Non-severe Injury Research Articles

Clinical prediction of wound re-epithelisation outcomes in non-severe burn injury using the plasma lipidome

Whilst wound repair in severe burns has received substantial research attention, non-severe burns (<20% total body surface area) remain relatively understudied, despite causing considerable physiological impact and constituting most of the hospital admissions for burns. Early prediction of healing outcomes would decrease financial and patient burden, and aid in preventing long-term complications from poor wound healing. Lipids have been implicated in inflammation and tissue repair and may play essential roles in burn wound healing. In this study, plasma samples were collected from 20 non-severe burn patients over 6 weeks from admission, including surgery, and analysed by liquid chromatography-tandem mass spectrometry and nuclear magnetic resonance spectroscopy to detect 850 lipids and 112 lipoproteins. Orthogonal projections to latent structures-discriminant analysis was performed to identify changes associated with re-epithelialisation and delayed re-epithelisation.We demonstrated that the lipid and lipoprotein profiles at admission could predict re-epithelisation outcomes at 2 weeks post-surgery, and that these discriminatory profiles were maintained up to 6 weeks post-burn. Inflammatory markers GlycB and C-reactive protein indicated divergent systemic responses to the burn injury at admission. Triacylglycerols, diacylglycerols and low-density lipoprotein subfractions were associated with delayed wound closure (p-value <0.02, Cliff’s delta >0.7), whilst high-density lipoprotein subfractions, phosphatidylinositols, phosphatidylcholines, and phosphatidylserines were associated with re-epithelisation at 2 weeks post-surgery (p-value <0.01, Cliff’s delta <-0.7). Further model validation will potentially lead to personalised intervention strategies to reduce the risk of chronic complications post-burn injury.

The role of emergency department thoracotomy in patients with cranial gunshot wounds.

Although several society guidelines exist regarding emergency department thoracotomy (EDT), there is a lack of data upon which to base guidance for multiple gunshot wound (GSW) patients whose injuries include a cranial GSW. We hypothesized that survival in these patients would be exceedingly low. We used Pennsylvania Trauma Outcomes Study data, 2002 to 2021, and included EDTs for GSWs. We defined EDT by International Classification of Diseases codes for thoracotomy or procedures requiring one, with a location flagged as emergency department. We defined head injuries as any head Abbreviated Injury Scale (AIS) score of ≥1 and severe head injuries as head AIS score of ≥4. Head injuries were "isolated" if all other body regions have an AIS score of <2. Descriptive statistics were performed. Discharge functional status was measured in five domains. Over 20 years in Pennsylvania, 3,546 EDTs were performed; 2,771 (78.1%) were for penetrating injuries. Most penetrating EDTs (2,003 [72.3%]) had suffered GSWs. Survival among patients with isolated head wounds (n = 25) was 0%. Survival was 5.3% for the non-head injured (n = 94 of 1,787). In patients with combined head and other injuries, survival was driven by the severity of the head wound-0% (0 of 81) with a severe head injury ( p = 0.035 vs. no severe head injury) and 4.5% (5 of 110) with a nonsevere head injury. Of the five head-injured survivors, two were fully dependent for transfer mobility, and three were partially or fully dependent for locomotion. Of 211 patients with a cranial injury who expired, 2 (0.9%) went on to organ donation. Although there is clearly no role for EDT in patients with isolated head GSWs, EDT may be considered in patients with combined injuries, as most of these patients have minor head injuries and survival is not different from the non-head injured. However, if a severe head injury is clinically apparent, even in the presence of other body cavity injuries, EDT should not be pursued. Therapeutic/Care Management; Level IV.

Non-severe thermal burn injuries induce long-lasting downregulation of gene expression in cortical excitatory neurons and microglia.

Burn injuries are devastating traumas, often leading to life-long consequences that extend beyond the observable burn scar. In the context of the nervous system, burn injury patients commonly develop chronic neurological disorders and have been suggested to have impaired motor cortex function, but the long-lasting impact on neurons and glia in the brain is unknown. Using a mouse model of non-severe burn injury, excitatory and inhibitory neurons in the primary motor cortex were labelled with fluorescent proteins using adeno-associated viruses (AAVs). A total of 5 weeks following the burn injury, virus labelled excitatory and inhibitory neurons were isolated using fluorescence-activated cell sorting (FACS). In addition, microglia and astrocytes from the remaining cortical tissue caudal to the motor cortex were immunolabelled and isolated with FACS. Whole transcriptome RNA-sequencing was used to identify any long-lasting changes to gene expression in the different cell types. RNA-seq analysis showed changes to the expression of a small number of genes with known functions in excitatory neurons and microglia, but not in inhibitory neurons or astrocytes. Specifically, genes related to GABA-A receptors in excitatory neurons and several cellular functions in microglia were found to be downregulated in burn injured mice. These findings suggest that non-severe burn injuries lead to long lasting transcriptomic changes in the brain, but only in specific cell types. Our findings provide a broad overview of the long-lasting impact of burn injuries on the central nervous system which may help identify potential therapeutic targets to prevent neurological dysfunction in burn patients.

Development of a 3D multifunctional collagen scaffold impregnated with peptide LL-37 for vascularised bone tissue regeneration

Bone is a highly dynamic connective tissue that provides structural support, locomotion and acts as a shield for many vital organs from damage. Bone inherits the ability to heal after non-severe injury. In case of severe bone abnormalities due to trauma, infections, genetic disorders and tumors, there is a demand for a scaffold that can enhance bone formation and regenerate the lost bone tissue. In this study, a 3D collagen scaffold (CS) was functionalized and assessed under in vitro and in vivo conditions. For this, a collagen scaffold coated with hydroxyapatite (Ap-CS) was developed and loaded with a peptide LL-37. The physico-chemical characterisation confirmed the hydroxyapatite coating on the outer and inner surfaces of Ap-CS. In vitro studies confirmed that LL-37 loaded Ap-CS promotes osteogenic differentiation of human osteosarcoma cells without showing significant cytotoxicity. The efficacy of the LL-37 loaded Ap-CS for bone regeneration was evaluated at 4 and 12 weeks post-implantation by histopathological and micro-CT analysis in rabbit femur defect model. The implanted LL-37 loaded Ap-CS facilitated the new bone formation at 4 weeks compared with Ap-CS without LL-37. The LL-37 loaded Ap-CS incorporating apatite and peptide LL-37 would be useful as a multifunctional scaffold for bone tissue engineering.

Nonsevere Burn Induces a Prolonged Systemic Metabolic Phenotype Indicative of a Persistent Inflammatory Response Postinjury.

Globally, burns are a significant cause of injury that can cause substantial acute trauma as well as lead to increased incidence of chronic comorbidity and disease. To date, research has primarily focused on the systemic response to severe injury, with little in the literature reported on the impact of nonsevere injuries (<15% total burn surface area; TBSA). To elucidate the metabolic consequences of a nonsevere burn injury, longitudinal plasma was collected from adults (n = 35) who presented at hospital with a nonsevere burn injury at admission, and at 6 week follow up. A cross-sectional baseline sample was also collected from nonburn control participants (n = 14). Samples underwent multiplatform metabolic phenotyping using 1H nuclear magnetic resonance spectroscopy and liquid chromatography-mass spectrometry to quantify 112 lipoprotein and glycoprotein signatures and 852 lipid species from across 20 subclasses. Multivariate data modeling (orthogonal projections to latent structures-discriminate analysis; OPLS-DA) revealed alterations in lipoprotein and lipid metabolism when comparing the baseline control to hospital admission samples, with the phenotypic signature found to be sustained at follow up. Univariate (Mann-Whitney U) testing and OPLS-DA indicated specific increases in GlycB (p-value < 1.0e-4), low density lipoprotein-2 subfractions (variable importance in projection score; VIP > 6.83e-1) and monoacyglyceride (20:4) (p-value < 1.0e-4) and decreases in circulating anti-inflammatory high-density lipoprotein-4 subfractions (VIP > 7.75e-1), phosphatidylcholines, phosphatidylglycerols, phosphatidylinositols, and phosphatidylserines. The results indicate a persistent systemic metabolic phenotype that occurs even in cases of a nonsevere burn injury. The phenotype is indicative of an acute inflammatory profile that continues to be sustained postinjury, suggesting an impact on systems health beyond the site of injury. The phenotypes contained metabolic signatures consistent with chronic inflammatory states reported to have an elevated incidence postburn injury. Such phenotypic signatures may provide patient stratification opportunities, to identify individual responses to injury, personalize intervention strategies, and improve acute care, reducing the risk of chronic comorbidity.

Non-severe burn injury causes sustained platelet hyperreactivity

Individuals who present to a hospital for treatment of a burn of any magnitude are more frequently hospitalised for ischemic heart disease, even decades after injury. Blood platelets are key mediators of cardiovascular disease. To investigate platelet involvement in post-burn cardiovascular risk, platelet reactivity was assessed in patients at 2- and 6-weeks after non-severe (TBSA < 20%) burn injury, and in a murine model 30 days after 8% TBSA full-thickness burn injury. Platelets were stimulated with canonical agonists and function reported by GPIIb/IIIa PAC1-binding site, CD62P expression, and formation of monocyte-platelet aggregates. In vivo thrombosis in a modified Folts model of vascular injury was assessed. Burn survivors had elevated frequencies of circulating monocyte-platelet aggregates, and platelets were hyperreactive, primarily to collagen stimulation. Burn plasma did not cause hyper-reactivity when incubated with control platelets. Platelets from burn injured mice also demonstrated increased response to collagen peptides but did not show any change in thrombosis following vascular injury. This study demonstrates the persistence of a small but significant platelet hyperreactivity following burn injury. Although our data does not suggest this heightened platelet sensitivity modulates thrombosis following vascular injury, the contribution of sub-clinical platelet hyperreactivity to accelerating atherogenesis merits further investigation.

Glomerular mTORC1 activation was associated with podocytes to endothelial cells communication in lupus nephritis

ObjectiveThis study was initiated to evaluate the mammalian target of the rapamycin (mTOR) signalling pathway involved in renal endothelial-podocyte crosstalk in patients with lupus nephritis (LN).MethodsWe compared the kidney protein...

376 Neurologic Deterioration in Children with Non-Severe Traumatic Intracranial Hemorrhage: A Multicenter Cross-Sectional Study

OBJECTIVES/GOALS: Children with traumatic intracranial hemorrhage are monitored closely for deterioration and need for intervention. Data on risk factors for deterioration in nonsevere head injury are limited. Our objective was to identify children with hemorrhage from non-severe head injury who are at risk for deterioration. METHODS/STUDY POPULATION: We conducted a 10-site cross-sectional study of children 8. Our primary outcome was clinically important hemorrhage after injury and within 96 hours of ED arrival, defined as ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (new or worsening signs/symptoms with an acute change in management). After testing model assumptions, we used logistic regression to identify clinical and neuroradiographic factors associated with clinically important hemorrhage. RESULTS/ANTICIPATED RESULTS: We studied 763 children with intracranial hemorrhage, with a median (IQR) age of 3.0 (0.4, 10.5) years. Initial GCS was mild (14-15) in 89.4% (n=682) and moderate (9-13) in 10.6% (n=81). Clinically important hemorrhage was observed in 19.5% (n=149), and 7.8% (n=59) developed clinically important deterioration. Median (IQR) time to deterioration was 17.6 (4.6, 37.9) hours. In our sample, 16.3% (n=124) underwent critical interventions, 54.9% (n=419) were admitted to an ICU, and 50.1% (n=382) underwent repeat neuroimaging. We found older age (OR 1.6; 95% CI 1.3, 1.9), lower GCS (OR 5.0; 95% CI 2.9, 8.5), and epidural hemorrhage (OR 3.3; 95% CI 2.0, 5.5) was associated with clinically important hemorrhage. DISCUSSION/SIGNIFICANCE: Clinically important hemorrhage occurred in one in five children with non-severe head injury. Clinical and neuroradiographic factors associated with ED interventions and deterioration were identified. Risk stratification algorithms using these data will be developed to assist clinicians caring for children with head injury.

Vestibular/ocular motor screening (VOMS) score for identification of concussion in cases of non-severe head injury: A systematic review

Background and importance Each year, 1.4 million patients attend a UK ED with a head injury. Mild traumatic brain injury affects up to 300/100 000 admitted patients/year and a greater number of non-admitted patients. Identifying those patients with a head injury that have concussion, and of those, which will have a prolonged recovery, is critical for discharge planning. The Vestibular/Ocular Motor Screening test (VOMS) has been reported as a useful “sideline tool” to evaluate for sports-related concussion (SRC). VOMS has been assessed for utility primarily for predicting in head-injured, which cases will have concussion, and secondarily in predicting in concussed patients, which will have prolonged recovery. Originally described in 2014, VOMS has not been subject to systematic review or meta-analysis, with regard to its predictive performance for concussion. Objective To assess the state of VOMS evidence for dichotomously classifying concussion status in patients with non-severe head injury Design Systematic review. Setting and participants Studies comprising the review enrolled ambulatory head-injured adults and children, usually from sports-related settings, in Europe or the USA. Exposure VOMS. Outcome measures Presence of concussion, presence of prolonged recovery in concussed patients Main results The review identified 17 studies, characterized by a wide variety of specific approaches to administering and scoring VOMS. While VOMS showed promise as a screening tool for concussion, marked study heterogeneity precluded generation of a pooled effect estimate for VOMS performance. Conclusion VOMS is potentially useful as a concussion screening tool. Available evidence from the SRC arena suggests sensitivity ranging from 58–96%, with specificity 46−92%. Directions for future VOMS research should include evaluation of standardized administration and scoring, potentially of a simpler VOMS (with fewer components), in a general head-injured population. Further analysis of precisely defined VOMS application may be useful to determine the proper place of VOMS screening for the head-injured.

Plasma lipidomics reveal systemic changes persistent throughout early life following a childhood burn injury

Abstract Background Non-severe paediatric burns can result in poor long-term health outcomes. This occurs even in cases with good acute burn-related outcomes, including minimal scarring. The mechanisms that underpin the transition from non-severe burn to sustained negative long-term health impacts are currently unknown. However, sustained metabolic and immune changes have been observed in paediatric burn studies, suggesting these changes may be important. The plasma lipidome consists of a rich pool of bioactive metabolites that play critical roles in systemic processes including molecular signalling and inflammation. We hypothesised that changes in the plasma lipidome may reflect underlying changes in health status and be linked to long-term health after burn trauma. Methods This study analysed the lipidome in children who had previously experienced a non-severe burn, compared to non-injured controls. Thirty-three participants were recruited between the ages of 5 and 8 years who had experienced a non-severe burn between the ages of 1 and 3 years. Plasma samples were also collected from a non-injured, healthy, age and gender matched control group (n = 21). Plasma lipids were measured using reversed-phase liquid chromatographymass spectrometery (LC-MS). Results In total 838 reproducible lipid species from 19 sub-classes passed quality control procedures and progressed to statistical analysis. Analysis of individual lipid metabolites showed significantly higher concentrations of lysophosphatidylethanolamines and phosphatidylethanolamines, and significantly lower concentrations in myristic, palmitic and palmitoleic acids in the plasma of those who had experienced burn injury compared to controls. Conclusion Long-term changes in the lipid profile may give insight into the mechanisms underlying poor long-term health subsequent to non-severe burn injury. Further work to investigate the relationship between long-term pathology and lipidomic changes may lead to a better understanding of the causes of secondary morbidity post-burn and to clinical intervention to reduce the long-term health burden of burn trauma.

New methods for analysing circulating cell‐free mitochondrial DNA

Trauma, ischemia, inflammatory stress and environmental conditions can cause tissue injury and damage. This damage spurs the release of cellular components and debris into the extracellular environment, including damage associated molecular pattern (DAMP) molecules. These DAMPs are sensed by pattern recognition receptors that activate a cellular damage response to the pathological insult. Mitochondrial components have recently been recognised as potent DAMPs.1, 2 The mitochondrial genome shares features with bacterial genomes, due to their shared origin. Therefore, when mitochondrial DNA (mtDNA) is released into the extracellular space it is recognised as a foreign molecule and initiates an innate immune response.1, 2 Not only have DAMP molecules been of interest in studying the relationships between cellular damage and immune responses, but emerging evidence suggests that DAMPs may serve as ‘liquid biopsies’ to indicate tissue damage or disease status. For example, plasma levels of circulating cell-free mtDNA (ccf-mtDNA) can be isolated and quantified easily using quantitative real-time PCR (qPCR). The results of many studies suggest that there are higher levels of ccf-mtDNA after trauma, acute myocardial infarction, sepsis and in some inflammatory conditions.3 A recent systematic review examined published articles on utilising ccf-mtDNA as a predictor of mortality in critically ill patients.4 The authors noted that in their analysis there are inconsistencies in ccf-mtDNA isolation methods and quantification. For example, most often qPCR primers were designed against subunits of the NADH dehydrogenase (MT-ND, MT-ND1, MT-ND2 or MT-ND6).4 However, some studies use one primer set, others use multiple primer sets and some use primer sets recognising different genes in the mitochondrial genome. This may explain the discrepancies in the findings linking ccf-mtDNA to mortality in some studies but not in all. Therefore, there is a need for the development of technologies that improve upon these current methods to quantify ccf-mtDNA. Daly and colleagues recently developed a protocol that provides a new approach to analysing plasma ccf-mtDNA.5 In their approach, they utilised a target bait-capture kit consisting of biotinylated RNA probes complementary to the entire mitochondrial genome. First, the biotinylated probes bind to mitochondrial sequences and then are enriched, pooled, and sequenced on a standard Illumina instrument. Second, a Workflow Description Language-based computational pipeline aligns the reads to both the nuclear and mitochondrial genome and then custom programs call mitochondrial and nuclear coverage, insert fragment size and mtDNA variants. Nuclear genomes contain sequences of mitochondrial origin, called nuclear mitochondrial DNA segments (NUMTs). NUMT pseudogenes can also be enriched using these methods. Therefore, to exclude the possibility that reads are from the nuclear genome, this method excludes sequences that aligned to both nuclear and mitochondrial genomes. This approach may underestimate the mtDNA levels but increases classification accuracy. In fact, this protocol was shown to enrich for mean coverage of the mtDNA genome compared to whole genome sequencing. Therefore, this protocol allows for the simultaneous quantification of mtDNA levels across the entire mitochondrial genome, differentiation of fragment lengths, and the identification of mtDNA variants.5 The authors utilised their protocol to investigate ccf-mtDNA in comparison to clinical phenotypes of injury and severity scores in a cohort of 30 trauma patients.5 There were no significant differences in ccf-mtDNA abundance between patients with non-severe or severe injuries. The ccf-mtDNA fragment length was significantly shorter in patients with major trauma and in patients where acute lung injury occurred after admission compared to non-severe injury patients. There were also mtDNA variants that were discovered that were associated with various clinical scores of injuries and severity in this cohort. Therefore, the authors utilised samples from this trauma cohort to validate that their protocol can be implemented to examined mtDNA levels, fragment length, and variants.5 This technological advance has advantages over the standard qPCR methods, as the entire mitochondrial genome can be analysed in one protocol. However, additional experiments and validation studies should be performed to directly compare the sensitivity and accuracy of this protocol versus the standard qPCR methods. Nevertheless, these methods will give scientists an additional tool to examine ccf-mtDNA in relation to tissue damage or disease status. This work was funded by the Intramural Research Program of the National Institute on Aging, National Institutes of Health. The authors declare no conflict of interest.

Cost–benefit analysis of a distracted pedestrian intervention

ObjectiveCellphone ubiquity has increased distracted pedestrian behaviour and contributed to growing pedestrian injury rates. A major barrier to large-scale implementation of prevention programmes is unavailable information on potential monetary benefits....

Grip strength in children after non-severe burn injury

PurposeTo characterise grip strength in children with non-severe burn injury, and further understanding of how demographic and clinical variables impact musculoskeletal recovery. MethodsA retrospective, cross-sectional audit of routinely collected clinical data was performed. Standardised protocols were used to measure height, weight and grip strength. Demographic and clinical information was collected from patient medical records. Grip strength comparisons were made against normative data using paired t-tests. General linear regressions with backwards elimination were performed to assess impact of clinical, demographic and physical variables on grip strength. ResultsChildren who were right hand (RH) dominant had reduced RH (18.9 ± 9.9 kg, p = 0.001) and left hand (LH)(17.6 ± 9.3 kg, p = 0.027) grip strength compared to age, sex and hand-dominance matched norms (RH, 20.0 ± 10.0 kg; LH, 18.4 ± 9.5 kg). Children who were assessed closer to the time of their injury, and those who were burnt at a young age were more likely to score grip strength values below the norm (p < 0.001 for all analyses). In particular, females appeared to be at a higher risk of low grip strength scores if burnt at a young age (p < 0.001). ConclusionsChildren with non-severe burn injury struggle to recover musculoskeletal strength, with those who were assessed closer to the time of injury or burnt at a young age especially at risk of impaired grip strength performance. Grip strength does not appear to be influenced by any other clinical variables or burn injury characteristics.

562 Influence of the COVID-19 Pandemic on Emergency Room Visits for Burn Injury

IntroductionThe COVID-19 pandemic was a devastating occurrence that left millions in critical condition in emergency rooms (ER) across the country. While hospitalizations due to COVID-19 increased exponentially in the last year, several reports have indicated declines in ER use due to common non-COVID related problems. There is currently a dearth of literature examining the effect of the COVID-19 pandemic on emergency room use for acute burn injuries. Thus, we performed a retrospective database analysis using the TriNetX database to quantify the effects of COVID-19 on United States ER visits for acute burn injuries. We hypothesize that ER visits due to burn injury decreased, especially in patients with severe burn injuries- defined as burned total burn surface area (TBSA) >20%.MethodsPatients who visited the ER from 2010-2020 due to burn injury were identified using ICD-10 codes. We then stratified these patients by age (< 18 and ≥18), severe ( >20% TBSA) vs. non-severe (< 20% TBSA) burn injury, and by change over time in 1-year intervals from 2010 to 2020. Extracted data was analyzed using chi-square with p< .05 considered significant.ResultsWe identified a total of 24,620,393 ER visits from 2010-2020. Of these, 142,007 (0.58%) were due to burn injury. A large majority of burn-related ER visits were for non-severe burns (n=134,120, 94.4%). ER visits for acute burn injury decreased by 21.6% during 2020 when compared to years prior. Stratification by age group revealed that pediatric patients (< 18) had more significant decreases in ER Visits than adult patients (≥18). Pediatric patients visited the ER 71.6% less than adults during 2020. When stratified by burn severity, patients with severe burns ( >20% TBSA) and patients with non-severe burns (< 20% TBSA) had similar decreases in ER usage during 2020 when compared to years prior (21.7% and 24.6%, respectively). Further age analysis revealed that both pediatric patients with severe burns and pediatric patients with non-severe burns visited the ER less than their adult counterparts (71.4% and 60.9%, respectively). All of the above differences were statistically significant (p< .05).ConclusionsDuring the COVID-19 pandemic in 2020, there was a sharp decrease in ER usage by patients with severe and non-severe burn injuries. This decrease was particularly salient in pediatric populations across all TBSA data points measured.

Non-severe burn injury increases cancer incidence in mice and has long-term impacts on the activation and function of T cells.

BackgroundRecent evidence suggests that burn patients are at increased risk of hospital admission for infection, mental health conditions, cardiovascular disease and cancer for many years after discharge for the burn injury itself. Burn injury has also been shown to induce sustained immune system dysfunction. This change to immune function may contribute to the increased risk of chronic disease observed. However, the mechanisms that disrupt long-term immune function in response to burn trauma, and their link to long-term morbidity, remain unknown. In this study we investigated changes to immune function after burn injury using a murine model of non-severe injury.MethodsAn established mouse model of non-severe burn injury (full thickness burn equivalent to 8% total body surface area) was used in combination with an orthotopic model of B16 melanoma to investigate the link between burns and cancer. Considering that CD8+ T cells are important drivers of effective tumour suppression in this model, we also investigated potential dysregulation of this immune population using mouse models of burn injury in combination with herpes simplex virus infection. Flow cytometry was used to detect and quantify cell populations of interest and changes in immune function.ResultsWe demonstrate that 4 weeks after a non-severe burn injury, mice were significantly more susceptible to tumour development than controls using an orthotopic model of B16 melanoma. In addition, our results reveal that CD8+ T cell expansion, differentiation and memory potential is significantly impaired at 1 month post-burn.ConclusionsOur data suggests that CD8+ T cell-mediated immunity may be dysfunctional for a sustained period after even non-severe burn injury. Further studies in patients to validate these findings may support clinical intervention to restore or protect immunity in patients after burn injury and reduce the increased risk of secondary morbidities observed.

A bivariate extreme value model for estimating crash frequency by severity using traffic conflicts

Estimating crash frequency by severity levels using traffic conflicts remains relatively unexplored in conflict-based traffic safety assessment, limiting its application scope and appeal compared to traditional methods. No studies to date have predicted the frequency of severe and non-severe crashes utilizing traffic conflicts. This study aims to address this critical gap and stimulate discussion and development in this critical area. The study estimates the frequency of severe crashes and non-severe crashes by jointly modeling the indicators of crash frequency, namely, Time to Collision (TTC) and Modified Time to Collision (MTTC), and crash severity, namely, predicted post-collision change in velocity (Delta-V or Δv), using bivariate Extreme Value. Severe crashes here are defined as crashes with a Maximum Abbreviated Injury Scale rating of greater than or equal to 3. Rear-end conflict data (TTC ≤ 3.0 s) were collected for two days (12 h each day) from two four-legged signalized intersections in Brisbane, Australia. Bivariate peak-over-threshold models for both TTC and MTTC indicators, combined with Delta-V, were estimated. Alternatively, another univariate approach was also attempted where the probability of crash occurrence was estimated using the univariate peak-over-threshold model with TTC (or MTTC) and then multiplied with the injury probability estimated from Delta-V to estimate the frequencies of severe and non-severe injury crashes. The study results demonstrate that the bivariate approach is more advantageous than the univariate approach due to a superior statistical fit to the data and more precise estimations of crash frequencies by severity levels. Both TTC and MTTC indicators, in combination with Delta-V, provide comparable results using the bivariate approach owing to the weak asymptotic dependence between the frequency and severity indicators. Comparing the combined dataset model of the two intersections with the intersection-based models shows that sharing information between similar traffic sites improves the accuracy and precision of prediction.

Epidemiological analysis of injury occurrence and current prevention strategies on international amateur football level during the UEFA Regions Cup 2019

IntroductionFootball is the most popular sport worldwide and results in a high frequency of injuries. So far, mainly injuries in professional football have been investigated, and the literature lacks data regarding detailed injury epidemiology and current prevention data in amateur football tournaments.Materials and methodsA prospective cohort study investigated an international amateur football tournament, the UEFA Regions’ Cup, which took place in 2019 in Germany. Injury epidemiology, current prevention strategies of the teams and the implementation of the UEFA concussion protocol were investigated in detail by means of standardized injury definitions and data samples for football (Fuller et al., Scand J Med Sci Sports 16:83–92, https://doi.org/10.1111/j.1600-0838.2006.00528.x, 2006).Results138 player of 8 teams participated in this study, while 39 players were excluded. Overall injury incidence was 12.5 per 1000 h total football exposure, 43.5 per 1000 h for match exposure. No injuries were registered during training. Injury prevalence was 14.1% per player and 1.1 injuries per match were registered. The lower extremity was predominantly affected by injuries (71.4%) and the majority of injuries (78.6%) were non-severe injury types like contusions (50%) and sprains (18.2%). Two head injuries, one contusion and one skin lesion, were handled by the guidelines of the UEFA concussion protocol. 44.4% of the players indicated at least one previous injury before tournament, 45.3% of them during the last two football seasons before start of the tournament. Injury prevention performance was included in all participating teams during the tournament by warm up or training strategies (100%). During the warm-up program just 5 exercises of the FIFA 11 + program was detected by this investigation in participating teams to be done by more half of the teams. Running exercises were the most frequently performed exercises, while trunk muscle exercises were less represented (14.3%).ConclusionThis study presents for the first time epidemiological injury and prevention data of the UEFA Regions Cup. Injury incidence was higher compared to injury reports of regular seasons, but lower compared to other amateur football tournaments. Currently used prevention programs revealed trunk muscle exercises as often neglected.

Prediction of severe chest injury using natural language processing from the electronic health record

IntroductionTrauma injury severity scores are currently calculated retrospectively from the electronic health record (EHR) using manual annotation by certified trauma coders. Natural language processing (NLP) of clinical documents in the EHR may enable automated injury scoring. We hypothesize that NLP with machine learning can discriminate between cases of severe and non-severe injury to the thorax after trauma. MethodsClinical documents from a trauma center were examined between 2014 and 2018. Severe chest injury was defined as a thorax abbreviated injury score (AIS) >2 and served as the reference standard for supervised learning. Free text unigrams and concept unique identifiers (CUIs) from the Unified Medical Language Systems (UMLS) were extracted from clinical documents collected at one hour, four hours, and eight hours after patient arrival to the emergency department. Logistic regression models with elastic net regularization were tuned to maximize area under the receiver operating characteristic curve (AUROC) using 10-fold cross-validation on the training dataset (80%) and tested on a hold-out 20% dataset. ResultsThere were 6,891 traumas that met inclusion criteria. The complete data corpus consisted of 473,694 documents. Models trained using the first hour of data had a mean AUROC of 0.88 (95%CI [0.86, 0.89]); model discrimination and reclassification from the first hour significantly improved after eight hours with a mean AUROC of 0.94 (95%CI [0.93, 0.95]). Performance of models using CUIs were similar to unigrams (p>0.05). Models demonstrated excellent clinical face validity. ConclusionsBoth CUIs and unigrams demonstrated excellent discrimination in predicting severity of chest injury using the first eight hours of clinical documents. Our model demonstrates that automated anatomical injury scoring is feasible and may be used for aggregation of data for trauma research and quality programs.

Pediatric Burn Survivors Have Long-Term Immune Dysfunction With Diminished Vaccine Response.

Epidemiological studies have demonstrated that survivors of acute burn trauma are at long-term increased risk of developing a range of morbidities. The mechanisms underlying this increased risk remain unknown. This study aimed to determine whether burn injury leads to sustained immune dysfunction that may underpin long-term morbidity. Plasma and peripheral blood mononuclear cells were collected from 36 pediatric burn survivors >3 years after a non-severe burn injury (<10% total body surface area) and from age/sex-matched non-injured controls. Circulating cytokine and vaccine antibody levels were assessed using multiplex immunoassays and cell profiles compared using a panel of 40 metal-conjugated antibodies and mass cytometry. TNF-α (1.31-fold change from controls), IL-2 (1.18-fold), IL-7 (1.63-fold), and IFN-γ (1.18-fold) were all significantly elevated in the burn cohort. Additionally, burn survivors demonstrated diminished antibody responses to the diphtheria, tetanus, and pertussis vaccine antigens. Comparisons between groups using unsupervised clustering identified differences in proportions of clusters within T-cells, B-cells and myeloid cells. Manual gating confirmed increased memory T-regulatory and central memory CD4+ T-cells, with altered expression of T-cell, B-cell, and dendritic cell markers. Conclusions: This study demonstrates a lasting change to the immune profile of pediatric burn survivors, and highlights the need for further research into post-burn immune suppression and regulation.

Trends, Cost, and Mortality From Sepsis After Trauma in the United States: An Evaluation of the National Inpatient Sample of Hospitalizations, 2012-2016.

Identification and outcomes in patients with sepsis have improved over the years, but little data are available in patients with trauma who develop sepsis. We aimed to examine the cost and epidemiology of sepsis in patients hospitalized after trauma. Retrospective cohort study. National Inpatient Sample. Sepsis was identified between 2012 and 2016 using implicit and explicit International Classification of Diseases, Ninth and Tenth Revision codes. Analyses were stratified by injury severity score greater than or equal to 15. Annual trends were modeled using generalized linear models. Survey-adjusted logistic regression was used to compare the odds for in-hospital mortality, and the average marginal effects were calculated to compare the cost of hospitalization with and without sepsis. There were 320,450 (SE = 3,642) traumatic injury discharges from U.S. hospitals with sepsis between 2012 and 2016, representing 6.0% (95% CI, 5.9-6.0%) of the total trauma population (n = 5,329,714; SE = 47,447). In-hospital mortality associated with sepsis after trauma did not change over the study period (p > 0.40). In adjusted analysis, severe (injury severity score ≥ 15) and nonsevere injured septic patients had an odds ratio of 1.39 (95% CI, 1.31-1.47) and 4.32 (95% CI, 4.06-4.59) for in-hospital mortality, respectively. The adjusted marginal cost for sepsis compared with nonsepsis was $16,646 (95% CI, $16,294-$16,997), and it was greater than the marginal cost for severe injury compared with nonsevere injury $8,851 (95% CI, $8,366-$8,796). While national trends for sepsis mortality have improved over the years, our analysis of National Inpatient Sample did not support this trend in the trauma population. The odds risk for death after sepsis and the cost of care remained high regardless of severity of injury. More rigor is needed in tracking sepsis after trauma and evaluating the effectiveness of hospital mandates and policies to improve sepsis care in patients after trauma.