Wound fluid sampling methods for proteomic studies: A scoping review

Understanding why some wounds are hard to heal is important for improving care and developing more effective treatments. The method of sample collection used is an integral step in the research process and thus may affect the results obtained. The primary objective of this study was to summarise and map the methods currently used to sample wound fluid for protein profiling and analysis. Eligible studies were those that used a sampling method to collect wound fluid from any human wound for analysis of proteins. A search for eligible studies was performed using MEDLINE, Embase and CINAHL Plus in May 2020. All references were screened for eligibility by one reviewer, followed by discussion and consensus with a second reviewer. Quantitative data were mapped and visualised using appropriate software and summarised via a narrative summary. After screening, 280 studies were included in this review. The most commonly used group of wound fluid collection methods were vacuum, drainage or use of other external devices, with surgical wounds being the most common sample source. Other frequently used collection methods were extraction from absorbent materials, collection beneath an occlusive dressing and direct collection of wound fluid. This scoping review highlights the variety of methods used for wound fluid collection. Many studies had small sample sizes and short sample collection periods; these weaknesses have hampered the discovery and validation of novel biomarkers. Future research should aim to assess the reproducibility and feasibility of sampling and analytical methods for use in larger longitudinal studies.

Cost Reduction for Knee-Spanning External Fixation in the Staged Treatment of Tibial Plateau Fractures: A Practical Intervention

OBJECTIVE

To determine whether an educational intervention affects surgeon implant decision making measured by total implant costs for temporizing a knee-spanning external fixation construct.

DESIGN

A total of 24 cases were prospectively collected after an educational intervention and matched to 24 cases before intervention using Schatzker classification and by surgeon.

SETTING

A single Level 1 trauma center.

PATIENTS/PARTICIPANTS

Forty-eight patients with Schatzker II-VI tibial plateau fractures.

INTERVENTION

Education session to create transparency with component pricing and to provide 3 clinical cases of Orthopaedic Trauma Association/AO 41-C3 (Schatzker VI) with accompanying images and fixator construct costs. Total implant costs displayed in the session ranged from $2354 to $11,696.

OUTCOME MEASUREMENT

External fixator construct cost.

RESULTS

The mean cost of constructs in the postintervention group was $4550.20 [95% confidence interval (CI) $3945.60-$5154.00], which was significantly different compared with the preintervention group cost of $6046.75 (95% CI = $5309.54-$6783.97, P = 0.003). After 1 year, the total implant costs of external fixation constructs were reduced by an average of almost $1500 per patient.

CONCLUSION

An educational intervention created a reduction in the average total implant construction costs for temporary knee-spanning external fixation in the treatment of tibial plateau fractures. Surgical implant selection and cost variance remain an ideal area to improve value for patients and hospitals. Empowering surgeons with knowledge regarding implant prices is a critical part of working toward the cost reductions of external fixation constructs.

Surgeons Consider Initial Nonoperative Treatment With Potential for Future Conversion to Reverse Arthroplasty a Reasonable Option for Older, Relatively Infirm, and Less-Active Patients

OBJECTIVES

Two recent developments favor initial nonoperative treatment of proximal humerus fractures among the older, relatively infirm, less-active patients that represent most patients with such fractures: (1) evidence of minimal benefit of open reduction, internal fixation over nonoperative treatment, and (2) evidence of the effectiveness of the reverse total shoulder arthroplasty. As one step in determining the feasibility of a strategy of initial nonoperative treatment of proximal humerus fracture among older, relatively infirm, less-active people, we performed a survey-based experiment to measure factors associated with surgeon recommendation for initial nonoperative treatment.

METHODS

Members of the Science of Variation Group viewed 8 hypothetical patients with radiographs of complex proximal humeral fractures and 7 randomized patient variables. For each scenario, surgeons were asked whether they would recommend (1) initial nonoperative treatment with bailout reverse arthroplasty or (2) immediate reverse arthroplasty.

RESULTS

The mean percentage of recommendations for initial nonoperative treatment was 63%, with wide variation by surgeon (range 0%-100%). In multilevel mixed-effects logistic regression, recommendation for initial nonoperative treatment was associated with specific radiographs, older age, having a comorbidity, being homebound, surgical subspecialists, and more than 20 years in practice.

CONCLUSIONS

These findings suggest that surgeons may consider initial nonoperative treatment with potential for future conversion to reverse arthroplasty an acceptable treatment option, particularly for older, less-active, more infirm individuals, and relatively less displaced fractures with little comminution.

Vacuum-Assisted Wound Closure Management for Posterior Lumbar Spine Infections

A postoperative infection involving the tissues deep to the fascia is defined as a deep wound infection (DWI). Management of such infections after lumbar spinal surgery remains a challenge. One strategy is the use of vacuum-assisted wound closure (VAC) which applies negative pressure to the wound to improve microcirculation and to promote the formation of granulation tissue. When combined with antibiotics, VAC has been shown to successfully treat DWIs and is now a common strategy for treating deep postoperative wound infections after spinal surgery. In this article, we review the technique of VAC, its mechanism of action, indications and contraindications, and clinical outcomes in the treatment of DWIs after lumbar spinal surgery.

Minimally Invasive Stent Screw-Assisted Internal Fixation Technique Corrects Kyphosis in Osteoporotic Vertebral Fractures with Severe Collapse: A Pilot "Vertebra Plana" Series

BACKGROUND AND PURPOSE

Fractures with "vertebra plana" morphology are characterized by severe vertebral body collapse and segmental kyphosis; there is no established treatment standard for these fractures. Vertebroplasty and balloon kyphoplasty might represent an undertreatment, but surgical stabilization is challenging in an often elderly osteoporotic population. This study assessed the feasibility, clinical outcome, and radiologic outcome of the stent screw-assisted internal fixation technique using a percutaneous implant of vertebral body stents and cement-augmented pedicle screws in patients with non-neoplastic vertebra plana fractures.

MATERIALS AND METHODS

Thirty-seven consecutive patients with vertebra plana fractures were treated with the stent screw-assisted internal fixation technique. Vertebral body height, local and vertebral kyphotic angles, outcome scales (numeric rating scale and the Patient's Global Impression of Change), and complications were assessed. Imaging and clinical follow-up were obtained at 1 and 6 months postprocedure.

RESULTS

Median vertebral body height restoration was 7 mm (+74%), 9 mm (+150%), and 3 mm (+17%) at the anterior wall, middle body, and posterior wall, respectively. Median local and vertebral kyphotic angles correction was 8° and 10° and was maintained through the 6-month follow-up. The median numeric rating scale score improved from 8/10 preprocedure to 3/10 at 1 and 6 months (P < .001). No procedural complications occurred.

CONCLUSIONS

The stent screw-assisted internal fixation technique was effective in obtaining height restoration, kyphosis correction, and pain relief in patients with severe vertebral collapse.

Outcomes following surgical management of proximal hamstring tendon avulsions

Aims

Avulsion of the proximal hamstring tendon origin can result in significant functional impairment, with surgical re-attachment of the tendons becoming an increasingly recognized treatment. The aim of this study was to assess the outcomes of surgical management of proximal hamstring tendon avulsions, and to compare the results between acute and chronic repairs, as well as between partial and complete injuries.

Methods

PubMed, CINAHL, SPORTdiscuss, Cochrane Library, EMBASE, and Web of Science were searched. Studies were screened and quality assessed.

Results

In all, 35 studies (1,530 surgically-repaired hamstrings) were included. Mean age at time of repair was 44.7 years (12 to 78). A total of 846 tears were acute, and 684 were chronic, with 520 tears being defined as partial, and 916 as complete. Overall, 92.6% of patients were satisfied with the outcome of their surgery. Mean Lower Extremity Functional Score was 74.7, and was significantly higher in the partial injury group. Mean postoperative hamstring strength was 87.0% of the uninjured limb, and was higher in the partial group. The return to sport (RTS) rate was 84.5%, averaging at a return of 6.5 months. RTS was quicker in the acute group. Re-rupture rate was 1.2% overall, and was lower in the acute group. Sciatic nerve dysfunction rate was 3.5% overall, and lower in the acute group (p < 0.05 in all cases).

Conclusion

Surgical treatment results in high satisfaction rates, with good functional outcomes, restoration of muscle strength, and RTS. Partial injuries could expect a higher functional outcome and muscle strength return. Acute repairs result in a quicker RTS with a reduced rate of re-rupture and sciatic nerve dysfunction. Cite this article: Bone Jt Open 2022;3(5):415–422.

Chronic psychological stress alters gene expression in rat colon epithelial cells promoting chromatin remodeling, barrier dysfunction and inflammation

Chronic stress is commonly associated with enhanced abdominal pain (visceral hypersensitivity), but the cellular mechanisms underlying how chronic stress induces visceral hypersensitivity are poorly understood. In this study, we examined changes in gene expression in colon epithelial cells from a rat model using RNA-sequencing to examine stress-induced changes to the transcriptome. Following chronic stress, the most significantly up-regulated genes included Atg16l1, Coq10b, Dcaf13, Nat2, Ptbp2, Rras2, Spink4 and down-regulated genes including Abat, Cited2, Cnnm2, Dab2ip, Plekhm1, Scd2, and Tab2. The primary altered biological processes revealed by network enrichment analysis were inflammation/immune response, tissue morphogenesis and development, and nucleosome/chromatin assembly. The most significantly down-regulated process was the digestive system development/function, whereas the most significantly up-regulated processes were inflammatory response, organismal injury, and chromatin remodeling mediated by H3K9 methylation. Furthermore, a subpopulation of stressed rats demonstrated very significantly altered gene expression and transcript isoforms, enriched for the differential expression of genes involved in the inflammatory response, including upregulation of cytokine and chemokine receptor gene expression coupled with downregulation of epithelial adherens and tight junction mRNAs. In summary, these findings support that chronic stress is associated with increased levels of cytokines and chemokines, their downstream signaling pathways coupled to dysregulation of intestinal cell development and function. Epigenetic regulation of chromatin remodeling likely plays a prominent role in this process. Results also suggest that super enhancers play a primary role in chronic stress-associated intestinal barrier dysfunction.

Severe isolated injuries have a high impact on resource use and mortality: a Dutch nationwide observational study

PURPOSE

The Berlin poly-trauma definition (BPD) has proven to be a valuable way of identifying patients with at least a 20% risk of mortality, by combining anatomical injury characteristics with the presence of physiological risk factors (PRFs). Severe isolated injuries (SII) are excluded from the BPD. This study describes the characteristics, resource use and outcomes of patients with SII according to their injured body region, and compares them with those included in the BPD.

METHODS

Data were extracted from the Dutch National Trauma Registry between 2015 and 2019. SII patients were defined as those with an injury with an Abbreviated Injury Scale (AIS) score ≥ 4 in one body region, with at most minor additional injuries (AIS ≤ 2). We performed an SII subgroup analysis per AIS region of injury. Multivariable linear and logistic regression models were used to calculate odds ratios (ORs) for SII subgroup patient outcomes, and resource needs.

RESULTS

A total of 10.344 SII patients were included; 47.8% were ICU admitted, and the overall mortality was 19.5%. The adjusted risk of death was highest for external (2.5, CI 1.9-3.2) and for head SII (2.0, CI 1.7-2.2). Patients with SII to the abdomen (2.3, CI 1.9-2.8) and thorax (1.8, CI 1.6-2.0) had a significantly higher risk of ICU admission. The highest adjusted risk of disability was recorded for spine injuries (10.3, CI 8.3-12.8). The presence of ≥ 1 PRFs was associated with higher mortality rates compared to their poly-trauma counterparts, displaying rates of at least 15% for thoracic, 17% for spine, 22% for head and 49% for external SII.

CONCLUSION

A severe isolated injury is a high-risk entity and should be recognized and treated as such. The addition of PRFs to the isolated anatomical injury criteria contributes to the identification of patients with SII at risk of worse outcomes.

Neuroinflammation in Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a well-known mental illness, which is caused by various stressors, including memories of past physical assaults and psychological pressure. It is diagnosed as a mental and behavioral disorder, but increasing evidence is linking it to the immune system and inflammatory response. Studies on the relationship between inflammation and PTSD revealed that patients with PTSD had increased levels of inflammatory cytokine biomarkers, such as interleukin-1, interleukin-6, tumor necrosis factor-α, nuclear factor-κB, and C-reactive protein, compared with healthy controls. In addition, animal model experiments imitating PTSD patients suggested the role of inflammation in the pathogenesis and pathophysiology of PTSD. In this review, we summarize the definition of PTSD and its association with increased inflammation, its mechanisms, and future predictable diseases and treatment possibilities. We also discuss anti-inflammatory treatments to address inflammation in PTSD.

An evolutionary machine learning for pulmonary hypertension animal model from arterial blood gas analysis

Pulmonary hypertension (PH) is a rare and fatal condition that leads to right heart failure and death. The pathophysiology of PH and potential therapeutic approaches are yet unknown. PH animal models' development and proper evaluation are critical to PH research. This work presents an effective analysis technology for PH from arterial blood gas analysis utilizing an evolutionary kernel extreme learning machine with multiple strategies integrated slime mould algorithm (MSSMA). In MSSMA, two efficient bee-foraging learning operators are added to the original slime mould algorithm, ensuring a suitable trade-off between intensity and diversity. The proposed MSSMA is evaluated on thirty IEEE benchmarks and the statistical results show that the search performance of the MSSMA is significantly improved. The MSSMA is utilised to develop a kernel extreme learning machine (MSSMA-KELM) on PH from arterial blood gas analysis. Comprehensively, the proposed MSSMA-KELM can be used as an effective analysis technology for PH from arterial Blood gas analysis with an accuracy of 93.31%, Matthews coefficient of 90.13%, Sensitivity of 91.12%, and Specificity of 90.73%. MSSMA-KELM can be treated as an effective approach for evaluating mouse PH models.

Stress-induced pro- and anti-inflammatory cytokine concentrations in female PTSD and depressive patients

Alterations of the hypothalamus pituitary-axis on one hand and heightened rates of somatic diseases and mortality on the other hand are consistently found for PTSD and MDD patients. A possible link between these factors might be the immune system, in particular pro- and anti-inflammatory cytokines. A 'low-grade inflammation' in PTSD and MDD patients was found, whereas the influence of acute stress and the role of anti-inflammatory cytokines was rarely examined. In this study, 17 female PTSD patients participated in the Trier social stress test while serum cytokine levels (IL-6, IL-10) were assessed. Cytokine levels of PTSD patients were compared with levels of female depressive patients (n = 18) and female healthy controls (n = 18). Group differences were assessed using a 3 (group) x 8 (time: -15, -1, +1, +10, +20, +30, +45, +60 min) ANCOVA for repeated measures with baseline values as covariates. There was no group difference regarding IL-6 levels (p = 0.920) but PTSD patients showed significantly higher levels of IL-10 compared with depressive patients (p < 0.001, d = 0.16) and healthy controls (p = 0.001, d = 0.38). Under acute stress, PTSD patients did not show the widely found elevated IL-6 levels but showed an increase of anti-inflammatory IL-10. Therefore, acute stress seems to promote an imbalance of pro- and anti-inflammatory cytokine levels in PTSD and might indicate a hyperreactive immune response. This should be considered in future studies to further understand the role of the immune system as a link between stress response and somatic diseases.

Association Between Changes in Post-hospital Cardiac Symptoms and Changes in Acute Coronary Syndrome-Induced Symptoms of Post-traumatic Stress

Background

After acute coronary syndrome (ACS), one in eight patients develops clinically significant symptoms of Post-traumatic stress disorder (PTSD). We hypothesized that changes in cardiac symptoms from 3 to 12 months after ACS are associated with changes in ACS-induced PTSD symptoms.

Methods

At 3 (n = 154) and/or 12 months (n = 106) post-ACS, patients (n = 156, mean age 59 years, 85% men) completed a clinical interview assessing chest tightness/pain (at rest and/or during exertion), heartbeat symptoms (heart palpitations, racing of heart, heart stumbling or skipping a beat) and PTSD symptoms during the prior 4 weeks. Random mixed regression models examined the association between the onset (or remission) from 3 to 12 months in cardiac symptoms with changes in PTSD symptoms, adjusting for a range of potential predictors of ACS-induced PTSD symptoms.

Results

The onset of chest tightness/pain [estimate = 0.588, 95% confidence interval: 0.275, 0.090; p &lt; 0.001] and of heartbeat symptoms [0.548 (0.165, 0.931); p = 0.005] from 3 to 12 months was independently associated with an increase in total PTSD symptoms. There were also independent associations between the onset of chest tightness/pain and heartbeat symptoms with an increase in PTSD symptom clusters. Specifically, the onset of chest tightness/pain showed associations with an increase in re-experiencing [0.450 (0.167, 0.733); p = 0.027] and avoidance/numbing [0.287 (0.001, 0.574); p = 0.049]. The onset of heartbeat symptoms showed associations with an increase in re-experiencing [0.392 (0.045, 0.739); p = 0.002], avoidance/numbing [0.513 (0.161, 0.864); p = 0.004] and hyperarousal [0.355 (0.051, 0.659); p = 0.022]. An increase in the total number of cardiac symptoms (score range 0–6) was also associated with an increase in total PTSD symptoms [0.343 (0.202, 0.484); p &lt; 0.001]. Psychotherapy in the post-hospital period moderated the association between the change in heartbeat symptoms and the change in total PTSD symptoms [−0.813 (−1.553, −0.074); p = 0.031 for interaction]; the association between the onset of heart beat symptoms and an increase in total PTSD symptoms was weaker in patients who attended psychotherapy [0.437 (−0.178, 1.052); p = 0.16] than in those who did not [0.825 (0.341, 1.309); p &lt; 0.001].

Conclusion

Changes in cardiac symptoms between 3 and 12 months after hospitalization are associated with changes in ACS-induced PTSD symptoms. ClinicalTrials.gov #NCT01781247.

Discrimination and calibration of a prediction model for mortality is decreased in secondary transferred patients: a validation in the TraumaRegister DGU

INTRODUCTION

The Revised Injury Severity Classification II (RISC II) score represents a data-derived score that aims to predict mortality in severely injured patients. The aim of this study was to assess the discrimination and calibration of RISC II in secondary transferred polytrauma patients.

METHODS

This study was performed on the multicentre database of the TraumaRegister DGU. Inclusion criteria included Injury Severity Score (ISS)≥9 points and complete demographic data. Exclusion criteria included patients with 'do not resuscitate' orders or late transfers (>24 hours after initial trauma). Patients were stratified based on way of admission into patients transferred to a European trauma centre after initial treatment in another hospital (group Tr) and primary admitted patients who were not transferred out (group P). The RISC II score was calculated within each group at admission after secondary transfer (group Tr) and at primary admission (group P) and compared with the observed mortality rate. The calibration and discrimination of prediction were analysed.

RESULTS

Group P included 116 112 (91%) patients and group Tr included 11 604 (9%) patients. The study population was predominantly male (n=86 280, 70.1%), had a mean age of 53.2 years and a mean ISS of 20.7 points. Patients in group Tr were marginally older (54 years vs 52 years) and a had slightly higher ISS (21.5 points vs 20.1 points). Median time from accident site to hospital admission was 60 min in group P and 241 min (4 hours) in group Tr. Observed and predicted mortality based on RISC II were nearly identical in group P (10.9% and 11.0%, respectively) but predicted mortality was worse (13.4%) than observed mortality (11.1%) in group Tr.

CONCLUSION

The way of admission alters the calibration of prediction models for mortality in polytrauma patients. Mortality prediction in secondary transferred polytrauma patients should be calculated separately from primary admitted polytrauma patients.

In vitro study of the mesenchymal stem cells-conditional media role in skin wound healing process: A systematic review

Mesenchymal stromal cell (MSC)-conditioned medium (CM) offers a potential opportunity in the skin wound healing treatment. In this systematic review, an overview of the knowledge on this topic has been provided. A multistep search of the PubMed, Scopus and Science Direct database has been performed to identify papers on MSCs-conditional media used in skin wound healing. Eligibility checks were performed based upon predefined selection criteria. Of the 485 articles initially identified, consequently, only 96 articles apparently related to MSC-conditional media were initially assessed for eligibility. Finally, the 32 articles, strictly regarding the in vitro use of MSCs-conditional media in skin wounds, were analysed. The information analysed highlights the efficacy of MSCs-conditional media on skin wound healing in vitro models. The outcome of this review may be used to guide pre-clinical and clinical studies on the role of MSCs-conditional media in skin wound healing.

Initial acuity of firearm injuries in the United States: are civilian injuries similar to combat casualty statistics

Military studies have identified significant trends in combat related preventable death, particularly with respect to limb hemorrhage. Little is known, however regarding preventable death due to firearms in the civilian patient population, or the anatomic distribution of these injuries. An understanding of this information and the applicability of military studies to the civilian patient population is critical to developing strategies for treating these injuries. A retrospective database review of The National Emergency Medical Services Information Systems (NEMESIS) national database based on ICD 10 codes for firearm injuries logged in 2019 in the pre-hospital environment. Twenty three thousand three hundred and thirty-three firearm injuries were logged in NEMESIS in 2019, of which 15,148 were ultimately included as the other cases had incomplete information. Of these injuries there were 1438 (9.49%) to the chest, 913 (6.03%) to the abdomen, 221 (1.46%) to the neck, 468 (3.09%) to the back. These four anatomic locations were the most likely to be classified as Critical-Red by prehospital providers: 62.66% of chest injuries, 54.22% of abdomen injuries, 48.42% of neck injuries, and 42.31% of back injuries. The NEMESIS data on patient acuity indicates that the number of firearm related preventable deaths due to torso injury may be significantly greater than those due to limb exsanguination. In addition to the focus on tourniquet use, research focused on improved prehospital care of firearm injuries to the torso may provide additional strategies for reducing preventable death.

A Tale of Two Centers: Visual Exploration of Health Disparities in Cancer Care

The annual incidence of head and neck cancers (HNC) worldwide is more than 550,000 cases, with around 300,000 deaths each year. However, the incidence rates and disease-characteristics of HNC differ between treatment centers and different populations, due to undetermined reasons, which may or not include socioeconomic factors. The multi-faceted and multi-variate nature of the data in the context of the emerging field of health disparities research makes automated analysis impractical. Hence, we present a visual analysis approach to explore the health disparities in the data of HNC patients from two different cohorts at two cancer care centers. Our approach integrates data from multiple sources, including census data and city data, with custom visual encodings and with a nearest neighbor approach. Our design, created in collaboration with oncology experts, makes it possible to analyze the patients' demographic, disease characteristics, treatments and outcomes, and to make significant comparisons of these two cohorts and of individual patients. We evaluate this approach through two case studies performed with domain experts. The results demonstrate that this visual analysis approach successfully accomplishes the goal of comparing two cohorts in terms of different significant factors, and can provide insights into the main source of health disparities between the two centers.

Neural alterations in working memory of mild-moderate TBI: An fMRI study in Malaysia

Working memory (WM) encompasses crucial cognitive processes or abilities to retain and manipulate temporary information for immediate execution of complex cognitive tasks in daily functioning such as reasoning and decision-making. The WM of individuals sustaining traumatic brain injury (TBI) was commonly compromised, especially in the domain of WM. The current study investigated the brain responses of WM in a group of participants with mild-moderate TBI compared to their healthy counterparts employing functional magnetic resonance imaging. All consented participants (healthy: n = 26 and TBI: n = 15) performed two variations of the n-back WM task with four load conditions (0-, 1-, 2-, and 3-back). The respective within-group effects showed a right hemisphere-dominance activation and slower reaction in performance for the TBI group. Random-effects analysis revealed activation difference between the two groups in the right occipital lobe in the guided n-back with cues, and in the bilateral occipital lobe, superior parietal region, and cingulate cortices in the n-back without cues. The left middle frontal gyrus was implicated in the load-dependent processing of WM in both groups. Further group analysis identified that the notable activation changes in the frontal gyri and anterior cingulate cortex are according to low and high loads. Though relatively smaller in scale, this study was eminent as it clarified the neural alterations in WM in the mild-moderate TBI group compared to healthy controls. It confirmed the robustness of the phenomenon in TBI with the reproducibility of the results in a heterogeneous non-Western sample.

Ghani ARIG, Wan Mohamad WNA, Mohamed Mustafar MF, Hanafi MH, Reza MF, Umar H, Mohd Zulkifly MF, Ang SY, Zakaria Z, Musa KI, Othman A, Embong Z, Sapiai NA, Kandasamy R, Ibrahim H, Abdullah MZ, Amaruchkul K, Valdes-Sosa P, Luisa-Bringas M, Biswal B, Songsiri J, Yaacob HS, Sumari P, Jamir Singh PS, Azman A, Abdullah JM. Alteration in the Functional Organization of the Default Mode Network Following Closed Non-severe Traumatic Brain Injury

The debilitating effect of traumatic brain injury (TBI) extends years after the initial injury and hampers the recovery process and quality of life. In this study, we explore the functional reorganization of the default mode network (DMN) of those affected with non-severe TBI. Traumatic brain injury (TBI) is a wide-spectrum disease that has heterogeneous effects on its victims and impacts everyday functioning. The functional disruption of the default mode network (DMN) after TBI has been established, but its link to causal effective connectivity remains to be explored. This study investigated the differences in the DMN between healthy participants and mild and moderate TBI, in terms of functional and effective connectivity using resting-state functional magnetic resonance imaging (fMRI). Nineteen non-severe TBI (mean age 30.84 ± 14.56) and twenty-two healthy (HC; mean age 27.23 ± 6.32) participants were recruited for this study. Resting-state fMRI data were obtained at the subacute phase (mean days 40.63 ± 10.14) and analyzed for functional activation and connectivity, independent component analysis, and effective connectivity within and between the DMN. Neuropsychological tests were also performed to assess the cognitive and memory domains. Compared to the HC, the TBI group exhibited lower activation in the thalamus, as well as significant functional hypoconnectivity between DMN and LN. Within the DMN nodes, decreased activations were detected in the left inferior parietal lobule, precuneus, and right superior frontal gyrus. Altered effective connectivities were also observed in the TBI group and were linked to the diminished activation in the left parietal region and precuneus. With regard to intra-DMN connectivity within the TBI group, positive correlations were found in verbal and visual memory with the language network, while a negative correlation was found in the cognitive domain with the visual network. Our results suggested that aberrant activities and functional connectivities within the DMN and with other RSNs were accompanied by the altered effective connectivities in the TBI group. These alterations were associated with impaired cognitive and memory domains in the TBI group, in particular within the language domain. These findings may provide insight for future TBI observational and interventional research.

DeepBiomarker: Identifying Important Lab Tests from Electronic Medical Records for the Prediction of Suicide-Related Events among PTSD Patients

Identifying patients with high risk of suicide is critical for suicide prevention. We examined lab tests together with medication use and diagnosis from electronic medical records (EMR) data for prediction of suicide-related events (SREs; suicidal ideations, attempts and deaths) in post-traumatic stress disorder (PTSD) patients, a population with a high risk of suicide. We developed DeepBiomarker, a deep-learning model through augmenting the data, including lab tests, and integrating contribution analysis for key factor identification. We applied DeepBiomarker to analyze EMR data of 38,807 PTSD patients from the University of Pittsburgh Medical Center. Our model predicted whether a patient would have an SRE within the following 3 months with an area under curve score of 0.930. Through contribution analysis, we identified important lab tests for suicide prediction. These identified factors imply that the regulation of the immune system, respiratory system, cardiovascular system, and gut microbiome were involved in shaping the pathophysiological pathways promoting depression and suicidal risks in PTSD patients. Our results showed that abnormal lab tests combined with medication use and diagnosis could facilitate predicting SRE risk. Moreover, this may imply beneficial effects for suicide prevention by treating comorbidities associated with these biomarkers.

Interactions between the Nociceptin and Toll-like Receptor Systems

Nociceptin and the nociceptin receptor (NOP) have been described as targets for treatment of pain and inflammation, whereas toll-like receptors (TLRs) play key roles in inflammation and impact opioid receptors and endogenous opioids expression. In this study, interactions between the nociceptin and TLR systems were investigated. Human THP-1 cells were cultured with or without phorbol myristate acetate (PMA 5 ng/mL), agonists specific for TLR2 (lipoteichoic acid, LTA 10 µg/mL), TLR4 (lipopolysaccharide, LPS 100 ng/mL), TLR7 (imiquimod, IMQ 10 µg/mL), TLR9 (oligonucleotide (ODN) 2216 1 µM), PMA+TLR agonists, or nociceptin (0.01−100 nM). Prepronociceptin (ppNOC), NOP, and TLR mRNAs were quantified by RT-qPCR. Proteins were measured using flow cytometry. PMA upregulated ppNOC mRNA, intracellular nociceptin, and cell membrane NOP proteins (all p < 0.05). LTA and LPS prevented PMA’s upregulating effects on ppNOC mRNA and nociceptin protein (both p < 0.05). IMQ and ODN 2216 attenuated PMA’s effects on ppNOC mRNA. PMA, LPS, IMQ, and ODN 2216 increased NOP protein levels (all p < 0.05). PMA+TLR agonists had no effects on NOP compared to PMA controls. Nociceptin dose-dependently suppressed TLR2, TLR4, TLR7, and TLR9 proteins (all p < 0.01). Antagonistic effects observed between the nociceptin and TLR systems suggest that the nociceptin system plays an anti-inflammatory role in monocytes under inflammatory conditions.

Polysaccharides From the Aerial Parts of Tetrastigma Hemsleyanum Diels et Gilg Induce Bidirectional Immunity and Ameliorate LPS-Induced Acute Respiratory Distress Syndrome in Mice

Tetrastigma hemsleyanum Diels et Gilg (Sanyeqing, SYQ) has traditionally been used to treat inflammation, high fever and improve immune function of patients. Polysaccharides have been proved to be one of the important components of SYQ. Previous studies have confirmed the antipyretic and antitumor effects of polysaccharides from SYQ (SYQP), and clarified that SYQP could enhance immunity through TLR4 signalling pathway. However, there were more possibilities for the mechanism by which SYQP exerted immunomodulatory effects and the role of SYQP in acute respiratory distress syndrome (ARDS) is elusive. The purpose of this study was further to explain the bidirectional modulation of immunity mechanism of SYQP in vitro and its effect in LPS-induced ARDS in vivo. Experimental results showed that SYQP significantly stimulated gene expressions of TLR1, TLR2 and TLR6 and secretion of cytokines in RAW264.7 cells. Individual or combined application of TLR2 antagonist C29 and TLR4 antagonist TAK-242 could reduce SYQP-mediated stimulation of cytokine secretion in RAW264.7 cells and mouse peritoneal macrophages (MPMs) to varying degrees. On the other hand, SYQP markedly inhibited the expression levels of inflammatory cytokines, NO, iNOS and COX-2 in LPS-treatment RAW264.7 cells. Moreover, in vivo results indicated that SYQP significantly reduced LPS-induced damage in ARDS mice through alleviating LPS-induced pulmonary morphological damage, inhibiting myeloperoxidase (MPO) expression levels, ameliorating the inflammatory cells in bronchoalveolar lavage fluid (BALF) and improving hematological status. Meanwhile, SYQP evidently reduced IL-6, TNF-α and IFN-γ secretion, the overexpression levels of TLR2 and TLR4, as well as the phosphorylation of NF-κB p65. In addition, SYQP reduced the phosphorylation of JAK2 and STAT1 and the overexpression of NLRP3, caspase-1, caspase-3 and caspase-8 in lung tissues of ARDS mice. In summary, our study confirmed that SYQP induced bidirectional immunity and ameliorated LPS-induced acute respiratory distress syndrome in mice through TLR2/TLR4-NF-κB, NLRP3/caspase and JAK/STAT signaling pathways, which provided a theoretical basis for further use of SYQP.

Intra- and inter-observer reliability assessment of widely used classifications and the "Ten-segment classification" of tibial plateau fractures

BACKGROUND

Ten-segment classification provides a different approach to the evaluation of tibial plateau fractures. The purpose of this study was to assess the intra- and inter-observer reliability of three widely used classification systems (Schatzker, Arbeitsgemeinschaft für Osteosynthesefragen (AO/OTA), and the updated three-column concept (uTCC)) with ten-segment classification in two-dimensional computed tomography (2D-CT) and three-dimensional computed tomography (3D-CT).

METHOD

Ninety 2D-CT and 3D-CT scans of patients with tibial plateau fractures were included in this retrospective cohort study. The included data were independently classified by six observers of different years of seniority and were independently observed and classified again after eight weeks. Inter-observer and intra-observer reliability of the four fracture classifications made by the six observers was analyzed using the kappa statistic. Kappa values were interpreted according to the categorical rating by Landis and Koch.

RESULTS

When the inter-observer reliability was based on 2D-CT/3D-CT analysis, the mean Kappa values for the Schatzker, AO/OTA, uTCC, and ten-segment classification were 0.64/0.66, 0.56/0.59, 0.53/0.65, and 0.60/0.73, respectively. When intra-observer reliability was based on 2D-CT/3D-CT, the mean Kappa values for the Schatzker, AO/OTA, uTCC, and ten-segment classification were 0.68/0.83, 0.69/0.83, 0.74/0.85, and 0.80/0.91, respectively.

CONCLUSIONS

The use of 3D-CT is important for the reliable diagnosis and recognition of tibial plateau fracture features compared to 2D-CT. When using 3D-CT, ten-segment classification showed high intra- and inter-observer agreement.

The relations between C-reactive protein and trauma exposure, PTSD and depression symptoms, and PTSD psychotherapy treatment response in treatment seeking veterans and service members

While inflammatory markers have been implicated in the link between PTSD and poor health outcomes, there is a paucity of research investigating C-reactive protein (CRP) and psychotherapy treatment response for posttraumatic stress disorder (PTSD). The present study utilized a large, well-characterized sample of veterans and service members (N = 493) engaged in intensive psychotherapy to investigate the associations between CRP, trauma exposure, related variables, and PTSD and depression, as well as investigating if CRP was associated with PTSD psychotherapy treatment response. Bivariate correlation results indicate that CRP was significantly associated with BMI (r = 0.48) and severity of experiences of childhood physical and sexual abuse (r = 0.14 and 0.15, respectively) and was not significantly associated with baseline PTSD total symptom severity, PTSD symptom clusters, or depression symptom severity (rs ranging from -0.03 to 0.04). In multivariate regression models investigating if CRP and related variables were associated with PTSD baseline symptom severity, CRP was not a significant predictor (β = -0.03). Hierarchical linear modeling did not identify CRP as a significant predictor of PTSD psychotherapy outcome. Given that findings indicate that CRP was broadly elevated in this treatment seeking sample but not associated with PTSD and depression symptom severity, results suggest CRP may not be a specific biomarker for PTSD or depression but may be elevated in psychiatric disease more generally.

The Bidirectional Link Between Sleep Disturbances and Traumatic Brain Injury Symptoms: A Role for Glymphatic Dysfunction?

Mild traumatic brain injury (mTBI), often referred to as concussion, is a major cause of morbidity and mortality worldwide. Sleep disturbances are common after mTBI. Moreover, subjects who develop subjective sleep complaints after mTBI also report more severe somatic, mental health, and cognitive impairment and take longer to recover from mTBI sequelae. Despite many previous studies addressing the role of sleep in post-mTBI morbidity, the mechanisms linking sleep to recovery after mTBI remain poorly understood. The glymphatic system is a brainwide network that supports fluid movement through the cerebral parenchyma and the clearance of interstitial solutes and wastes from the brain. Notably, the glymphatic system is active primarily during sleep. Clearance of cellular byproducts related to somatic, mental health, and neurodegenerative processes (e.g., amyloid-β and tau, among others) depends in part on intact glymphatic function, which becomes impaired after mTBI. In this viewpoint, we review the current knowledge regarding the association between sleep disturbances and post-mTBI symptoms. We also discuss the role of glymphatic dysfunction as a potential link between mTBI, sleep disruption, and posttraumatic morbidity. We outline a model where glymphatic dysfunction and sleep disruption caused by mTBI may have an additive effect on waste clearance, leading to cerebral dysfunction and impaired recovery. Finally, we review the novel techniques being developed to examine glymphatic function in humans and explore potential interventions to alter glymphatic exchange that may offer a novel therapeutic approach to those experiencing poor sleep and prolonged symptoms after mTBI.

Training Effectiveness and Impact on Safety, Treatment Quality, and Communication in Prehospital Emergency Care: The Prospective Longitudinal Mixed-Methods EPPTC Trial

BACKGROUND

Emergency training is designed to improve medical care teams' knowledge, practical skills, and treatment procedures in patient care to increase patient safety. This requires effective training, but the multifactorial effects of training are difficult to measure.

METHODS

We assessed the impact of emergency team training on treatment procedures and quality, processes, technical skills, and nontechnical skills in simulated trauma emergencies in a longitudinal analysis, using videos that were recorded before (t0), immediately after (t1), and 1 year after the training (t2). The training was evaluated with the validated PERFECT checklist, which includes 7 scales: primary assessment, secondary assessment, procedures, technical skills, trauma communication, nontechnical skills, and a global performance scale.The primary end point was the change from before a training intervention (t0) to 1 year after training (t2), measured by a metric point score. The second end point was the impact of the intervention from before training to after and from immediately after training to 1 year later.

RESULTS

A total of 146 trainings were evaluated. In simulated traumatological emergencies, training participants showed significantly better treatment capacity after 1 year (t0: 28.8 ± 5.6 points versus t2: 59.6 ± 6.6 points, P < 0.001), with greater improvement from t0 to t1 (28.8 ± 5.6 points versus 65.1 ± 7.9 points, P < 0.001). The most significant change from t0 to t2 was seen in the primary assessment, with a mean change of 11.1 ± 5.1, followed by the scale of the procedure (6.1 ± 3.0) and nontechnical skills (6.0 ± 3.0).

CONCLUSIONS

Team trainings with intensive scenario training and short theoretical inputs lead to a significant improvement in simulated care of severely injured patients, especially in identifying and intervening in life-threatening symptoms, processes, and nontechnical skills, even 1 year after the course. Positive, longitudinally positive effects were also in communication and subjective safety of prehospital health care personnel.

Identification and Validation of Ferroptosis-Related LncRNA Signatures as a Novel Prognostic Model for Colon Cancer

Background

Ferroptosis is a newly defined form of programmed cell death that plays an important role in many cancers. However, ferroptosis-related lncRNAs (FRLs) involved in the regulation of colon cancer are not thoroughly understood. This study aimed to identify a prognostic FRL signature in colon cancer and explore its potential molecular function.

Methods

RNA-seq data and relevant clinical information were obtained from The Cancer Genome Atlas (TCGA) database, and a list of ferroptosis-related genes was extracted from the FerrDb website. Analysis of differentially expressed FRLs was performed using the 'limma' package in R software. By implementing coexpression analysis and univariate Cox analysis, we then identified prognostic FRLs. Using Cox regression analysis with the least absolute shrinkage and selection operator (LASSO) algorithm, we constructed a prognostic model based on 4 FRLs. We evaluated the prognostic power of this model using Kaplan-Meier (K-M) survival curve analysis and receiver operating characteristic (ROC) curve analysis. Moreover, the relationships between the signature and immune landscape, somatic mutation and drug sensitivity were explored. Finally, in vitro experiments were conducted to validate the functions of AP003555.1 and AC000584.1.

Results

A 4-FRL signature was constructed. Two risk groups were classified based on the risk score calculated by this signature. The signature-based risk score exhibited a more powerful capacity for survival prediction than traditional clinicopathological features in colon patients. Additionally, we observed a significant difference in immune cells, such as CD4+ and CD8+ T cells and macrophages, between the two groups. Moreover, the high-risk group exhibited lower IC50 values for certain chemotherapy drugs, such as cisplatin, docetaxel, bleomycin or axitinib. Finally, the in vitro experiments showed that ferroptosis processes were suppressed after AP003555.1 and AC000584.1 knockdown.

Conclusion

The proposed 4-FRL signature is a promising biomarker to predict clinical outcomes and therapeutic responses in colon cancer patients.

Natural disaster and immunological aging in a nonhuman primate

Weather-related disasters are increasing in frequency and severity, leaving survivors to cope with ensuing mental, financial, and physical hardships. This adversity can exacerbate existing morbidities, trigger new ones, and increase the risk of mortality-features that are also characteristic of advanced age-inviting the hypothesis that extreme weather events may accelerate aging. To test this idea, we examined the impact of Hurricane Maria and its aftermath on immune cell gene expression in large, age-matched, cross-sectional samples from free-ranging rhesus macaques (Macaca mulatta) living on an isolated island. A cross section of macaques was sampled 1 to 4 y before (n = 435) and 1 y after (n = 108) the hurricane. Hurricane Maria was significantly associated with differential expression of 4% of immune-cell-expressed genes, and these effects were correlated with age-associated alterations in gene expression. We further found that individuals exposed to the hurricane had a gene expression profile that was, on average, 1.96 y older than individuals that were not-roughly equivalent to an increase in 7 to 8 y of a human life. Living through an intense hurricane and its aftermath was associated with expression of key immune genes, dysregulated proteostasis networks, and greater expression of inflammatory immune cell-specific marker genes. Together, our findings illuminate potential mechanisms through which the adversity unleashed by extreme weather and potentially other natural disasters might become biologically embedded, accelerate age-related molecular immune phenotypes, and ultimately contribute to earlier onset of disease and death.

Frontal White Matter Hyperintensities Effect on Default Mode Network Connectivity in Acute Mild Traumatic Brain Injury

The functional connectivity of the brain depends not only on the structural integrity of the cortex but also on the white matter pathways between cortical areas. White matter hyperintensities (WMH), caused by chronic hypoperfusion in the white matter, play a role in the outcome of traumatic brain injury (TBI) and other neurodegenerative disorders. Herein, we investigate how the location and volume of WMH affect the default-mode network (DMN) connectivity in acute mild TBI (mTBI) patients. Forty-six patients with acute mTBI and 46 matched healthy controls were enrolled in the study. All participants underwent T2-weighted fluid-attenuated inversion recovery magnetic resonance imaging (MRI), resting-state functional MRI (fMRI),and neuropsychological assessments. The volume and location of WMH were recorded. The relationships between the WMH volume and clinical assessments were evaluated using Spearman’s correlation. Patients with higher frontal lobe WMH volume had more severe post-concussion symptoms and poorer information processing speed. Moreover, these patients had significantly lower functional connectivity in the right middle temporal gyrus, left middle frontal gyrus, right superior frontal gyrus, and left anterior cingulate cortex, compared with patients with low frontal lobe WMH volume. Compared to the controls, the patients with high frontal WMH volume exhibited significantly lower functional connectivity in the right inferior temporal gyrus, left anterior cingulate cortex, and right superior frontal gyrus. These findings suggest that frontal lobe WMH volume may modulate the functional connectivity within the DMN. Therefore, the WMH volume in specific regions of the brain, particularly the frontal and parietal lobes, may accelerate the process of aging and cognitive impairment may be a useful biomarker for the diagnosis and prognosis of acute mTBI.

Interobserver Reliability of Schatzker, AO Foundation-Orthopaedic Trauma Association, and Luo Classifications for Tibial Plateau Fractures: Does Three-Dimensional CT Improve Outcomes?

Objective

To assess the interobserver agreement of the most widely used classification systems (Schatzker, AO Foundation-Orthopaedic Trauma Association (AO-OTA), and Luo) and investigate the impact of multiplane CT scans on their reliability.

Methods

Twelve raters (seven consultants and five senior trainees) were invited to classify 25 cases of tibial plateau fracture randomly selected out of a large database. Initially, they were asked to classify the fracture according to Schatzker, AO-OTA, and Luo based on plain anteroposterior (AP) X-ray and axial CT images. This procedure was applied for 25 cases consecutively. Next, the raters are given access to the multiplanar CT views of the same cases and were requested to reclassify each case. The interobserver agreement was calculated using the Fleiss kappa coefficient.

Results

An overall fair inter-rater agreement was observed for the Schatzker classification based on the plain AP X-ray (k=0.361) with a slight improvement after three-dimensional (3D) plane CT views (X-ray: k=0.361; 3D CT: k=0.364). For the AO-OTA classification, the relevant values were 0.204 and 0.231 based on plain X-ray and multiplanar CT, respectively. Finally, the Luo classification achieved the highest scores among the three classification systems (k=0.498), but its inter-rater agreement can still be characterized as moderate. No statistically significant improvement in the interobserver agreement was found for any classification even if only the consultants’ subgroup was included in the data analysis.

Conclusion

All three classification systems failed to achieve a substantial agreement among the raters, with only a nonsignificant improvement after providing advanced imaging. This finding reflects the intrinsic weaknesses of the classification systems themselves rather than the disagreement on the fracture pattern due to unsatisfactory imaging.

An interdisciplinary computational model for predicting traumatic brain injury: Linking biomechanics and functional neural networks

The brain is a complex network consisting of neuron cell bodies in the gray matter and their axonal projections, forming the white matter tracts. These neurons are supported by an equally complex vascular network as well as glial cells. Traumatic brain injury (TBI) can lead to the disruption of the structural and functional brain networks due to disruption of both neuronal cell bodies in the gray matter as well as their projections and supporting cells. To explore how an impact can alter the function of brain networks, we integrated a finite element (FE) brain mechanics model with linked models of brain dynamics (Kuramoto oscillator) and vascular perfusion (Balloon-Windkessel) in this study. We used empirical resting-state functional magnetic resonance imaging (MRI) data to optimize the fit of our brain dynamics and perfusion models to clinical data. Results from the FE model were used to mimic injury in these optimized brain dynamics models: injury to the nodes (gray matter) led to a decrease in the nodal oscillation frequency, while damage to the edges (axonal connections/white matter) progressively decreased coupling among connected nodes. A total of 53 cases, including 33 non-injurious and 20 concussive head impacts experienced by professional American football players were simulated using this integrated model. We examined the correlation of injury outcomes with global measures of structural connectivity, neural dynamics, and functional connectivity of the brain networks when using different lesion methods. Results show that injurious head impacts cause significant alterations in global network topology regardless of lesion methods. Changes between the disrupted and healthy functional connectivity (measured by Pearson correlation) consistently correlated well with injury outcomes (AUC≥0.75), although the predictive performance is not significantly different (p>0.05) to that of traditional kinematic measures (angular acceleration). Intriguingly, our lesion model for gray matter damage predicted increases in global efficiency and clustering coefficient with increases in injury risk, while disrupting axonal connections led to lower network efficiency and clustering. When both injury mechanisms were combined into a single injury prediction model, the injury prediction performance depended on the thresholds used to determine neurodegeneration and mechanical tolerance for axonal injury. Together, these results point towards complex effects of mechanical trauma to the brain and provide a new framework for understanding brain injury at a causal mechanistic level and developing more effective diagnostic methods and therapeutic interventions.

Head-to-head comparison of all the prognostic models recommended by the European Association of Urology Guidelines to predict oncologic outcomes in patients with renal cell carcinoma

OBJECTIVES

European Urology Association guidelines suggest the use of integrated prognostic systems to assess oncologic outcomes after surgery in patients with localized renal cell carcinoma (RCC). We performed a head-to-head comparison among all the EAU guidelines recommended prognostic models in RCC.

METHODS

The study included 2,014 patients treated with surgery for clinically localized RCC. Patients were classified into prognostic risk groups, based on each of the five EAU guidelines recommended prognostic model definition, namely UISS, Leibovich 2003, VENUSS, GRANT, and Leibovich 2018 score. Prognostic accuracy of each prognostic model to predict clinical progression or cancer-specific mortality (CSM) was assessed, and ROC curves were calculated, according to histological subtype, namely clear-cell, papillary, and chromophobe RCC.

RESULTS

Of 2,014 patients, 1,575 (78%) harboured clear-cell, 312 (16%) papillary, and 127 (6%) chromophobe RCC. Median follow-up was 66 months [Interquartile range (IQR): 29-120]. In clear-cell RCC, low-risk patients rates ranged from 21% to 64%, according prognostic model. The same phenomenon was observed for papillary and chromophobe RCC. In clear-cell RCC, Leibovich 2018 resulted the most accurate model in predicting clinical progression (88.1%) and CSM (86.8%). Conversely, VENUSS or UISS prognostic models predicting oncologic outcomes represented the most accurate in papillary (88.7% and 84.8%) or chromophobe (87.8% and 89.1%) RCC, respectively.

CONCLUSIONS

A non-negligible difference in terms of performance accuracy exists among the EAU guidelines recommended prognostic models. Thus, their adoption in RCC should be histology-specific and follow-up strategies based on prognostic risk class appear justified only if the appropriate model is used to stratify patients into prognostic risk groups.

The Therapeutic Role of Nanoparticle Shape in Traumatic Brain Injury : An in vitro Comparative Study

Objective

To perform a comparative analysis of therapeutic effects associated with two different shapes of ceria nanoparticles, ceria nanorods (Ceria NRs) and ceria nanospheres (Ceria NSs), in an in vitro model of traumatic brain injury (TBI).

Methods

In vitro TBI was induced using six-well confluent plates by manually scratching with a sterile pipette tip in a 6×6-square grid. The cells were then incubated and classified into cells with scratch injury without nanoparticles and cells with scratch injury, which were treated separately with 1.16 mM of Ceria NSs and Ceria NRs. Antioxidant activities and anti-inflammatory effects were analyzed.

Results

Ceria NRs and Ceria NSs significantly reduced the level of reactive oxygen species compared with the control group of SH-SY5Y cells treated with Dulbecco's phosphate-buffered saline. The mRNA expression of superoxide dismutases was also reduced in nanoparticle-treated SH-SY5Y cells, but apparently the degree of mRNA expression decrease was not dependent on the nanoparticle shape. Exposure to ceria nanoparticles also decreased the cyclooxygenase-2 expression, especially prominent in Ceria NR-treated group than that in Ceria NS-treated group.

Conclusion

Ceria nanoparticles exhibit antioxidant and anti-inflammatory effects in TBI models in vitro. Ceria NRs had better antiinflammatory effect than Ceria NSs, but showed similar antioxidant activity.

Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches

Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.

When REBOA grows wings: Resuscitative endovascular balloon occlusion of the aorta to facilitate aeromedical transport

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a helpful adjunct in the control of non-compressible truncal hemorrhage. Concerns regarding ischemia time limits its applicability in transfer. We describe the first reported case of civilian transfer via aeromedical transport to a higher level of care with a zone 3 REBOA catheter deployed.

Case report

We present the case of a patient in hemorrhagic shock with a complex pelvic fracture exceeding the capability of a rural level-two trauma center requiring the use of REBOA catheter to permit aeromedical transport to a level-one trauma center for definitive embolization.

Conclusion

Deployment of REBOA catheter to facilitate aeromedical transport to an appropriate level of care may be considered if travel times can be kept brief and there is a process and training in place to empower flight medics to consider transporting with a REBOA deployed.

Femoral neck fracture: the reliability of radiologic classifications

BACKGROUND

Femoral neck fractures (FNF) are one of the most common injury in the elderly. A valid radiographic classification system is mandatory to perform the correct treatment and to allow surgeons to facilitate communication. This study aims to evaluate reliability of 2018 AO/OTA Classification, AO/OTA simplified and Garden classification.

METHODS

Six Orthopaedic surgeons, divided in three groups based on trauma experience, evaluated 150 blinded antero-posterior and latero-lateral radiography of FNF using Garden classification, 2018 AO/OTA and simplified AO/OTA classification. One month later, the radiographs were renumbered and then each observer performed a second evaluation of the radiographs. The Kappa statistical analysis was used to determine the reliability of the classifications. Cohen's Kappa was calculated to determine intra and inter observer reliability. Fleiss' Kappa was used to determine multi-rater agreement.

RESULTS

The k values of interobserver reliability for Garden classification was from 0,28 to 0,73 with an average of 0,49. AO classification showed reliability from 0,2 to 0,42, with average of 0,30. Simplified AO/OTA classification showed a reliability from 0,38 to 0,58 with an average of 0,48. The values of intra observer reliability for Garden classification was from 0,48 to 0,79 with an average of 0,63. AO classification showed reliability from 0,2 to 0,64 with an average of 0,5. Simplified AO/OTA classification showed a reliability from 0,4 to 0,75 with an average of 0,61.

CONCLUSION

The revised 2018 AO/OTA classification simplified the previous classification of intracapsular fracture but remain unreliable with only fair interobserver reliability. The simplified AO/OTA classification show a reliability similar to Garden classification, with a moderate interobserver reliability. The experience of the surgeons seems not to improve reliability. No classification has been shown to be superior in terms of reliability.

Potential Immune Indicators for Predicting the Prognosis of COVID-19 and Trauma: Similarities and Disparities

Although cellular and molecular mediators of the immune system have the potential to be prognostic indicators of disease outcomes, temporal interference between diseases might affect the immune mediators, and make them difficult to predict disease complications. Today one of the most important challenges is predicting the prognosis of COVID-19 in the context of other inflammatory diseases such as traumatic injuries. Many diseases with inflammatory properties are usually polyphasic and the kinetics of inflammatory mediators in various inflammatory diseases might be different. To find the most appropriate evaluation time of immune mediators to accurately predict COVID-19 prognosis in the trauma environment, researchers must investigate and compare cellular and molecular alterations based on their kinetics after the start of COVID-19 symptoms and traumatic injuries. The current review aimed to investigate the similarities and differences of common inflammatory mediators (C-reactive protein, procalcitonin, ferritin, and serum amyloid A), cytokine/chemokine levels (IFNs, IL-1, IL-6, TNF-α, IL-10, and IL-4), and immune cell subtypes (neutrophil, monocyte, Th1, Th2, Th17, Treg and CTL) based on the kinetics between patients with COVID-19 and trauma. The mediators may help us to accurately predict the severity of COVID-19 complications and follow up subsequent clinical interventions. These findings could potentially help in a better understanding of COVID-19 and trauma pathogenesis.

Resting-State Functional MRI Metrics in Patients With Chronic Mild Traumatic Brain Injury and Their Association With Clinical Cognitive Performance

Mild traumatic brain injury (mTBI) accounts for more than 80% of people experiencing brain injuries. Symptoms of mTBI include short-term and long-term adverse clinical outcomes. In this study, resting-state functional magnetic resonance imaging (rs-fMRI) was conducted to measure voxel-based indices including fractional amplitude of low-frequency fluctuation (fALFF), regional homogeneity (ReHo), and functional connectivity (FC) in patients suffering from chronic mTBI; 64 patients with chronic mTBI at least 3 months post injury and 40 healthy controls underwent rs-fMRI scanning. Partial correlation analysis controlling for age and gender was performed within mTBI cohort to explore the association between rs-fMRI metrics and neuropsychological scores. Compared with controls, chronic mTBI patients showed increased fALFF in the left middle occipital cortex (MOC), right middle temporal cortex (MTC), and right angular gyrus (AG), and increased ReHo in the left MOC and left posterior cingulate cortex (PCC). Enhanced FC was observed from left MOC to right precuneus; from right MTC to right superior temporal cortex (STC), right supramarginal, and left inferior parietal cortex (IPC); and from the seed located at right AG to left precuneus, left superior medial frontal cortex (SMFC), left MTC, left superior temporal cortex (STC), and left MOC. Furthermore, the correlation analysis revealed a significant correlation between neuropsychological scores and fALFF, ReHo, and seed-based FC measured from the regions with significant group differences. Our results demonstrated that alterations of low-frequency oscillations in chronic mTBI could be representative of disruption in emotional circuits, cognitive performance, and recovery in this cohort.

The Omnipresence of Autonomic Modulation in Health and Disease

The Autonomic Nervous System (ANS) is a critical part of the homeostatic machinery with both central and peripheral components. However, little is known about the integration of these components and their joint role in the maintenance of health and in allostatic derailments leading to somatic and/or neuropsychiatric (co)morbidity. Based on a comprehensive literature search on the ANS neuroanatomy we dissect the complex integration of the ANS: (1) First we summarize Stress and Homeostatic Equilibrium - elucidating the responsivity of the ANS to stressors; (2) Second we describe the overall process of how the ANS is involved in Adaptation and Maladaptation to Stress; (3) In the third section the ANS is hierarchically partitioned into the peripheral/spinal, brainstem, subcortical and cortical components of the nervous system. We utilize this anatomical basis to define a model of autonomic integration. (4) Finally, we deploy the model to describe human ANS involvement in (a) Hypofunctional and (b) Hyperfunctional states providing examples in the healthy state and in clinical conditions.

Structural brain connectivity correlates with outcome in mild traumatic brain injury

We investigated the topology of structural brain connectivity networks and its association to outcome following mild traumatic brain injury, a major cause of permanent disability. Eighty-five patients with mild traumatic brain injury underwent MRI twice, about three weeks and eight months after injury, and 30 age-matched orthopedic trauma control subjects were scanned. Outcome was assessed with Extended Glasgow Outcome Scale on average eight months after injury. We performed constrained spherical deconvolution based probabilistic streamlines tractography on diffusion MRI data and parcellated cortical and subcortical gray matter into 84 regions based on T1-weighted data to reconstruct structural brain connectivity networks weighted by the number of streamlines. Graph theoretical methods were employed to measure network properties in both patients and controls, and correlations between these properties and outcome were calculated. We found no global differences in the network properties between patients with mild traumatic brain injury and orthopedic control subjects at either stage. However, we found significantly increased betweenness centrality of the right pars opercularis in the chronic stage compared to control subjects. Furthermore, both global and local network properties correlated significantly with outcome. Higher normalized global efficiency, degree, and strength as well as lower small-worldness were associated with better outcome. Correlations between the outcome and the local network properties were the most prominent in the left putamen and the left postcentral gyrus. Our results indicate that both global and local network properties provide valuable information about the outcome already in the acute/subacute stage, and therefore, are promising biomarkers for prognostic purposes in mild traumatic brain injury.

Proximal hamstring tendon avulsions: comparable clinical outcomes of operative and non-operative treatment at 1-year follow-up using a shared decision-making model

OBJECTIVE

To prospectively evaluate 1-year clinical and radiological outcomes after operative and non-operative treatment of proximal hamstring tendon avulsions.

METHODS

Patients with an MRI-confirmed proximal hamstring tendon avulsion were included. Operative or non-operative treatment was selected by a shared decision-making process. The primary outcome was the Perth Hamstring Assessment Tool (PHAT) score. Secondary outcome scores were Proximal Hamstring Injury Questionnaire, EQ-5D-3L, Tegner Activity Scale, return to sports, hamstring flexibility, isometric hamstring strength and MRI findings including proximal continuity.

RESULTS

Twenty-six operative and 33 non-operative patients with a median age of 51 (IQR: 37-57) and 49 (IQR: 45-56) years were included. Median time between injury and initial visit was 12 (IQR 6-19) days for operative and 21 (IQR 12-48) days for non-operative patients (p=0.004). Baseline PHAT scores were significantly lower in the operative group (32±16 vs 45±17, p=0.003). There was no difference in mean PHAT score between groups at 1 year follow-up (80±19 vs 80±17, p=0.97). Mean PHAT score improved by 47 (95% CI 39 to 55, p<0.001) after operative and 34 (95% CI 27 to 41, p<0.001) after non-operative treatment. There were no relevant differences in secondary clinical outcome measures. Proximal continuity on MRI was present in 20 (95%, 1 recurrence) operative and 14 (52%, no recurrences) non-operative patients (p=0.008).

CONCLUSION

In a shared decision-making model of care, both operative and non-operative treatment of proximal hamstring tendon avulsions resulted in comparable clinical outcome at 1-year follow-up. Operative patients had lower pretreatment PHAT scores but improved substantially to reach comparable PHAT scores as non-operative patients. We recommend using this shared decision model of care until evidence-based indications in favour of either treatment option are available from high-level clinical trials.

Increased mortality after intramedullary nailing of trochanteric fractures: a comparison of sliding hip screws with nails in 19,935 patients

Background and purpose - Intramedullary nails (IMN) have become increasingly common as treatment for trochanteric hip fractures (THF) although they are costlier, and without proven superiority compared with sliding hip screws (SHS). We investigated whether the 2 methods differ in terms of short-term mortality when used in fractures where both methods are suitable. Patients and methods - We extracted data from the Swedish Fracture Register (SFR) on 19,935 patients ≥ 60 years with trochanteric fractures AO type 31-A1 or -A2 who had been treated with either SHS or IMN. We assessed absolute mortality rates and the relative risks (RR) of death after 7, 30, 90, and 365 days using generalized linear models, adjusting for age, sex, and fracture type. We performed a sensitivity analysis on a subgroup of 3,673 patients with information on comorbidity to address this potential confounder. Results - 69% of the patients were women and mean age was 84 years (60-107). IMN was used in 35% of A1 and in 71% of A2 fractures. The use of IMN was associated with a slightly increased adjusted risk of death within 30 days compared with SHS (RR = 1.1, 95% CI 1.0-1.2) with no difference at any other time point. Interpretation - The slightly increased risk of death up to 30 days postoperatively does not support the use of IMN instead of SHS in stable THF.

Effect of Early Psychological Counseling for the Prevention of Posttraumatic Stress Induced by Acute Coronary Syndrome at Long-Term Follow-Up

OBJECTIVE

Psychological consequences of myocardial infarction (MI) are substantial, as 4% of all MI patients develop posttraumatic stress disorder (PTSD) and 12% clinically relevant posttraumatic stress symptoms (PTSS). The study investigated the course and development within 12 months of MI-induced PTSS to gain novel insights in potentially delayed response to early trauma-focused counseling aimed at preventing the incidence of MI-induced PTSS.

METHODS

In the MI-SPRINT two-group randomized controlled trial, 190 MI-patients were randomly allocated to receive a single-session intervention of either trauma-focused counseling or an active control intervention targeting the general role of stress in patients with heart disease. Blind interviewer-rated PTSS (primary outcome) and additional health outcomes were assessed at 12-month follow-up.

RESULTS

12-month follow-up of outcomes were available for 106 (55.8%) of 190 participants: In the entire sample, one patient (0·5%, 1/190) who received trauma-focused counseling developed full PTSD. There was no significant difference between trauma-focused counseling and stress counseling regarding total score of interviewer-rated PTSS (p > 0.05). The only group difference emerged in terms of more severe hyperarousal symptoms in the trauma-focused counseling group in the ITT analysis, but not in the completer analysis.

CONCLUSIONS

No benefits were found for trauma-focused counseling after 12 months when compared with an active control intervention. PTSD prevalence in the present study was low highlighting a potential beneficial effect of both interventions. Further studies are needed to determine the most accurate approach of counseling.

OUP accepted manuscript

Objective

The aim of this study was to describe treatment patterns in RA, including the frequency and reasons for switching or stopping biologic and targeted synthetic DMARDs (b/tsDMARDs).

Methods

The reasons for switching or stopping b/tsDMARDs were extracted from the Australian Rheumatology Association Database (ARAD) from 2003 to 2018 for RA participants. Switching patterns for each b/tsDMARD and time on first-, second- and third-line b/tsDMARDs were evaluated using Sankey diagrams and survival methods.

Results

A total of 2839 participants were included in the analysis. The first-line b/tsDMARDs were etanercept (n = 1414), adalimumab (n = 1024), infliximab (n = 155), golimumab (n = 98), abatacept (n = 66), certolizumab (n = 38), tocilizumab (n = 21) and tofacitinib (n = 23). Of those starting first-, second- and third-line biologic therapy, 24.0%, 31.8% and 24.4% switched to another b/tsDMARD within 12 months, respectively. Inefficacy or adverse effects were the most common reasons for stopping therapy, irrespective of line of treatment. Compared with first-line etanercept, participants were more likely to stop adalimumab [Hazard ratio (HR) 1.16, 95% CI: 1.04, 1.29] and infliximab (HR 1.77, 95% CI: 1.46, 2.16). No differences were seen for other b/tsDMARDs. For second-line therapies compared with etanercept, the risk of stopping was lower for tocilizumab (HR 0.41, 95% CI: 0.25, 0.70), rituximab (HR 0.51, 95% CI: 0.30, 0.85) and tofacitinib (HR 0.29, 95% CI: 0.15, 0.57). Participants taking rituximab, tocilizumab and tofacitinib were also less likely to stop third-line therapy in comparison with participants taking etanercept.

Conclusions

Switching between b/tsDMARDs was common among ARAD participants with RA, most commonly due to inefficacy or adverse effects. Durability of exposure and reasons for switching varied between b/tsDMARDs.

Morphometric changes in the cortex following acute mild traumatic brain injury

Morphometric changes in cortical thickness (CT), cortical surface area (CSA), and cortical volume (CV) can reflect pathological changes after acute mild traumatic brain injury (mTBI). Most previous studies focused on changes in CT, CSA, and CV in subacute or chronic mTBI, and few studies have examined changes in CT, CSA, and CV in acute mTBI. Furthermore, acute mTBI patients typically show transient cognitive impairment, and few studies have reported on the relationship between cerebral morphological changes and cognitive function in patients with mTBI. This prospective cohort study included 30 patients with acute mTBI (15 males, 15 females, mean age 33.7 years) and 27 matched healthy controls (12 males, 15 females, mean age 37.7 years) who were recruited from the Second Xiangya Hospital of Central South University between September and December 2019. High-resolution T1-weighted images were acquired within 7 days after the onset of mTBI. The results of analyses using FreeSurfer software revealed significantly increased CSA and CV in the right lateral occipital gyrus of acute-stage mTBI patients compared with healthy controls, but no significant changes in CT. The acute-stage mTBI patients also showed reduced executive function and processing speed indicated by a lower score in the Digital Symbol Substitution Test, and reduced cognitive ability indicated by a longer time to complete the Trail Making Test-B. Both increased CSA and CV in the right lateral occipital gyrus were negatively correlated with performance in the Trail Making Test part A. These findings suggest that cognitive deficits and cortical alterations in CSA and CV can be detected in the acute stage of mTBI, and that increased CSA and CV in the right lateral occipital gyrus may be a compensatory mechanism for cognitive dysfunction in acute-stage mTBI patients. This study was approved by the Ethics Committee of the Second Xiangya Hospital of Central South University, China (approval No. 086) on February 9, 2019.

Dorsal Subluxation of the Proximal Interphalangeal Joint After Volar Base Fracture of the Middle Phalanx

Background: Treatment decisions regarding volar base fractures of the middle phalanx depend on whether the proximal interphalangeal (PIP) joint is reduced. Our aim was to study the agreement among hand surgeons in determining whether the PIP joint fractures are subluxated and to study the factors associated with subluxation of these fractures. Methods: In this retrospective chart review, 413 volar base fractures of the middle phalanx were included. Demographic and injury-related factors were gathered from medical records and radiographs. Using a Web-based survey, interobserver agreement was determined among 105 hand surgeons on the assessment of PIP joint subluxation of a series of 26 cases. Using the cohort of 413 fractures, a threshold for percent articular involvement and relative fracture displacement that corresponds with subluxation of the PIP joint was analyzed. Results: We found moderate to substantial agreement between hand surgeons on subluxation (κ = 0.59, P < .0001) and an overall percent agreement of 85%. Percent articular involvement and relative fracture displacement were independently associated with subluxation of the PIP joint (P < .001). Percent articular involvement of 35% had a specificity of 90% and a negative predicting value (NPV) of 92% for joint subluxation. Relative fracture displacement of 35% had a specificity of 92% and an NPV of 94% for joint subluxation. Conclusions: Surgeons generally agree on whether a PIP joint is subluxated. Percent articular involvement and relative fragment displacement are objective measurements that can help characterize joint stability and assist with decision-making.

An immunogenomic phenotype predicting behavioral treatment response: Toward precision psychiatry for mothers and children with trauma exposure

Inflammatory pathways predict antidepressant treatment non-response among individuals with major depression; yet, this phenomenon may have broader transdiagnostic and transtherapeutic relevance. Among trauma-exposed mothers (M_age = 32 years) and their young children (M_age = 4 years), we tested whether genomic and proteomic biomarkers of pro-inflammatory imbalance prospectively predicted treatment response (PTSD and depression) to an empirically-supported behavioral treatment. Forty-three mother-child dyads without chronic disease completed Child Parent Psychotherapy (CPP) for roughly 9 months. Maternal blood was drawn pre-treatment, CD14 + monocytes isolated, gene expression derived from RNA sequencing (n = 34; Illumina HiSeq 4000;TruSeqcDNA library), and serum assayed (n = 43) for C-Reactive Protein (CRP) and interleukin-1ß (IL-1ß). Symptoms of PTSD and depression decreased significantly from pre- to post-treatment for both mothers and children (all p's < 0.01). Nonetheless, a higher pre-treatment maternal pro-inflammatory imbalance of M1-like versus M2-like macrophage-associated RNA expression (M1/M2) (ß = 0.476, p = .004) and IL-1ß (ß=0.333, p = .029), but not CRP, predicted lesser improvements in maternal PTSD symptoms, unadjusted and adjusting for maternal age, BMI, ethnicity, antidepressant use, income, education, and US birth. Only higher pre-treatment M1/M2 predicted a clinically-relevant threshold of PTSD non-response among mothers (OR = 3.364, p = .015; ROC-AUC = 0.78). Additionally, higher M1/M2 predicted lesser decline in maternal depressive symptoms (ß = 0.556, p = .001), though not independent of PTSD symptoms. For child outcomes, higher maternal IL-1ß significantly predicted poorer PTSD and depression symptom trajectories (ß's = 0.318-0.429, p's < 0.01), while M1/M2 and CRP were marginally associated with poorer PTSD symptom improvement (ß's = 0.295-0.333, p's < 0.056). Pre-treatment pro-inflammatory imbalance prospectively predicts poorer transdiagnostic symptom response to an empirically-supported behavioral treatment for trauma-exposed women and their young children.