Severe Injury Research Articles

Changes in Secondary Health Conditions Among Individuals With Spinal Cord Injury After Transition From Inpatient Rehabilitation to Community Living.

The aim of the study is to examine the changes in the burden of secondary health conditions and their risk factors among newly injured individuals with spinal cord injury after discharge from inpatient rehabilitation to community living. This is a prospective cohort study. Among 280 included persons, the majority were men with traumatic spinal cord injury and paraplegia. The most common secondary health conditions at discharge from rehabilitation and in the community setting were pain (60.8% vs. 75.9%), urinary tract infections (27.8% vs. 47.6%), and pressure sores (9.9% vs. 27.5%). There was also a significant increase in reported heart disease (9.3% vs. 14.8%) and diabetes (0% vs. 4.2%). The odds of experiencing pain, pressure sores, depression and urinary tract infections increased after discharge from rehabilitation, whereas the odds of respiratory problems decreased significantly during the observation period. Factors such as sex, injury severity, activity limitations, and duration of follow-up were identified as potential risk factors influencing secondary health condition occurrence. Our study emphasizes a significant rise in secondary health conditions after the transition to community living. Future research should prioritize development of targeted intervention programs tailored to address the unique needs of affected individuals at this pivotal stage in the continuum of spinal cord injury care.

Patients with crush syndrome and kidney disease: lessons learned from the earthquake in Kahramanmaraş, Türkiye

This study investigated in-hospital outcomes and related factors in patients diagnosed with postearthquake crush syndrome after the earthquakes in Kahramanmaraş, Türkiye. One thousand twenty-four adult patients diagnosed with crush syndrome were analyzed. Data on demographic characteristics, clinical presentation, laboratory values, treatments, and outcomes were collected. A total of 9.8% of patients died during their hospital stay. Nonsurvivors were generally older, more likely to have preexisting chronic kidney disease, and faced more severe injuries and complications, including hypotension-shock, arrhythmias, elevated markers of renal dysfunction, and higher rates of acute kidney injury (AKI) and compartment syndrome. In addition, intensive care unit needs were higher. Multivariate analysis confirmed that age, injury severity, shock, high potassium, uric acid, and lactate levels on admission, development of AKI, compartment syndrome, and intensive care unit admission were significant predictors of mortality. Better disaster preparedness and improved health care infrastructure could be potential explanations for improved in-hospital mortality in the current era, as compared to previous earthquakes.

Comparison of gauze packing, sponge-based, and hemostatic Surgicel wound stasis dressings to treat hemorrhages from grade IV liver injuries: An experimental study

BackgroundUncontrolled bleeding is still the major factor leading to preventable deaths following trauma. This study sought to assess the effectiveness of mini sponge-based wound stasis, cellulose-based local hemostatic, and traditional gauze dressings for the control of hemorrhages resulting from grade 4 liver injuries in rats. MethodsThirty Sprague-Dawley rats were divided into three equal groups. In the first group, a liver laceration was treated with gauze packing. The second group received XStat minisponge dressing (MDS), and the third group was administered a combination of MDS dressing and Surgicel hemostatic agent. After gaining access to the intra-abdominal cavity, a liver laceration measuring 10 mm in length, 5 mm in depth, and extending to the middle lobe was created. The dressings were removed after 2 and 10 minutes to assess the amount of bleeding, and any bleeding was documented again after 48 hours. Intraperitoneal adhesions were evaluated during euthanasia. ResultsAt 2 minutes post-injury, the gauze packing group had an average bleeding volume of 0.97±0.15 mL, compared to 1.08±0.25 mL in the MDS group (P=0.26) and 1.02±0.18 mL in the MDS+Surgicel group (P=0.69). At 10 minutes, the bleeding volumes were 0.13±0.05 mL, 0.22±0.01 mL (P=0.09), and 0.14±0.05 mL (P=0.19), respectively. At 48 hours, significant differences were observed in bleeding volumes (gauze: 0.55±0.18 mL, MDS: 1.15±0.21 mL, MDS+Surgicel: 0.82±0.06 mL, P<0.001). Mortality rates after 14 days were 0% in the gauze packing group, 60% in the MDS group (P=0.001), and 60% in the MDS+Surgicel group (P=0.001). The gauze packing group displayed no adhesions, while the other groups exhibited adhesions in the liver, bowel, omentum, and abdominal wall. ConclusionOur results indicate that, when it comes to managing bleeding in severe liver injuries, traditional gauze packing remains the tried-and-true method, showing superior effectiveness in terms of blood loss and mortality when compared to XStat minisponge dressings and the fibrillar Surgicel hemostatic agents.

Trauma Program Value Assessment at an Academic Health Network System Over 12 Years.

Trauma is a leading cause of global death, with 200000 deaths and over 3 million non-fatal injuries/year in the United States. We aim to assess trauma care value for patients who underwent urgent laparotomies (LAP) and thoracotomies (THO) in our Health Network System. Clinical variables (v = 84) from trauma patients (>18 yo) were retrieved retrospectively (Jan-2010 to July-2016) and prospectively (Aug-2016 to Sept-2021) from a Health System warehouse under IRB-approved protocols. Patients were divided according to their Injury Severity Score (ISS) into mild/moderate cases (ISS <15) and severe cases (ISS >15). Value was assessed using quality and cost domains. Quality surrogates included graded postoperative complications (PCs), length of stay (LOS), 30-day readmission (RA), patient satisfaction (PS), and textbook (TB) cases. Total charges (TCs) and reimbursement index (RI) were included as surrogates for cost. Value domains were displayed in scorecards comparing Observed (O) with Expected (E) (using the ACS risk calculator) outcomes. Uni-/multivariate analyses were performed using SPSS. 41,927 trauma evaluations were performed, leading to 16044 admissions, with 528 (3.2%) patients requiring urgent surgical procedures (LAP = 413 and THO = 115). Although the M:F ratio (7:3) was similar in LAP vs THO groups, age and BMI were significantly different (41.8 ± 19.1 vs 51.8 ± 19.9 years, 28.6 ± 9.9 vs 27.4 ± 7Kg/m2, respectively, P < .05). Blunt trauma was involved in 68.8/77.3% of the LAP/THO procedures, respectively (P < .05). Multivariate analyses showed ISS, age, ASA class, and medical center as factors significantly predicting PC (P < .05). Postoperative complication grades from the LAP/THO groups showed above-average outcomes; nonetheless, LOS was higher than the national averages. The Trauma Program holds high value in our Health Network System. Protocols for decreasing LOS are being implemented.

Ipsilateral Femoral Neck and Shaft Fractures: Complex Injuries With High Rates of Femoral Shaft Nonunion.

To investigate nonunion rates and risk factors in patients with ipsilateral femoral neck and shaft fractures. Retrospective review. Two Level I trauma centers. Two hundred seven patients treated for ipsilateral femoral neck (AO/OTA 31-B) and shaft (AO/OTA 32A-C) fractures from 2013 to 2022. Patients with less than 6 months of follow-up were excluded. The primary outcome of this study was femoral shaft nonunion. Risk factors for nonunion were evaluated, including smoking, open fracture, delay to full weight-bearing, blood transfusions, and AO/OTA classification. Two hundred twenty-seven patients were initially identified, but only 154 patients had sufficient follow-up and were included in final analysis. The mean age was 38.9 years (SD = 15.3), and injury severity score was 19.5 (9.7). One hundred ten patients (71%) were male and 69 (45%) required intensive care unit care. Thirty-eight patients (25%) experienced an open fracture, and 44 fractures (29%) were AO/OTA Type C. Thirty patients (20%) underwent initial external fixation, and 88 patients (57%) received a perioperative transfusion. Thirty-four patients (22%) developed a femoral shaft nonunion, and 5 (3%) experienced a surgical site infection. Nonunion was associated with perioperative blood transfusion, AO/OTA Type C fracture, postoperative non-weight-bearing, and delay to full weight-bearing ≥12 weeks. Multivariable regression identified perioperative blood transfusion ≥3 (risk ratio [RR] = 1.91; CI, 1.12-2.72; P = 0.02) and AO/OTA Type C fracture (RR = 2.45; CI, 1.50-3.34; P = 0.001) as independent risk factors. Ipsilateral femoral neck and shaft fractures remain difficult injuries to treat. Much attention is given to diagnosis and treatment of the femoral neck component. These results suggest that successful treatment of the femoral shaft component presents its own challenges with high nonunion rates. Prognostic Level III.

No benefit from the addition of low-dose ketamine infusion to standard evidence-based care of patients with multiple rib fractures.

Multiple rib fractures from blunt thoracic trauma cause significant morbidity. Optimal current management includes multimodal analgesia, pulmonary hygiene, and early mobilization. Low-dose ketamine infusion (LDKI) has been proposed as an adjunctive analgesic in this setting. A prior study reported decreased pain scores with LDKI in patients with multiple rib fractures. We hypothesized that LDKI would decrease morphine milligram equivalents (MMEs) in patients with multiple rib fractures. A prospective randomized placebo-controlled trial was performed in adult (18 years or older) patients with three or more rib fractures. A prestudy power analysis calculated an 80% chance of identifying a 15% decrease in MMEs with 50 subjects. The study was approved by the institutional review board and informed consent obtained in all subjects. Demographic (age, sex) and injury specific information (Injury Severity Score, number of rib fractures) were obtained. Subjects were randomized 1:1 to receive continuous LDKI (0.1 mg/kg/h) or placebo infusion (0.9% NaCl) for ≤48 hours. All patients received a standard evidence-based multidisciplinary protocol for rib fractures management. Primary outcome measure was MME use or pulmonary complications. Statistical comparison of LDKI versus placebo was performed using the Mann-Whitney U test. All 50 enrolled subjects (placebo, 25; LDKI, 25) received study drug infusion. The two groups were well matched for age, Injury Severity Score, and number of rib fractures. We observed no differences in the Day 1 (p = 0.961), Day 2 (p = 0.373), or total MMEs (p = 0.946) between groups. Similar total MME use was observed when subjects who received ≥40 hours of study drug and were compared (p = 0.924). Use of LDKI did not alter subsequent need for opiate analgesics postinfusion, hospital length of stay, pulmonary complications, or need for readmission. The addition of LDKI to an established multimodal, evidence-based protocol for management of multiple rib fractures did not decrease opiate usage or impact pulmonary complications. Therapeutic/Care Managaement; Level I.

Surgical Treatment and Outcomes of Trans-Ulnar Basal Coronoid Fracture-Dislocations

Trans-ulnar fracture-dislocations of the elbow are complex injuries that can be difficult to classify and treat. Trans-ulnar basal coronoid injuries, in which the coronoid is not attached to either the olecranon or the metaphysis, present substantial challenges to achieve anatomic reduction and stable internal fixation. The purpose of this study was to analyze the outcome of surgical treatment of trans-ulnar basal coronoid fracture-dislocations. Between 2002 and 2019, 32 consecutive trans-ulnar basal coronoid fracture-dislocations underwent open reduction and internal fixation (ORIF) at our institution. Four elbows were lost to follow-up within the first 6 months after surgery and were excluded. Among the 28 elbows remaining, there were 13 females and 15 males with a mean age of 56 (range 28-78) years at the time of injury. The mean clinical and radiographic follow-up times were 37 months and 29 months, respectively. Radiographs were reviewed to determine rates of union, Hastings and Graham heterotopic ossification (HO) grade, and Broberg and Morrey arthritis grade. Union occurred in 25 elbows. Union could not be determined for 1 elbow at most recent follow-up and the remaining 2 elbows developed nonunion of the coronoid. Complications occurred in 10 elbows (36%): deep infection (4), ulnar neuropathy (2), elbow contracture (2), and nonunion (2). There were reoperations in 11 elbows (39%): irrigation and débridement with hardware removal (4), hardware removal (2), ulnar nerve transposition (2), contracture release with HO removal (2), and revision ORIF with iliac crest autograft (1). At most recent follow-up, the mean flexion-extension arc was 106° (range 10-150°), and the mean pronation-supination arc was 137° (range 0-170°). The mean Quick Disabilities of Arm, Shoulder, and Hand score was 11 (range 0-39) points with a mean Single Assessment Numeric Evaluation-Elbow score of 81 (range 55-100) points. At final radiographic follow-up, 16 elbows (57%) had HO (8 class I and 8 class II), and 20 elbows (71%) had arthritis (8 grade 1, 6 grade 2, and 6 grade 3). Trans-ulnar basal coronoid fracture dislocations are severe injuries associated with high rates of reoperation, heterotopic ossification, and post-traumatic arthritis. However, the majority of elbows achieve union, a functional range of motion, and reasonable patient reported outcome measures. Over the study period, surgeons were more likely to utilize multiple deep approaches and separate fixation of the coronoid (either with lag screws or anteromedial plates) to ensure anatomic reduction.

Spiny mice are primed but fail to regenerate volumetric skeletal muscle loss injuries

BackgroundIn recent years, the African spiny mouse Acomys cahirinus has been shown to regenerate a remarkable array of severe internal and external injuries in the absence of a fibrotic response, including the ability to regenerate full-thickness skin excisions, ear punches, severe kidney injuries, and complete transection of the spinal cord. While skeletal muscle is highly regenerative in adult mammals, Acomys displays superior muscle regeneration properties compared with standard laboratory mice following several injuries, including serial cardiotoxin injections of skeletal muscle and volumetric muscle loss (VML) of the panniculus carnosus muscle following full-thickness excision injuries. VML is an extreme muscle injury defined as the irrecoverable ablation of muscle mass, most commonly resulting from combat injuries or surgical debridement. Barriers to the treatment of VML injury include early and prolonged inflammatory responses that promote fibrotic repair and the loss of structural and mechanical cues that promote muscle regeneration. While the regeneration of the panniculus carnosus in Acomys is impressive, its direct relevance to the study of VML in patients is less clear as this muscle has largely been lost in humans, and, while striated, is not a true skeletal muscle. We therefore sought to test the ability of Acomys to regenerate a skeletal muscle more commonly used in VML injury models.MethodsWe performed two different VML injuries of the Acomys tibialis anterior muscle and compared the regenerative response to a standard laboratory mouse strain, Mus C57BL6/J.ResultsNeither Acomys nor Mus recovered lost muscle mass or myofiber number within three months following VML injury, and Acomys also failed to recover force production better than Mus. In contrast, Acomys continued to express eMHC within the injured area even three months following injury, whereas Mus ceased expressing eMHC less than one-month post-injury, suggesting that Acomys muscle was primed, but failed, to regenerate.ConclusionsWhile the panniculus carnosus muscle in Acomys regenerates following VML injury in the context of full-thickness skin excision, this regenerative ability does not translate to regenerative repair of a skeletal muscle.

Digital Arterial Anastomosis as an Outpatient Surgery

Background: In incomplete amputation with a skin bridge, patency of the artery indicates digit survival if sufficient venous return is secured. This study aimed to investigate the effectiveness of digital arterial repair on an outpatient basis without using intravenous anticoagulants. Methods: We identified a total of 34 patients (34 digits) who underwent arterial repair for single vascular bundle injury between January 2000 and December 2022 on an outpatient basis. The following information were obtained from the patients’ medical records: sex, age, comorbidities, active smoking status, number of affected digits, level of amputation, type of the fracture type, mechanism of injury, arterial diameter, needle used, requirement of vein graft and the outcome. Results: Only a few fingertip injuries and severe injuries were included. Arterial patency was achieved in most patients after repair of an outpatient basis. Conclusion: Outpatient arterial repair may be acceptable under inevitable circumstances or to cater to patients’ preferences, when the injury is neither on the fingertip nor severe. Background: In incomplete amputation with a skin bridge, patency of the artery indicates digit survival if sufficient venous return is secured. This study aimed to investigate the effectiveness of digital arterial repair on an outpatient basis without using intravenous anticoagulants. Methods: We identified a total of 34 patients (34 digits) who underwent arterial repair for single vascular bundle injury between January 2000 and December 2022 on an outpatient basis. The following information were obtained from the patients’ medical records: sex, age, comorbidities, active smoking status, number of affected digits, level of amputation, type of the fracture type, mechanism of injury, arterial diameter, needle used, requirement of vein graft and the outcome. Results: Only a few fingertip injuries and severe injuries were included. Arterial patency was achieved in most patients after repair of an outpatient basis. Conclusion: Outpatient arterial repair may be acceptable under inevitable circumstances or to cater to patients’ preferences, when the injury is neither on the fingertip nor severe.

Administrating first aid in road traffic accidents in Bulgaria: a cross-sectional study

Abstract Background Bulgaria had the highest road mortality rate among European Union members in 2023, having previously ranked second after Romania. Research has consistently demonstrated that prompt pre-hospital care can significantly reduce the adverse effects of road traffic accidents. Thus, we conducted a cross-sectional study to explore the involvement of trained road traffic casualties and bystanders in administering first aid. Methods The study, carried out between April and December 2021, collected data via an online survey administered to members of the Scientific and Academic Cooperation Council by the State Agency Road Safety. The survey encompassed a range of topics, including first aid training, involvement in traffic accidents, behaviour of bystanders, administration of first aid, and sociodemographics. Results Among the 292 respondents, a sizeable proportion (90%) reported having received first aid training. Of these, 35.1% (95% CI 29.2-41.1%; p &amp;lt; 0.001) had personally experienced a road traffic accident, and 64.5% (95% CI 58.1-70.1%; p &amp;lt; 0.001) had witnessed one. It is noteworthy that a fifth of those involved in accidents had employed the skills acquired from first aid training, which included applying a dressing to a wound, bleeding control, and immobilising a fracture. Correspondingly, an equivalent percentage of bystanders administrated aid, with the majority of them performing basic airway management. However, the findings revealed that a significant proportion of participants (79.3%) did not engage in providing first aid. The primary rationale stated was the assessment that it was nonessential. Conclusions Despite the growing road safety challenges and many respondents witnessing or being involved in accidents, only a quarter of those trained in first aid actually provided assistance. Considering the increasing number of deaths and severe injuries, it is crucial to assess the need for frequent first aid training and the population’s proficiency in first aid. Key messages • Bystanders’ competence in administrating first aid can mitigate the adverse effects of road traffic accidents. • Among other road safety measures, investments in first aid training can be beneficial in reducing fatalities and severe injuries.

Use of extracorporeal membrane oxygenation during a decompressive hemicraniectomy for severe traumatic brain injury: illustrative case.

Decompressive hemicraniectomy (DHC) can be a life-saving treatment for patients with severe traumatic brain injury (TBI) with a focal mass lesion who develop refractory elevated intracranial pressure (ICP). Nonetheless, successful completion of this procedure requires maintaining hemodynamic and respiratory stability. Extracorporeal membrane oxygenation (ECMO) use in patients with respiratory or cardiac failure is well described in the literature and has become routinely used in patients with refractory hypoxia unresponsive to traditional mechanical ventilation strategies, but few cases of its use have been reported in the neurosurgical literature. Herein, the authors describe a unique case in which a man presented after an unwitnessed fall that caused severe TBI without a focal mass lesion. The patient subsequently developed medically refractory elevated ICP secondary to traumatic cerebral edema. He required DHC, but the procedure could only be completed safely with the utilization of intraoperative ECMO. As more is learned about the techniques and pitfalls of ECMO, its indications are rapidly expanding. The case presented describes the safe use of ECMO during a major neurosurgical procedure, showing that the technique can be completed safely and offering a therapeutic option for effectively addressing refractory hypoxia and hypercarbia in patients with severe TBI who require urgent or emergency neurosurgical procedures. https://thejns.org/doi/10.3171/CASE24264.

Cost of fall injuries in traffic are for pedestrians and bicyclists - municipal respons needed

Abstract Motivation Pedestrians and bicyclists have been posting in news and social media with reflections on municipal efforts to clean bicycle paths and sidewalks in icy and wet conditions. The municipality have lowered budgets for these cleaning efforts in recent years. Methods Analysis of A&amp;E department registration data with the Nomesco core dataset allows for separation of location, age, sex, time of day and date of injury. Injury severity is classified according to diagnosis of treatment (minor/major). Cost calculations are based on national scales from the Ministry of Transport (ambulance/police/treatment/rehabilitation). Cold weather was defined as lowest day temperature &amp;lt; 5 degree C (Danish Metereological service DMI). Results During 2023 all pedestrians or bicyclists (n = 2516) treated at the A&amp;E following an incident on sidewalks, streets or bicyclepaths (population 225.000) were included. Non-serious were (total/cold weather): sidewalks (699/266), bicyclepaths (414/117), streets (762/277). Serious: sidewalks (290/130), bicyclepaths (123/32), streets (228/100). Assessment of economical costs was DKK: Non-serious were (total/cold weather): sidewalks (20.8/7.9), bicyclepaths (12.4/3.5), streets (22.7/8.3). Serious: sidewalks (42.2/18.9), bicyclepaths (17.9/4.7), streets (33.2/14.6). Discussion and conclusions The economic burden for the population and municipality far exceeds the costs for cleaning the streets, bicyclepaths and sidewalks in icy and wet conditions. With appropriate injury surveillance and communication to municipal authorities revised cleaning principles was decided at the political level Key messages • Appropriate and focused injury registration is needed for targeted political level decision. • Standardized and targeted economic calculations are persuasive in the political arena at the local level.

Fall risk factors and prevention among older adults in primary care in Belgium, 2019-2021

Abstract Background Falls are a major public health problem and ageing populations further increase the burden of fall-induced injuries. Falling among older persons is a multifactorial health condition needing multifactorial care. General practitioners (GPs) are well placed to implement a multifactorial management. A surveillance study of accidental falls studied characteristics of falls, risk groups and fall risk factors as well as fall prevention by GPs. Methods A 3-year retrospective population-based study by the Belgian network of Sentinel General Practitioners (SGP) on all patients aged ≥ 65 years consulting their GP for new fall-related injuries. Descriptive statistics were used to characterize falls, fallers, fall risks and preventive measures. Logistic regression analyses were performed to identify factors associated with a multifactorial fall risk profile. Results During 2019-21, 1138 accidental falls were registered. Medical and/or nursing intervention was required for 24% and 22% had a severe injury. During consult, 30% was referred to hospital. 61% of patients showed at least one of the four most prevalent fall risks, i.e. deficits of mobility or balance, polypharmacy, cognitive impairment or psychotropic medication. A multifactorial fall risk profile was observed in 45% of fallers and was associated with recurrent falling (p &amp;lt; 0.001), fall location (p &amp;lt; 0.05), activity when falling (p &amp;lt; 0.01) and pandemic year 2020 (p &amp;lt; 0.05). Addressing surrounding and walking problems were the most frequently delivered preventive measures. For 28% of patients, other primary care providers (mainly nurse and physiotherapist) were involved in preventive care. Conclusions This study highlights the importance of identifying fall risk factors among fallers in primary care. Preventive fall measures, taken in about one in four general practice patients in collaboration with other healthcare providers, are crucial for preventing accidental falls in older persons in Belgium. Key messages • A multifactorial management of fall risk factors by GPs is crucial for preventing accidental falls in older primary care patients. • Strengthening collaboration between primary healthcare professionals is needed for improving fall prevention in Belgium.

Severe Cervical Spine Injury with Concurrent Cardiac Complications

Severe Cervical Spine Injury with Concurrent Cardiac Complications

High infection prevalence in patients who develop severe acute kidney injury during heart failure hospital admission

Abstract Background Acute kidney injury (AKI) is common in acute HF and associated with poor prognosis. (1-3) The cause of AKI is often unknown. Purpose The aim of this analysis was to analyse the data for patients with a severe AKI which developed during a HF admission and identify potential triggers in the preceding 7 days (e.g., infection, hypotension, contrast agents.). Methods Data between January 2022 to March 2023 was obtained from that submitted by our centre to the mandatory National HF Audit which collects data from every patient admitted with acute HF. For this analysis, baseline renal function was retrospectively collected from electronic patient records, and chronic kidney disease and AKI were subsequently defined, as per KDIGO guidelines(4), using baseline and admission measurements. Electronic patient records were reviewed for all patients who developed AKI stage 2/3 ≥48 hours after admission. Data collected during the week prior to their AKI included any radioiodine contrast exposure, temperature ≥ 38⁰C, antibiotics, CRP &amp;gt;100mg/L and periods of sustained hypotension. Results Of the 843 HF hospital admissions between January 2022 and March 2023, 507 (60.1%) were not associated with AKI [inpatient (IP) mortality 5.9%], 237 (28.1%) had an AKI stage 1 [IP mortality 17.3%], 51 (6.0%) had an AKI stage 2 [IP mortality 25.5%] and 48 (5.7%) had an AKI stage 3 [IP mortality 33.3%]. The age, diabetic status and ejection fraction of patients was similar across AKI stages. Of these, 64 patients developed their AKI stage 2 (n=30) or 3 (n=34) on or after their second day of HF hospital admission. 22 (34.3%) of these patients died during this admission, and 37 (57.8%) had died after a median follow-up of 217.5 days (IQR 24-331.75) (Table 1). 71.9% had evidence of an infection (defined by a temperature spike ≥38⁰C, received antibiotics, OR CRP &amp;gt;100mg/dL) in the week prior to developing their AKI (Table 2). 39% of patients had received a contrast agent in the preceding week, and 39% had experienced persistent hypotension in the preceding 48 hours. 25% had 2 of these potential triggers, 17.2% had 3. Six patients (9.4%) had no apparent identifiable triggers. 25% had not had renal function checked for 48h prior to AKI. Conclusion The most frequent identifiable potential trigger for severe AKI was infection in 72%, followed by contrast agent (39%) and hypotension (39%). Many patients had multiple triggers. Over-diuresis in isolation was not identified as a trigger for AKI in this cohort. Severe AKI 2/3 is a marker of extreme mortality risk and identifies patients in need of intensive monitoring. Lack of daily bloods in one quarter of patients led to a delay in AKI alert. Close observation for all acute HF patients including daily bloods and early identification and treatment of infection plus judicious and least use of contrast is needed to reduce the high mortality rates in this population.

Long-term prognosis after ST-elevation myocardial infarction according to the Canadian Cardiovascular Society classification of tissue injury severity in acute myocardial infarction

Abstract Background The recently proposed Canadian Cardiovascular Society (CCS) classification of acute myocardial infarction (MI) describes 4 stages of tissue injury identified by cardiac magnetic resonance imaging (CMR); 1) oedema without late gadolinium enhancement (LGE); 2) LGE without microvascular obstruction (MVO); 3) MVO; and 4) intramyocardial haemorrhage (IMH). Prior studies examining the relationship between these characteristics and outcomes are limited by variations in imaging and measurement techniques, in particular the distinction between MVO and IMH. The relationship between the proposed CCS classification of MI and outcomes has not been described. Purpose To explore the prognostic significance of the CCS classification of MI tissue injury in patients with ST-elevation MI (STEMI). Methods The British Heart Foundation MR-MI study was a prospective single-centre CMR cohort study in patients with STEMI (July 2011-November 2012). CMR was performed on a single Siemens MAGNETOM Avanto 1.5-Tesla scanner at 2 days post-STEMI. The imaging protocol included LGE and T2* mapping, allowing for the identification of infarct, MVO, and IMH. Follow-up for the occurance of major adverse cardiovascular events (MACE) (recurrent MI, ischaemic stroke and cardiovascular death) and a composite outcome of heart failure hospitalization/ICD implantation (HFH) or all-cause death was performed via electronic case note review. Results 246 patients had complete data for this analysis. Of these, 6 (2%) were CCS Stage 1, 105 (43%) were Stage 2, 33 (13%) were Stage 3, and 102 (41%) were Stage 4. Due to the low number in CCS stage 1, these patients were pooled with Stage 2 for the purposes of this analysis (CCS Stage 1/2). Average age was 58 (SD 11) years and 188 (76%) were male. With higher CCS stage, more patients were Killip class III/IV at presentation, had the LAD as culprit artery and had TIMI flow 0/1 pre-PCI. Patients with higher CCS stage had higher peak troponin-I and NT-proBNP, lower left ventricular function, higher left ventricular volumes and larger infarct size (Table). Median follow-up was 11.8 years. HFH or all-cause death occurred in 80 (33%) patients (22 HFH and 58 all-cause deaths), and MACE occurred in 63 (26%) patients (41 recurrent MI, 11 ischaemic stroke events, and 11 cardiovascular deaths). There were no significant differences in outcomes between CCS Stage 3 and CCS Stage 1/2 (Figure). Patients with CCS Stage 4 had a higher risk of HFH or all-cause death (HR 1.73, 95%CI 1.08-2.77; p=0.022) and MACE (HR 1.88, 95%CI 1.10-3.20; p=0.021) as compared with those in CCS Stage 1/2 (Figure). Conclusion The novel CCS classification of MI tissue injury identifies patients at the highest risk of adverse outcomes following STEMI. The relationship between the presence of IMH (CCS Stage 4) and adverse outcomes highlights the importance of T2* imaging in post-MI CMR protocols in order to identify this prognostically important biomarker.

Long-term disability following childhood injury: an imperative to monitor and address the continuum of trauma care

Abstract Background While injuries remain a leading cause of childhood death, increasing proportions of children survive life-threatening injuries. However, robust epidemiological data on their risks of long-term disability are scant, undermining comprehensive injury control efforts. This population-based prospective cohort study investigated the functional status and health-related quality of life of seriously injured Australian children over a 5-year period. Methods Patients aged &amp;lt;18 years hospitalised for major trauma (Injury Severity Score &amp;gt;12) in the State of Victoria over a 12-month period were followed-up at 6, 12, 24, 36, 48 and 60-months post-injury. Primary outcomes were assessed using the PedsQL, King’s Outcome Scale for Childhood Head Injury and the Glasgow Outcome Scale-Extended. Multivariable regression models investigated factors associated with outcomes. Results Of the 186 participants, 71% were retained to 60 months post-injury. At five years post-injury, only 39% had fully recovered while 39% experienced moderate to severe disability. Despite gains in functional status across the five years, psychosocial recovery lagged improvements in physical health. Factors associated with adverse outcomes included older age at injury, female sex, socio-economic disadvantage, remote/regional (versus urban) residence, pre-existing comorbidities, and injuries deemed compensable, intentional, or involving head trauma. Implications The high risks of long-term disability following serious childhood injury highlight the need for robust injury control efforts that monitor and address the inequitable burden of childhood injury, including the social determinants influencing the occurrence as well as sequelae following injury.

Donor-derived cell-free DNA versus left ventricular global longitudinal strain in noninvasive detection of heart allograft injury

Abstract Introduction Invasive endomyocardial biopsy (EMB) is still considered the gold standard method for monitoring heart transplant (HTx) rejection. However, it is associated with potentially serious complications, and its histopathologic interpretation has high interobserver variability. Thus, noninvasive methods for surveillance of the transplanted organ remains of great interest. The noninvasive donor-derived cell-free DNA is a marker of graft injury which can indicate acute rejection, even before the histopathological diagnosis of rejection detected by EMB. The assay has a high negative predictive value for acute rejection. Left ventricular global longitudinal strain (LV GLS) is an emerging marker of subclinical myocardial injury which plays a crucial role in the evaluation of several cardiac diseases; however, its role in HTx injury has so far been poorly investigated. Purpose We aimed to investigate the efficacy of a local laboratory-run dd-cfDNA assay-based heart transplant rejection surveillance programme, and the prognostic and discriminatory performance of LV GLS for subsequent heart allograft injury. Methods HTx recipients without a history of allograft rejection requiring intensification of immunosuppressive therapy were transitioned from our EMB-based surveillance protocol to dd-cfDNA-based rejection surveillance. We assessed the percentage of dd-cfDNA to total cell-free DNA. Injury cut-off was defined by a dd-cfDNA level ≥0.20%, while the severe injury threshold was at ≥0.35%. LV ejection fraction was calculated using 2D Simpson’s method. To derive LV GLS, we analyzed apical 4-chamber, 2-chamber, and long-axis images by 2D speckle tracking echocardiography. Results A total of 244 dd-cfDNA samples were analyzed from 46 patients in fifteen runs performed monthly between October 2022 and December 2023. The dd-cfDNA fraction remained below the injury cut-off in most patients (81%). There were no missed rejection episodes. 88% of routine EMBs that would have otherwise been performed were safely avoided. Eighteen for-cause EMBs were performed based on dd-cfDNA levels suggesting injury. One EMB verified moderate cellular rejection (ISHLT grade 2R) that required steroid pulse therapy. Two EMBs proved mild cellular rejection, one EMB confirmed mild antibody-mediated rejection, while one EMB proved mixed rejection. Thirteen EMBs found no rejection. Mean LVEF was preserved (57.6%±7.6%). Mean LV GLS was -15.1%±2.5% in the whole cohort, while -15.6%±4.7% in recipients with HTx rejection on indication EMB. There was no significant correlation between dd-cfDNA and LV GLS (n=159). Conclusion The noninvasive dd-cfDNA assay is effective in ruling out acute rejection and safely decreases the necessity of invasive surveillance EMBs after HTx. LV GLS is less sensitive in comparison with the dd-cfDNA assay for detection of myocardial injury in the early stages of graft rejection in HTx recipients at low risk for rejection.

Health loss after road transport injury – new perspectives

Abstract Background Health loss in the road transport system is a major public health problem. Globally, about a fifth of all fatalities within the road transport system are represented by pedestrians, and bicyclists are the group with the highest number of severe injuries in the EU. Here we strive to add new perspectives of health loss in different road user groups examining sickness absence (SA) and disability pension (DP) and in the case of injuries after car crashes also relating them to permanent medical impairment (PMI). Methods Several register-based studies were conducted, based on microdata linked at individual level from several Swedish nationwide registers. In one study information about PMI from the insurance company Folksam was also used. In the main analyses we included all working individuals aged 20-59 years injured in a road traffic accident (pedestrians, bicyclists, car occupants, and other road users) in 2015 in Sweden and population-based matched references without any traffic-related injury. Diagnosis specific SA and DP were assessed during 1 year before and 4 years following the accident. Results A third of the traffic-related accidents involved bicyclists, 31% car occupants, 16% pedestrian, and 19% were other accidents. The excess SA days/year was elevated for all road user groups the whole study period. Excess SA due to injury diagnoses was 15-35 days/year during the first year following the accident. Among individuals injured in a car crash that reported the injury to Folksam, 2% had a new DP 2 years after the crash, and 8% had injuries resulting in PMI. A distinct trend showed that the proportion granted DP increased with increasing PMI grade. Conclusions Sickness absence is a common outcome among individuals injured in the road transport system. Together, these studies highlight the importance of preventing not only fatalities in the road transport system but also non-fatal injuries.

Machine Learning powered Patient Records Analysis for Injury Monitoring in Children and Adolescents

Abstract Background Injuries to children and adolescents are common and are associated with individual suffering and costs. Switzerland lacks data of injuries in children and adolescents. This study investigates the feasibility of utilizing machine learning (ML) methodology to automatically extract relevant data from electronic pediatric patient records needed for monitoring and prevention purposes. Methods The feasibility study follows three steps. 1. Utility evaluation of text data from electronic pediatric patient records regarding ML, injury monitoring and prevention requirements in a test-sample. 2. The development of an ML-based approach to extract relevant information based on electronic pediatric patient records (N = 30’884) of children treated for injuries at the University Children’s Hospital Zurich emergency department between 2018-2022. 3. The performance of the ML methodology is evaluated. Results Qualitative and ML expert assessment of the sample showed that the desired data on injuries is contained in the test-sample and necessary requirements are met. Data records differ in detail with severe injuries providing especially rich information records. The international IDB code-tree was proved to be too elaborate and adult-orientated and was adapted. Preliminary data analyses indicate that the number of accidents is highest in the age group from 0 to 4 years (36%). More male (58%) children were treated. Majority of accidents were classified as less severe (73%), few (&amp;lt;1%) as very severe. Further lessons learned, along with more detailed prevalence data on injuries in children and adolescents, will be available by August 2024. Conclusions Extraction of injury information from electronic patient record by means of ML may provide valuable information for injury monitoring and prevention, so far missing in Switzerland. Prerequisites for the successful application of ML are digital record access, usable coding-tree, and detailed text input by the emergency departments. Key messages • An ML-based approach has the potential to improve the data basis by extracting valuable accidents information from existing texts of patient records. • To successfully apply this method, digital record access and detailed text data are needed.