Repeat Injury Research Articles

Preschool Children at Risk for Repeat Injuries

Home-related injuries are a major problem in young children. This study investigated maternal and child characteristics related to repeat injuries in preschool children. A secondary data analysis was conducted on a national probability sample of African American and White mothers who participated in the longitudinal study of the National Maternal and Infant Health Survey. Repeat injuries in the African American group were associated with poor maternal health status, maternal use of alcohol, and Ipecac in the home. Significant factors for the White group were male child, unmarried mother, difficulty managing the child, maternal depression, poor maternal health status, and Ipecac in the home. Findings support the need to identify high-risk children and to provide interventions specially aimed at amelioration of those factors related to repeat injuries.

Sequential injury of the rabbit abdominal aorta induces intramural coagulation and luminal narrowing independent of intimal mass: extrinsic pathway inhibition eliminates luminal narrowing.

We hypothesized that activation of the coagulation cascade is involved in arterial remodeling in response to sequential injury. An active site-inhibited recombinant human factor VIIa (FVIIai) was used to inhibit tissue factor, the primary cofactor in the extrinsic pathway of coagulation, in a sequential balloon injury model of the rabbit abdominal aorta. Single balloon injury produced limited intimal thickening at 3 weeks (intimal area, 0.40+/-0.05 mm2) and no loss in luminal area (12.2+/-0.9 mm2 before injury and 12.1+/-0.9 mm2 at 6 weeks after injury). Sequential balloon injury, 3 weeks after the first balloon denudation, produced a progressive loss of lumen, with 22% and 47% loss of luminal area, respectively, at 3 and 6 weeks. Luminal loss could not be accounted for by intimal growth (at 3 weeks after sequential injury, the intimal area was 0.47+/-0.08 mm2, <4% of the initial luminal area). Sequential injury acutely produced extensive mural and intramural fibrin deposition. Treatment with FVIIai inhibited both the fibrin deposition and the chronic loss of lumen. At 3 weeks after sequential injury, luminal cross-sectional areas were 9.8+/-0.6 mm2 for control rabbits and 14.3+/-1.4 mm2 for FVIIai-treated rabbits. Neither neointimal area nor cell proliferation was reduced by FVIIai treatment. The intimal cell proliferation index 3 days after injury was 7.6+/-1.1% in control rabbits versus 5.8+/-1.1% in treated rabbits (P>0.05). These results indicate that tissue factor is an important mediator of coagulation in repeat injury and implicate the extrinsic coagulation cascade in a blood vessel remodeling response that is independent of neointimal growth but leads to extensive loss of lumen.

The urban epidemiology of recurrent injury: beyond age, race, and gender stereotypes.

To profile all patients presenting to an urban ED with any injury, and to determine whether the rate of subsequent injury treated in the ED varied by demographic and E-code (external mechanism of injury) category. The hypothesis that young black males were disproportionately at risk for re-injury was addressed. A cohort of consecutive patients presenting to an urban ED with any injury between January 1, 1991, and November 31, 1992, were followed prospectively for 1 year from their index visit dates. Any repeat ED visits due to injury were sought. The mean number of injury visits per year (the total number of ED injury visits for each patient divided by 1 year) was computed for the overall population and by race, age, gender, and E-code. The sample consisted of 34,378 patients who made 44,813 visits to the ED for injury. Of these patients, 22% had a repeat injury in 1 year, with a cohort mean of 1.30 injury visits per year. This mean did not vary appreciably by race (black 1.33, white 1.27), age (1-17 yr, 1.21; 18-24 yr, 1.32; 25-64 yr, 1.34; > 65 yr, 1.23), gender (males 1.33, females 1.27), or E-code category. Having a prior injury visit in the preceding year was the best predictor of future injury (mean repeat visit rate = 2.08). When examining patients presenting with any injury to an urban ED, the mean numbers of injury visits are remarkably similar across demographic and E-code categories. Although there are factors that place patients at risk for recurrent injury, those factors are not demographic-all patients presenting to an ED with injury should be considered at risk for re-injury.

Sports-Related Recurrent Brain Injuries— United States

An estimated 300,000 sports-related traumatic brain injuries (TBIs) of mild to moderate severity, most of which can be classified as concussions (i.e., conditions of temporarily altered mental status as a result of head trauma), occur in the United States each year. The proportion of these concussions that are repeat injuries is unknown; however, there is an increased risk for subsequent TBI among persons who have had at least one previous TBI. Repeated mild brain injuries occurring over an extended period (i.e., months or years) can result in cumulative neurologic and cognitive deficits, but repeated mild brain injuries occurring within a short period (i.e., hours, days, or weeks) can be catastrophic or fatal. The latter phenomenon, termed "second impact syndrome", has been reported more frequently since it was first characterized in 1984. This report describes two cases of second impact syndrome and presents recommendations developed by the American Academy of Neurology to prevent recurrent brain injuries in sports and their adverse consequences.

Rejuvenation of the disposable soma: repeated injury extends lifespan in an asexual annelid.

The disposable soma theory of senescence proposes that aging is the result of the accumulation of somatic damage with age resulting from insufficient somatic maintenance and repair. Comparative studies that show a positive correlation between longevity and DNA excision repair efficiency in mammals provide support for the theory but their validity has been questioned. A more satisfactory approach to investigate the role of somatic damage accumulation in aging would be to manipulate experimentally the levels of somatic repair and observe its effect on longevity. Here I report the results of studies in the asexual annelid Paranais litoralis where I have experimentally extended the worms' lifespan by subjecting them to repeated injury. I propose that repeated injury enhanced the normal level of repair of the worms, resulting in a rejuvenation of the soma. These results provide experimental support for the disposable soma theory of senescence.

Restenosis is associated with decreased coronary artery nitric oxide synthase

The purpose of the present study was to test the hypothesis that restenosis is associated with decreased constitutive nitric oxide synthase activity. Male miniswine with moderately elevated serum cholesterol levels underwent cardiac catheterization and oversized balloon injury to the right and left circumflex coronary arteries, followed 2 weeks later by repeat injury on the same coronary segments. After 4 weeks, the coronary arteries were either immediately frozen in liquid nitrogen or pressure-perfusion fixed and prepared for histologic examination. Constitutive nitric oxide synthase activity was quantified using a fibroblast reporter cell method, while constitutive nitric oxide synthase protein was compared between balloon-injured and non-balloon-injured arteries using Western blot analysis. Immunohistochemical studies were performed using a specific antibody against constitutive nitric oxide synthase protein. Following balloon injury, there was decreased constitutive nitric oxide synthase activity in balloon-injured coronary arteries, compared to distal non-balloon-injured segments from the same artery. Histological examination demonstrated an intact endothelium. Specific antibody staining revealed that there was less constitutive nitric oxide synthase protein reactivity by immunohistochemical analysis. Western analysis confirmed less constitutive nitric oxide synthase protein. The data are consistent with the hypothesis that restenosis is associated with decreased endothelial cell nitric oxide production. The data suggest this is secondary to a decreased amount of constitutive nitric oxide synthase enzyme in the endothelium. A deficiency in constitutive nitric oxide synthase enzyme may contribute to the impaired second messenger and paracrine functions of the endothelium observed during restenosis following balloon injury, including abnormal vasomotion, extracellular matrix formation, and platelet aggregation.

Long-Term Prognosis of Isolated Partial Medial Collateral Ligament Ruptures

We prospectively observed 38 patients with nonoperatively treated isolated partial ruptures of the knee medial collateral ligament at 3 months, 4 years, and 10 years after the initial trauma using clinical and radiographic examinations. The initial diagnoses were based on clinical and arthroscopic examinations. Three months after injury, 28 patients (74%) had regained nearly normal knee function and muscle strength, and 75% of these patients could perform at their preinjury activity level (competitive team sports). Five patients (13%) had increased valgus laxity (grade 1) in the injured knee. After 4 years, the patients had a median Lysholm score of 100 (range, 64 to 100). Thirty-three patients (87%) had normal knee function during strenuous activities. Repeat injuries to the medial collateral ligament occurred in two patients (5%), and another two patients sustained cruciate ligament injuries during the follow-up period. After 10 years, the Lysholm score (median, 95; range, 73 to 100) was lower compared with the 4-year score (P < 0.03), but the patients still performed on a similarly high activity level. Five patients (13%) had distinct signs of beginning osteoarthritis (Fairbank's signs) on radiographs, but none had joint space reduction.

Risk factors of adolescent and young adult trauma victims

Repeated injury, or recidivism, because of intentional or unintentional injury is a growing chronic health problem among urban adolescents and young adults in the United States. To describe demographic, social, environmental, psychological, and developmental antecedents and risk-taking behaviors, and to examine their relationships to type of trauma and rate of trauma recidivism in adolescent and young adults in an urban trauma center. One hundred adolescent and young adult trauma victims in an urban trauma center were interviewed, using the Adolescent Risk-Taking Instrument, the Brief Anger/Aggression Questionnaire, and the Trauma Risk Factor Interview Schedule. Bivariate correlation, multiple regression, and discriminant function analysis were used to examine the data. Of the sample, 89% experienced trauma related to interpersonal violence, including firearm injuries, stab wounds, and blunt trauma. Male gender, unemployment, past arrest, lower levels of spirituality, and higher levels of anger/aggression and thrill-seeking accounted for 25% of the variance in the number of risk-taking behaviors. Factors such as male gender, past arrest, unemployment, having been a crime victim in the past, lower autonomy, use of weapons, fighting, and no psychological counseling distinguished subjects with firearm-related injuries from subjects with other injury sources. Use of alcohol on weekdays, past arrest, and higher education levels were associated with trauma recidivism, explaining 14% of the variance. Social/environmental and psychological/developmental variables, as well as risk-taking behaviors, are important correlates of trauma and recidivism. These findings suggest the importance of advocacy for social policies conductive to reducing the risks of violence and trauma and risk-reduction interventions as components of posttrauma care.

Substance abuse as a mediating factor in outcome from traumatic brain injury

A review of recent research addressed two questions: how common are problems of substance abuse in traumatic brain injury (TBI), and to what extent does alcohol and other drug use mediate outcome? Studies showed alcohol intoxication present in one third to one half of hospitalizations; data for other drug intoxication were not available. Nearly two thirds of rehabilitation patients may have a history of substance abuse that preceded their injuries. Intoxication was related to acute complications, longer hospital stays, and poorer discharge status; however, these relationships may have been caused by colinearity with history. History of substance abuse showed the same morbidity, and was further associated with higher mortality rates, poorer neuropsychological outcome, and greater likelihood of repeat injuries and late deterioration. The effect of history may be caused by subgroups with more severe substance abuse problems. Implications for rehabilitation are discussed, including the potential negative impact of untreated substance abuse on the ability to document efficacy of rehabilitation efforts.

Return to work following an aquafitness and muscle strengthening program for the low back injured

Our purpose, in this prospective clinical study, was to identify the best predictors of 2-month return to work or retraining for a group of low back injured subjects (n = 40) who completed at least 8 weeks of a community-based rehabilitation program that combined aerobic and flexibility exercise conducted in the water (aquafitness) with muscle strength and endurance training. Baseline demographic characteristics and changes in physical fitness, pain, disability, and psychological well-being during the course of program participation were compared between two groups of low back injured subjects: those who returned to work (RTW) [n = 24], and those who did not (N-RTW) [n = 16]. Subjects in both groups showed comparable improvement in measures of physical fitness at 8 weeks. However, multivariate analyses showed significant between-group differences in self-report measures. The RTW group showed significant improvement in measures of pain, disability, anxiety, and vigor while self-esteem and affect remained stable. The N-RTW group displayed no change in pain and disability variables and had significant deterioration in mean overall psychological well-being over time. The best predictors of return to work using logistic regression analyses were a first injury rather than a repeat injury to the lower back, and stability in self-esteem. Suggestions are offered for further research to examine the benefits of aquafit exercise for the low back injured, for additional interventions for those with a reinjury, and for maintaining or enhancing self-esteem as a treatment goal.

An audit of non-accidental injury in burned children

The incidence of non-accidental injury in burned children and the repeat injury rate following non-accidental injury is very high according to some reports. A retrospective follow-up review was undertaken for all patients admitted to the Plymouth Paediatric Burns Unit over a 47-month period. Hospital records, general practitioners' records and the Social Services Department were used to gain follow-up information. The incidence of confirmed abuse was about 3 per cent and this included intentional injury as well as other forms of abuse such as neglect. The repeat injury rate was very low indeed. These figures are very much lower than many of the published figures. This may be due to differences in the definition of non-accidental injury, differences in the population make-up or simply that a burn injury is a relatively uncommon form of non-accidental injury in Devon and Cornwall.

Injury Type, Injury Severity, and Repeat Occurrence of Alcohol‐Related Trauma in Adolescents

Injury associated with alcohol use is a significant problem among adolescents; however, routine evaluation of alcohol use in this population is not conducted. The purpose of this study was to compare injured adolescents presenting to an emergency room with a positive serum alcohol concentration (SAC+) with those injured adolescents with a negative serum alcohol concentration (SAC-). Data were collected retrospectively on 176 injured patients, between the ages of 13 and 18, consecutively admitted to a university hospital from January 1, 1989-December 31, 1990. Information collected included mechanism and severity of injury, outcome, SAC, length of stay, psychiatric history, prior or subsequent admission for injury, and hospital charges. Of those tested with an SAC, more than one-third had a positive SAC. Patients with positive SACs had a greater probability of having a psychiatric history and more frequently had a prior or subsequent injury. Furthermore, only 34% of SAC+ patients were referred for counseling. The results indicate that a SAC should be obtained on all adolescents admitted for trauma, that adolescents presenting with injuries and a positive SAC should be referred for alcohol and psychiatric assessment, and that injured adolescents may be at increased risk for repeat injuries in the future.

Evaluation of knee braces in Swedish ice hockey players.

In this retrospective investigation we have determined the rate and types of knee injuries among Swedish ice hockey players, and related these data to the use of knee braces. Thirty-seven of the originally selected 50 hockey teams (74%) of elite or first division calibre took part in the study, and 600 players answered a questionnaire. A total of 254 previous knee injuries sustained while playing hockey were reported by 243 players; tears of the medical collateral ligament (60%), meniscus (15%) or anterior cruciate ligament (12%) were the most commonly reported injuries. Prophylactic knee braces were worn by 138 (23%) of the players. Of these, 122 (88%) had earlier sustained a knee injury, and 16 had not. A total of 17 knee injuries had occurred while the players were wearing a brace. Six of these players had previously uninjured knees while 11 had repeat injury in a brace despite earlier successful rehabilitation or operation. The most common injury in braced knees was a tear of the medial collateral ligament. We conclude that the number of knee injuries is high among Swedish ice hockey players, and that the efficacy of functional knee braces to reduce knee injuries is questionable.

Neuropathological observations in a case of autism presenting with self-injury behavior

We report the neuropathological evaluation of a 24-year-old autistic woman suffering from a residual state of infantile autism and presenting with self-injury behavior since childhood. Her behavior included head-banging, eye-gouging and self-biting. All intended therapeutic measures remained without effect, including high doses of psychotropic drugs. At autopsy, numerous neurofibrillary tangles were found in the perirhinal and entorhinal cortex where they were frequently grouped in nests or clusters. A few neurofibrillary tangles were also observed in the amygdala and in the prepiriform and orbito-frontal cortex. In the cortex, tangles were located in both layers II and III. There were no neuritic plaques or amyloid deposits. Interestingly, neurofibrillary tangles have been described in brains of individuals who had experienced repeated head injuries such as boxers (dementia pugilistica) and soccer players, suggesting that in our case a similar mechanism induced tangle formation and resulted in the loss of selective neuronal populations.

The conservative treatment of the anterior cruciate deficient knee

Seventy-nine recreational athletes (average age, 26 years) with complete ACL tears were treated with nonligamentous arthroscopic surgery, monitored rehabilitation, functional bracing, and activity modification. The average followup was 52 months (range, 36 to 102 months). Six (8%) patients ultimately underwent ligament reconstruction and were considered failures of nonreconstructive treatment. The remaining 73 patients were the subject of detailed analysis. There were 9 (11%) excellent, 25 (32%) good, 17 (22%) fair, and 28 (35%) poor results. Although 71 patients (97%) were satisfied with their knee for activities of daily living, only 36 (49%) were satisfied with their knee for sports. Twenty-nine (40%) had significantly modified their athletic activities. Age, sex, interval from injury to treatment, associated meniscal tears (49 or 67%), and articular cartilage damage (21 or 29%) had no apparent effect on the outcome. Poor results were noted in 29 (40%) patients with significant pivot shifts. Multiple repeat injuries, repeat arthroscopy, isokinetic deficits, and increased length of followup were also associated with poor results.

The relation among vessel injury, thrombus formation, and platelet survival in rabbits

Continuous or repeated injury of rabbit aortae by indwelling vascular catheters caused the deposition of platelets on the injured vessels and the formation of thrombi rich in platelets and fibrin at sites where flow was most disturbed and injury was most extensive. Incorporation of 51Cr platelets into the thrombi reached a maximum between 3 and 24 hr. The platelet-fibrin-rich thrombi remained reactive to circulating platelets for at least 14 days. Continuing reactivity of thrombi and the turnover of platelets in the thrombi were accompanied by an increase in the proportion of platelets that separated in the least dense fraction on Stractan density gradients. Platelet survival was also shortened (43.5 ± 5.9 hr in animals with catheters, compared with 62.6 ± 4.5 hr in animals with a sham operation), indicating that some platelets that had taken part in thrombus formation or had interacted with the injured vessel wall were rapidly cleared from the circulation. Platelets from rabbits that had had indwelling aortic catheters in place for 3 or 6 days survived significantly longer than those from animals with a sham operation upon injection of the platelets into normal animals; thus, continuous turnover of platelets on injured vessels and thrombi, and the clearance of altered platelets, leads to a population of younger platelets that survive longer. The continuing reactivity of thrombi may in part account for repeated occlusive episodes in vascular disease. The contribution of thrombin generation and fibrin formation to the platelet-rich thrombi is substantial and warrants the ongoing evaluation of treatment with a combination of anticoagulant and antiplatelet agents in arterial thrombosis and in thrombus formation on vascular catheters.

The conservative treatment of the anterior cruciate deficient knee

Seventy-nine recreational athletes (average age, 26 years) with complete ACL tears were treated with nonligamentous arthroscopic surgery, monitored rehabilitation, functional bracing, and activity modification. The average followup was 52 months (range, 36 to 102 months). Six (8%) patients ultimately underwent ligament reconstruction and were considered failures of nonreconstructive treatment. The remaining 73 patients were the subject of detailed analysis. There were 9 (11%) excellent, 25 (32%) good, 17 (22%) fair, and 28 (35%) poor results. Although 71 patients (97%) were satisfied with their knee for activities of daily living, only 36 (49%) were satisfied with their knee for sports. Twenty-nine (40%) had significantly modified their athletic activities. Age, sex, interval from injury to treatment, associated meniscal tears (49 or 67%), and articular cartilage damage (21 or 29%) had no apparent effect on the outcome. Poor results were noted in 29 (40%) patients with significant pivot shifts. Multiple repeat injuries, repeat arthroscopy, isokinetic deficits, and increased length of followup were also associated with poor results.

Aluminium chloride injected in the snail Helix pomatia L. decreases the weights and calcium contents of shell-repair membranes

1. Aluminium (Al) was found to affect the process of shell-repair in the snail Helix pomatia L. The mean weights (MMWs) and calcium contents (MCCs) of the shell-repair membranes were decreased following injections of AlCl 3. 2. Repeated injury to the shell, without further Al-injections, resulted in increased MMWs and MCCs in snails injected with 10 and 50 mM Al, but not in animals receiving 100 mM. Following a longer period without injury, new damage resulted in membranes without differences between controls and treated animals. 3. Snails injected with 10 mM AlCl3 had ratios between MCCs and MMWs which were no different from the controls. The animals receiving the higher Al-concentrations did exhibit a decrease in this ratio. This implies that two mechanisms are involved; one affecting the synthesis of the organic matrix of the repair membrane and one in the subsequent mineralization of the matrix is inhibited.

Syndrome of deltoid and/or gluteal fibrotic contracture: an injection myopathy.

One hundred and fifteen cases of injection myopathy with deltoid and/or gluteal fibrotic contracture were studied, almost all of whom had definite histories of repeated intra-gluteal or intra-deltoid injections. One third had siblings affected by the same fibro-muscular disorders manifested by focal muscle atrophy and limitation of adduction and flexion of the shoulder or hip. Electromyography disclosed myopathic changes of the fibrotic muscles. Muscle biopsy showed marked perimysial and endomysial fibrosis with non-specific degeneration, regenerative changes and, in some cases, partial denervation signs. Under the electron microscope, endomysial and perimysial collagen fibrils lost their normal unimodal diameter distribution and showed a rather broad spectral distribution of diameters suggesting a defective control of collagen formation in this disease entity. Repeated injection injuries and myotoxicity resulting in multifocal myositis are the first trigger of this fibrotic syndrome, and abnormal control of collagen formation could be another important pathogenic factor.

Insights into coronary angioplasty-induced restenosis from examination of atherogenesis

Atherogenesis is a complex tissue reaction involving both vascular and circulating cells and components. The former include endothelial and smooth muscle cells, the latter circulating monocytes, platelets and lipoproteins. The role of growth factors secreted by platelets and all the cells involved in setting into motion a fibrocellular vascular reaction has been recently elucidated. Repeated injury or the presence of hyperlipidemia leads to occlusive disease. Many of these cellular events are also likely to be stimulated by the vascular injury that occurs as part of the angioplasty procedure. Restenosis, a major complication of the latter, may reflect the vascular response to iatrogenic injury. Progress in understanding the mechanisms involved in restenosis should also clarify important aspects of atherogenesis.