclosureAll authors have declared no conflicts of interest.

Effect of Age on Severity of Injuries in Traffic Accidents Involving Elderly Drivers

Background: The number of elderly drivers involves in traffic accidents is increasing with the aging of the population. This study aimed to investigate the relationship between the driver's age and injury severity in traffic accidents caused by elderly drivers. Methods: Data from the Emergency Department-based Injury In-depth Surveillance (EDIIS) from 2011-2016 was used to analyze traffic accidents by drivers aged 60 and older. Patients were classified into non-severe and severe injury group. The driver's age was subdivided by 5-year interval to compare the difference in age groups. Multivariate logistic regression was used to identify the factors related to the severe injury. Results: Among a total of 262,361 subjects, 6,427 patients were included, of which 890 (13.9%) were severely injured. There were more male in all age groups. The accidents occurred most in the daytime and general roads. In multivariate analysis, drivers aged 75-79 had 1.39 odds ratio (OR) of severe injury compared to drivers aged 60-64 (95% confidence interval [CI]: 1.06-1.84). Male (OR: 1.71, 95% CI: 1.40-2.09), alcohol intake (OR: 2.02, 95% CI: 1.39-2.94), and non-use of seatbelt (OR: 2.06, 95% CI: 1.71-2.48) were associated with severe injury, as well as the counterpart and road class. Conclusion: Among elderly drivers, there were significant differences in characteristics of traffic accidents according to age groups. The risk of severe injury increased in drivers aged over 75 years comparing to relatively young elderly drivers. These results provide the practical adjustment in determining the age standard when establishing traffic safety policies.

Minor Head Trauma in the Pediatric Emergency Department: Decision Making Nodes.

Minor head trauma is one of the leading causes of accessing pediatric emergency departments; however, only a limited number of patients develops clinically relevant brain injuries. The aim of this review is to provide physicians a clinical pathway for managing pediatric minor head trauma. A Pubmed/Medline search was conducted through the following entries: "minor head trauma", "mild head trauma", "minor head injury", "mild head injury" or "acute head trauma". All the studies including pediatric samples between 2000 and 2015 were considered for a critical review. A few articles written before 2000 were analyzed for their relevance. The Pediatric Emergency Care Applied Research Network (PECARN) algorithm identified children with a very low risk for clinically relevant brain injuries (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, no severe headache, no evident clinical worsening over time and no multiple symptoms) and offered the only validated clinical prediction rule to select candidates for CT scans. Other proposed clinical prediction rules (including NEXUS II, CHALICE and CATCH), that were not validated, have a lower sensitivity than PECARN algorithm. Skull X-ray, cerebral magnetic resonance and cranial ultrasonography could provide useful information in selected cases. The critical use of PECARN rule represents the best validated clinical tool for the early identification of children with a clinically relevant brain injury. Its application should be integrated with physician experience and judgement, parental compliance and clinical observation.

Risk factors for deep vein thrombosis and pulmonary embolism after traumatic injury: A competing risks analysis.

Venous thromboembolism, including deep vein thrombosis (DVT) and pulmonary embolism (PE), is typically reported as a composite measure of the quality of trauma center care. Given that recent data suggesting postinjury DVT and PE are distinct clinical processes, a better understanding may result from analyzing them as independent, competing events. Using competing risks analysis, we evaluated our hypothesis that the risk factors and timing of postinjury DVT and PE are different. We examined all adult trauma patients admitted to our Level I trauma center from July 2006 to December 2011 who received at least one surveillance duplex ultrasound of the lower extremities and who were at high risk or greater for DVT. Outcomes included DVT and PE events, and time-to-event from admission. We used competing risks analysis to evaluate risk factors for DVT while accounting for PE as a competing event, and vice versa. Of 2,370 patients, 265 (11.2%) had at least one venous thromboembolism event, 235 DVT only, 19 PE only, 11 DVT and PE. Within 2 days of admission, 38% of DVT cases had occurred compared with 26% of PE. Competing risks modeling of DVT as primary event identified older age, severe injury (Injury Severity Score, ≥ 15), mechanical ventilation longer than 4 days, active cancer, history of DVT or PE, major venous repair, male sex, and prophylactic enoxaparin and prophylactic heparin as associated risk factors. Modeling of PE as the primary event showed younger age, nonsevere injury (Injury Severity Score, < 15), central line placement, and prophylactic heparin as relevant factors. The risk factors for PE and DVT after injury were different, suggesting that they are clinically distinct events that merit independent consideration. Many DVT events occurred early despite prophylaxis, bringing into question the preventability of postinjury DVT. We recommend trauma center quality reporting program measures be revised to account for DVT and PE as unique events. Epidemiologic, level III.

Correlation between factor (F)XIa, FIXa and tissue factor and trauma severity.

It has been observed that trauma patients often display elevated procoagulant activity that could be caused, in part, by tissue factor (TF). We previously observed that trauma patients with thermal, blunt, and penetrating injuries have active FIXa and FXIa in their plasma. In the current study, we evaluated the effect of injury severity, with or without accompanying shock, on the frequency and concentration of TF, FIXa, and FXIa in plasma from trauma patients. Eighty trauma patients were enrolled and divided equally into four groups based on their Injury Severity Score and base deficit:Blood was collected at a 0 time-point (first blood draw upon arrival at hospital) and citrate plasma was prepared, frozen, and stored at -80 °C. FXIa, FIXa, and TF activity assays were based on a response of thrombin generation to corresponding monoclonal inhibitory antibodies. The frequency and median concentrations of TF were relatively low in non-severe injury groups (17.5% and 0 pM, respectively) but were higher in those with severe injury (65% and 0.5 pM, respectively). Although FXIa was observed in 91% of samples and was high across all four groups, median concentrations were highest (by approximately fourfold) in groups with shock. FIXa was observed in 80% of plasma samples and concentrations varied in a relatively narrow range between all four groups. No endogenous activity was observed in plasma from healthy individuals. (1) Frequency and concentration of TF is higher in patients with a higher trauma severity. (2) Concentration of FXIa is higher in patients with shock. (3) For the first time reported, the vast majority of plasma samples from trauma patients contain active FIXa and FXIa. Prognostic/epidemiological study, level II.

Importance of stratifying acute kidney injury in cardiogenic shock resuscitated with mechanical circulatory support therapy

ObjectiveAlthough the outcomes of patients with cardiogenic shock remain poor, short-term mechanical circulatory support has become an increasingly popular modality for hemodynamic assistance and organ preservation. Because the kidney is exquisitely sensitive to poor perfusion, acute kidney injury is a common sequela of cardiogenic shock. This study examines the incidence and clinical impact of acute kidney injury in patients with short-term mechanical circulatory support for cardiogenic shock. MethodsRetrospective review was performed of 293 consecutive patients with cardiogenic shock who were treated with short-term mechanical circulatory support. The well-validated 2014 Kidney Disease Improving Global Outcomes criteria were used to stage acute kidney injury. Outcomes of interest were long-term mortality and renal recovery. ResultsAcute kidney injury developed in 177 of 293 patients (60.4%), of whom 113 (38.6%) were classified with stage 3 (severe). Kaplan–Meier survival estimates indicated a 1-year survival of 49.2% in the nonsevere (stages 0-2) acute kidney injury cohort versus 27.3% in the severe acute kidney injury cohort (P < .001). Multivariable Cox regression demonstrated that severe acute kidney injury was a predictor of long-term mortality (hazard ratio, 1.54; confidence interval, 1.10-2.14; P = .011). Among hospital survivors, renal recovery occurred more frequently (82.4% vs 63.2%, P = .069) and more quickly (5.6 vs 24.5 days, P < .0001) in the nonsevere than in the severe acute kidney injury group. ConclusionsAcute kidney injury is common and frequently severe in patients in cardiogenic shock treated with short-term mechanical circulatory support. Milder acute kidney injury resolves with survival comparable to patients without acute kidney injury. Severe acute kidney injury is an independent predictor of long-term mortality. Nonetheless, many surviving patients with acute kidney injury do experience gradual renal recovery.

Burn Injury Leads to Increased Long-Term Susceptibility to Respiratory Infection in both Mouse Models and Population Studies

BackgroundBurn injury initiates an acute inflammatory response that subsequently drives wound repair. However, acute disruption to the immune response is also common, leading to susceptibility to sepsis and increased morbidity and mortality. Despite increased understanding of the impact of burn injury on the immune system in the acute phase, little is known about long-term consequences of burn injury on immune function. This study was established to determine whether burn injury has long-term clinical impacts on patients’ immune responses.MethodsUsing a population-based retrospective longitudinal study and linked hospital morbidity and death data from Western Australia, comparative rates of hospitalisation for respiratory infections in burn patients and a non-injured comparator cohort were assessed. In addition, a mouse model of non-severe burn injury was also used in which viral respiratory infection was induced at 4 weeks post-injury using a mouse modified version of the Influenza A virus (H3NN; A/mem/71-a).Results and conclusionsThe burn injured cohort contained 14893 adult patients from 1980–2012 after removal of those patients with evidence of smoke inhalation or injury to the respiratory tract. During the study follow-up study a total of 2,884 and 2,625 respiratory infection hospital admissions for the burn and uninjured cohorts, respectively, were identified. After adjusting for covariates, the burn cohort experienced significantly elevated admission rates for influenza and viral pneumonia (IRR, 95%CI: 1.73, 1.27–2.36), bacterial pneumonia (IRR, 95%CI: 2.05, 1.85–2.27) and for other types of upper and lower respiratory infections (IRR, 95% CI: 2.38, 2.09–2.71). In the mouse study an increased viral titre was observed after burn injury, accompanied by a reduced CD8 response and increased NK and NKT cells in the draining lymph nodes. This data suggests burn patients are at long-term increased risk of infection due to sustained modulation of the immune response.

The impact of non-severe burn injury on cardiac function and long-term cardiovascular pathology.

Severe burn injury significantly affects cardiovascular function for up to 3 years. However, whether this leads to long-term pathology is unknown. The impact of non-severe burn injury, which accounts for over 80% of admissions in developed countries, has not been investigated. Using a rodent model of non-severe burn injury with subsequent echocardiography we showed significantly increased left ventricular end systolic diameter (LVESD) and ventricular wall thickness at up to 3 months post-injury. Use of propranolol abrogated the changes in cardiac measures observed. Subsequently we investigated changes in a patient cohort with non-severe injury. Echocardiography measured at baseline and at 3 months post-injury showed increased LVESD at 3 months and significantly decreased posterior wall diameter. Finally, 32 years of Western Australian hospital records were used to investigate the incidence of cardiovascular disease admissions after burn injury. People who had experienced a burn had increased hospital admissions and length of stay for cardiovascular diseases when compared to a matched uninjured cohort. This study presents animal, patient and population data that strongly suggest non-severe burn injury has significant effects on cardiovascular function and long-term morbidity in some burn patients. Identification of patients at risk will promote better intervention and outcomes for burn patients.

Correlation between Factor (F)XIa, FIXa and Tissue Factor and Trauma Severity

Background. It has been observed that trauma patients often display an elevated procoagulant activity. This activity has been hypothesized to be caused in part by tissue factor (TF) located on the endothelium, blood cells and microparticles. We also observed in our previous studies that trauma patients with thermal, blunt and penetrating injuries have active FIXa and FXIa in their plasma, often persistent for several days to weeks. What is not known is the effect of injury type and severity on TF release after trauma. In the current study we evaluated how the severity of an injury with or without accompanying shock affects the frequency and concentration of TF, FIXa and FXIa in plasma from trauma patients.Methods. Eighty trauma patients presenting to a major urban level 1 trauma center (47 with blunt trauma and 33 with penetrating trauma) were enrolled. 62 patients were male and 18 female. The age of patients varied between 18 and 90 years (average 42.6±19.2 years) and the Injury Severity Score (ISS) varied between 1 and 75 (average 19.3±17.2). Blood was collected immediately upon emergency department arrival prior to any resuscitation or blood product transfusion. For analysis our cohort was divided into 4 groups (20 patients/group) based on their ISS and presence of shock (base deficit BD):Group 1: Non-severe injury, no shock (ISS≤15; BD>-6)Group 2: Non-severe injury, with shock (ISS≤15; BD≤-6)Group 3: Severe injury, no shock (ISS>15; BD>-6)Group 4: Severe injury, with shock (ISS>15; BD≤-6)Citrate plasma was prepared, frozen and stored at -80°C. No additional freeze/thaw cycles were involved prior to FXIa, FIXa and TF activity assays. The assays were based on a response of thrombin generation to corresponding monoclonal inhibitory antibodies (αFXIa-2, αFIXa-91 and αTF-5, respectively; all at 0.1 mg/mL).Results. The frequency of TF in less injured patients was relatively low (table) and increased by at least 3-fold in patients with severe injury (groups 3 and 4). The concentration of TF varied in a wide range in all 4 groups, but was the lowest in group 1 patient samples and the highest in groups 3 and 4. FXIa was observed in 91% of plasma samples and was high in all 4 groups of patients. Similar to TF, the concentration of FXIa varied in a wide range in the entire study population. Unlike TF however, FXIa was present in patients with shock at a higher concentration and did not correlate with the severity of injury. Only 9 of 20 group 1 plasma samples had detectable FIXa, whereas in groups 2-4 only 1 or 2 plasma samples had no FIXa activity. The median concentration of this protein varied in a relatively narrow range between all 4 groups, although the lowest was observed in group 1. For the entire cohort, there was a good correlation between FIXa and FXIa concentrations (R2 =0.33), but no correlation between TF and FIXa or FIXa. These data suggest that FXIa in trauma patient blood is generated primarily through the contact pathway, although the input of the TF pathway to FXI activation cannot be excluded. Table 1Patient GroupTFFXIaFIXaFrequencyConcentration (pM)FrequencyConcentration (pM)FrequencyConcentration (pM)RangeMedianRangeMedianRangeMedian14/20 (20%)0.1 - >6.40.2818/20 (90%)0.9 - >647.39/20 (45%)73 - >100017523/20 (15%)0.5 - >6.41.0019/20 (95%)3.2- >6423.418/20 (90%)38 - >1000270312/20 (60%)0.3 - >6.43.5017/20 (85%)0.7 - >6411.118/20 (90%)75 - >1000252414/20 (70%)0.2 - >6.42.4819/20 (95%)1.8 - >6426.519/20 (95%)26 - >1000205Overall33/80 (41%)0.1 - >6.41.0173/80 (91%)0.7 - >10017.064/80 (80%)26 - >1000250Conclusions. 1) Frequency and concentration of TF is higher in patients with a higher trauma severity, but it is independent of shock; 2) The vast majority of plasma samples from trauma patients contain active FIXa and FXIa; 3) Concentration of FXIa is higher in patients with shock and does not appear to be affected by the trauma severity. Taken together, these data suggest separate mechanisms for contact pathway activation after injury driven by shock and TF pathway activation driven by tissue injury. DisclosuresNo relevant conflicts of interest to declare.

Cells from the hematopoietic lineage are only present transiently during healing in a mouse model of non-severe burn injury.

IntroductionThe aim of our study is to identify the contribution of hematopoietic-derived cells to burn-wound healing in a non-severe injury. There are many conflicting reports of the contribution of bone marrow-derived cells to wound healing and whether these are hematopoietic or mesenchymal in origin. The role of hematopoietic lineage cells is investigated in this study in the context of the response to burn injury.MethodsTransgenic mice expressing the LacZ reporter gene in all cells of the hematopoietic lineage underwent a non-severe full-thickness burn injury (8 % of total body surface area). Wounds were assessed for LacZ-positive cells at days 7, 14, and 28 post-injury by using whole-mount staining. Cells were also cultured from the wounds at each time point and analysed for expression of fibroblast and myofibroblast markers.ResultsAt day 7, positive cells were identified in the wounds representing the inflammatory response. Some dermal cells were also identified at this early stage. At day 14, positive cells were also identified and were cultured from the wound tissue samples. However, by day 28, no positive cells could be detected or cultured from the healed wound tissue. Isolated LacZ-positive cells did not express collagen 1 or α-smooth muscle actin proteins, indicating that they had not differentiated into dermal fibroblast-type cells.ConclusionsIn this model of burn injury, hematopoietic lineage cells were present in the healing wound only transiently and did not appear to contribute to the long-term scar population. This is in contrast with reports demonstrating that fibrocytes contribute a long-term sustained population in scar tissue. This work demonstrates that in a non-severe burn injury model there is a sustained transient contribution of hematopoietic cells to the healed wound. Further characterisation of the types and extent of wounding required to establish a long-term hematopoietic response will be important in determining future cell-based therapies.

On scene injury severity prediction (OSISP) algorithm for car occupants

Many victims in traffic accidents do not receive optimal care due to the fact that the severity of their injuries is not realized early on. Triage protocols are based on physiological and anatomical criteria and subsequently on mechanisms of injury in order to reduce undertriage. In this study the value of accident characteristics for field triage is evaluated by developing an on scene injury severity prediction (OSISP) algorithm using only accident characteristics that are feasible to assess at the scene of accident. A multivariate logistic regression model is constructed to assess the probability of a car occupant being severely injured following a crash, based on the Swedish Traffic Accident Data Acquisition (STRADA) database. Accidents involving adult occupants for calendar years 2003–2013 included in both police and hospital records, with no missing data for any of the model variables, were included. The total number of subjects was 29128, who were involved in 22607 accidents. Partition between severe and non-severe injury was done using the Injury Severity Score (ISS) with two thresholds: ISS>8 and ISS>15. The model variables are: belt use, airbag deployment, posted speed limit, type of accident, location of accident, elderly occupant (>55 years old), sex and occupant seat position. The area under the receiver operator characteristic curve (AUC) is 0.78 and 0.83 for ISS>8 and ISS>15, respectively, as estimated by 10-fold cross-validation. Belt use is the strongest predictor followed by type of accident. Posted speed limit, age and accident location contribute substantially to increase model accuracy, whereas sex and airbag deployment contribute to a smaller extent and seat position is of limited value. These findings can be used to refine triage protocols used in Sweden and possibly other countries with similar traffic environments.

Decisión clínica para la realización de tomografía axial computarizada de cráneo en niños con traumatismo craneoencefálico no severo

BackgroundThe main goal of this article was to evaluate if the decision to perform cranial computed tomography (CT) in children with minor head injury is determined by the presence or absence of the physician during assessment in the emergency room. MethodsClinical files of 92 patients from 8 months to 4 years of age were selected. Those children were evaluated at the emergency department of the Spanish Hospital of Mexico due to non-severe traumatic brain injury. Glasgow Coma Scale (GCS) score was determined in all patients. Groups of patients were compared: 1) patients having CT, 2) patients with a physician who attended the initial assessment, 3) patients whose attending physician did not arrive to assess the patient and 4) patients assessed by the emergency room staff. Results38% of patients with non-severe brain injury underwent CT, 8.6% had a brain injury visible on the CT. Moderate intensity impacts were greater in patients with CT. Regarding the ECG, it was found that most children scored 15 points (p=0.03). In patients without a physician, a greater trend was demonstrated for performing CT. ConclusionsPatients with minor head injury but without neurological signs should undergo a detailed clinical evaluation in order to avoid unwarranted CT.

Severe bicycling injury risk factors in children and adolescents: A case–control study

BackgroundBicycling is the most common cause of sports and recreation injury in children and adolescents; yet, there is limited evidence on the factors associated with severe bicycling injuries in youth. MethodsCase–control study of injured bicyclists less than 18 years old seen in seven emergency departments (EDs) from May 2008 to October 2010. Cases were bicyclists hospitalized after their ED visit (severe injury). Controls were bicyclists seen and discharged from the ED (non-severe injury). Personal, environmental, and crash characteristics were collected by interview. Injury data were collected from medical charts. Crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) from logistic regression were used to estimate the odds of hospitalization associated with risk factors. Multiple imputation techniques were employed to address missing data. ResultsThere were 1470 participants including 119 cases. Those ages 13–17 had the highest proportion (23%) of severe injuries resulting from motor vehicle [MV] collision. In models including age, sex and MV collision, being male (OR: 2.02; 95% CI: 1.21–3.38), not wearing a helmet (OR: 2.18; 95% CI: 1.43–3.31) and MV collision (OR: 3.91; 95% CI: 2.26–6.78) were significant risk factors for severe injury. Riding on a paved surface (OR: 0.63; 95% CI: 0.41–0.97) and utilitarian (school, work) bicycling (OR: 0.44; 95% CI: 0.2–0.94) decreased injury risk. Results were similar, apart from utilitarian bicycling (OR: 0.49; 95% CI: 0.22–1.06), after imputation for missing data. ConclusionBicycle–MV collisions increase severe injury risk in youth, and adolescents are often injured in these events. This suggests separating bicyclists from MVs or traffic calming strategies could improve safety.

Non-severe burn injury leads to depletion of bone volume that can be ameliorated by inhibiting TNF-α

Bone loss after severe burn injury is well established, and is thought to be a consequence of the severe hyper-metabolic response as well as changes in cytokine and glucocorticoid levels that decrease bone synthesis and increase rate of loss. However, 90% of presentations are for non-severe burns which do not elicit this response. Little is known about whether these non-severe injuries may also affect bone tissue, and whether other mechanisms may be involved.To investigate whether bone loss occurs after a non-severe burn injury we used a mouse model of an approximately 8% total body surface area (TBSA) full-thickness burn and micro-CT. We also assessed whether blocking TNF-α after a burn injury by administration of an antibody could modulate the impacts of the burn on bone tissue.There was a significant loss of trabecular bone volume of (3.27% compared to 5.27%, p=0.0051) after non-severe burn injury. Trabecular number was significantly decreased (0.57/mm after injury compared to 1.02/mm controls, p=0.0051) and spacing increased after burn injury (0.40 compared to 0.28, p=0.0083). Anti-TNF-α antibodies significantly improved trabecular bone volume (8.53%, p=0.0034) and number after burn injury (1.28/mm, p=0.0034). There was no significant change observed in cortical bone after burn injury or administration of anti-TNF-α antibodies.These findings show that non-severe burn injury can lead to changes in bone metabolism. Monitoring bone density in patients with non-severe injuries and interventions to limit the impacts of the inflammatory storm may benefit patient recovery and outcomes.

RISK FACTORS FOR BODY REGION SPECIFIC INJURIES IN SKIERS AND SNOWBOARDERS

BackgroundLittle is known about risk factors (e.g., wrist guards, binding adjustment, equipment ownership) for body region specific skiing/snowboarding injuries.ObjectiveIdentify risk factors for body region specific injuries and severe injuries in...

Association Between ADHD & Ambulatory Care for Non-Severe Injury

Association Between ADHD & Ambulatory Care for Non-Severe Injury

Fatal Tetanus Complicating an Untreated Mild Open Head Injury: A Case-Illustrated Review of Cephalic Tetanus

Tetanus is now a rare disease in the Western world, but not so in developing countries. Cephalic tetanus, unlike some other local forms of the disease, is likely to be fatal. We describe the clinical presentation of a case of fatal cephalic tetanus complicating an unattended open non-severe head injury with a review of the literature on the disease. Few cases of cephalic tetanus complicating head injury are found in the world literature, and many were diagnosed late. Cephalic tetanus from open or compound depressed skull fracture is even more rare. Our patient was a young male with an uncertain tetanus immunization history who sustained mild head injury (scalp laceration) and an unattended open depressed skull fracture in a motorcycle crash. He developed cephalic tetanus seven days later, presented late to our service, and died while being prepared for surgical debridement of his cranial wounds. At the immediate post-trauma medical contact, in an across-the-street "clinic," he had received suboptimal care for his head wound and inadequate tetanus prophylaxis. Cephalic tetanus is a rare form of the disease. Although it is preventable easily by well-established medical and surgical treatment paradigms, it continues to catch many clinicians disastrously unaware.

G.P.128 The effect of non-severe dorsal burn injury on the contractile properties of fast-twitch hind limb skeletal muscle of the mouse

Abstract Loss of skeletal muscle function is cited as the most common reason preventing burn patients from returning to work. However, the effect of non-severe burn injury on muscle function has not been investigated, despite this type of burn accounting for >90% of all burn injuries. We examined the effect of non-severe burn injury on muscle mass and contractile function in the mouse extensor digitorum longus (EDL) muscle. Anaesthetised mice (4% isoflurane in O 2 ) received a full-thickness burn to 6% of total body surface area. Analgesics (buprenorphine (0.1 mg/kg) and paracetamol (0.01 mg/mL)) were administered post-injury. At 7, 28 or 84 days after burn injury, mice were anaesthetised with pentobarbitone (40 mg/kg) and EDL muscles were excised for assessment of contractile function. The effects of burn-injury on the contractile filaments were also determined using the skinned fibre technique. The muscle mass from burn-injured and control mice were not significantly different at any time point. The maximum specific force (N/cm 2 ) in EDL muscles from burn-injured mice was significantly higher than controls at day 7 (by 16%), but significantly lower at days 28 and 84 (by 18% and 14%, respectively). Skinned fibres from burn injured muscles exhibited significantly greater maximum force at day 7, but were not significantly different from controls at day 28 or day 84 post-injury. Non-severe burn injuries caused significant long-term contractile dysfunction in remotely located hind-limb muscles. These effects were independent of muscle atrophy or direct effects on the contractile apparatus. Therefore, non-severe burn injury-related muscle weakness may be an important factor impeding patient recovery. If similar effects occur in humans, non-severe burn injury-related muscle weakness may be an important factor impeding patient recovery.

Severe Traumatic Head Injury Affects Systemic Cytokine Expression

The neuroimmunologic effect of traumatic head injury remains ill-defined. This study aimed to characterize systemic cytokine profiles among traumatically injured patients to assess the effect of traumatic head injury on the systemic inflammatory response. For 5 years, 1,022 patients were evaluated from a multi-institutional Trauma Immunomodulatory Database. Patients were stratified by presence of severe head injury (SHI; head Injury Severity Score ≥4, n = 335) vs nonsevere head injury (NHI; head Injury Severity Score ≤3, n = 687). Systemic cytokine expression was quantified by ELISA within 72 hours of admission. Patient factors, outcomes, and cytokine profiles were compared by univariate analyses. SHI patients were more severely injured with higher mortality, despite similar ICU infection and ventilator-associated pneumonia rates. Expression of early proinflammatory cytokines, interleukin-6 (p < 0.001) and tumor necrosis factor-α (p = 0.02), was higher among NHI patients, and expression of immunomodulatory cytokines, interferon-γ (p = 0.01) and interleukin-12 (p = 0.003), was higher in SHI patients. High tumor necrosis factor-α levels in NHI patients were associated with mortality (p = 0.01), increased mechanical ventilation (p = 0.02), and development of ventilator-associated pneumonia (p = 0.01). Alternatively, among SHI patients, high interleukin-2 levels were associated with survival, decreased mechanical ventilation, and absence of ventilator-associated pneumonia. The presence of severe traumatic head injury significantly alters systemic cytokine expression and exerts an immunomodulatory effect. Early recognition of these profiles can allow for targeted intervention to reduce patient morbidity and mortality.