Clinical characteristics and prognosis of traumatic head injury following road traffic accidents admitted in ICU "analysis of 694 cases"

The Australian Traumatic Brain Injury Initiative: Systematic Review and Consensus Process to Determine the Predictive Value of Demographic, Injury Event, and Social Characteristics on Outcomes for People With Moderate-Severe Traumatic Brain Injury

The objective of the Australian Traumatic Brain Injury (AUS-TBI) Initiative is to develop a data dictionary to inform data collection and facilitate prediction of outcomes of people who experience moderate-severe TBI in Australia. The aim of this systematic review was to summarize the evidence of the association between demographic, injury event, and social characteristics with outcomes, in people with moderate-severe TBI, to identify potentially predictive indicators. Standardized searches were implemented across bibliographic databases to March 31, 2022. English-language reports, excluding case series, which evaluated the association between demographic, injury event, and social characteristics, and any clinical outcome in at least 10 patients with moderate-severe TBI were included. Abstracts and full text records were independently screened by at least two reviewers in Covidence. A pre-defined algorithm was used to assign a judgement of predictive value to each observed association. The review findings were discussed with an expert panel to determine the feasibility of incorporation of routine measurement into standard care. The search strategy retrieved 16,685 records; 867 full-length records were screened, and 111 studies included. Twenty-two predictors of 32 different outcomes were identified; 7 were classified as high-level (age, sex, ethnicity, employment, insurance, education, and living situation at the time of injury). After discussion with an expert consensus group, 15 were recommended for inclusion in the data dictionary. This review identified numerous predictors capable of enabling early identification of those at risk for poor outcomes and improved personalization of care through inclusion in routine data collection.

Traffic safety and public health in China - Past knowledge, current status, and future directions

Transportation-related harms have developed into a social disease, threatening public safety and health in China. We aimed to increase the global understanding of traffic safety and public health in China from past knowledge, current status, and future directions by collecting, collating, and analyzing the Chinese traffic incidents reported in the published literature. A systematic search of China National Knowledge Infrastructure, Weipu, and published articles referenced in PubMed, Web of Science and ProQuest between January 1, 1988 and April 30, 2023 was performed. China encountered the first recorded traffic accident as early as three thousand years ago in the Shang Dynasty. An increase in vehicle capacity and velocity increased the traffic risks during the transition from rickshaws and livestock to motor vehicles in varying traffic environments. Humans are not only the decisive factor of a large number of vehicles, traffic routes, and environmental variables, but also the victims at the end and starting point of traffic accidents. Injuries (mechanical force, burns) and diseases (traffic-related air pollution, noise) caused by traffic activities not only threaten public health, but also cause risks to safe driving. Analysis of traffic activities and biomarkers promotes the treatment of traffic injuries in ethology and medicine. China prepared for the construction of healthy transportation in the "decade of road safety" toward an estimation of worldwide road traffic injuries in 2030. Improvement of traffic safety concerning public health under the "Outline of the National Comprehensive Three-dimensional Transportation Network Planning" in China will propel the realization of worldwide traffic environmental advancement.

Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review of the Literature

Low- and middle-income countries (LMICs) experience the majority of traumatic brain injuries (TBIs), yet few studies have examined the epidemiology and management strategies of TBI in LMICs. The objective of this narrative review is to discuss the epidemiology of TBI within LMICs, describe the adherence to Brain Trauma Foundation (BTF) guidelines for the management of severe TBI in LMICs, and document TBI management strategies currently used in LMICs. Articles from January 1, 2009 to September 30, 2021 that included patients with TBI greater than 18 years of age in low-, low middle-, and high middle-income countries were queried in PubMed. Search results demonstrated that TBI in LMICs mostly impacts young males involved in road traffic accidents. Within LMICs there are a myriad of approaches to managing TBI with few randomized controlled trials performed within LMICs to evaluate those interventions. More studies are needed in LMICs to establish the effectiveness and appropriateness of BTF guidelines for managing TBI and to help identify methods for managing TBI that are appropriate in low-resource settings. The problem of limited pre- and post-hospital care is a bigger challenge that needs to be considered while addressing management of TBI in LMICs.

Epidemiological and clinical characteristics predictive of ICU mortality of patients with traumatic brain injury treated at a trauma referral hospital - a cohort study

BACKGROUND

Traumatic brain injury (TBI) has substantial physical, psychological, social and economic impacts, with high rates of morbidity and mortality. Considering its high incidence, the aim of this study was to identify epidemiological and clinical characteristics that predict mortality in patients hospitalized for TBI in intensive care units (ICUs).

METHODS

A retrospective cohort study was carried out with patients over 18 years old with TBI admitted to an ICU of a Brazilian trauma referral hospital between January 2012 and August 2019. TBI was compared with other traumas in terms of clinical characteristics of ICU admission and outcome. Univariate and multivariate analyses were used to estimate the odds ratio for mortality.

RESULTS

Of the 4816 patients included, 1114 had TBI, with a predominance of males (85.1%). Compared with patients with other traumas, patients with TBI had a lower mean age (45.3 ± 19.1 versus 57.1 ± 24.1 years, p < 0.001), higher median APACHE II (19 versus 15, p < 0.001) and SOFA (6 versus 3, p < 0.001) scores, lower median Glasgow Coma Scale (GCS) score (10 versus 15, p < 0.001), higher median length of stay (7 days versus 4 days, p < 0.001) and higher mortality (27.6% versus 13.3%, p < 0.001). In the multivariate analysis, the predictors of mortality were older age (OR: 1.008 [1.002-1.015], p = 0.016), higher APACHE II score (OR: 1.180 [1.155-1.204], p < 0.001), lower GCS score for the first 24 h (OR: 0.730 [0.700-0.760], p < 0.001), greater number of brain injuries and presence of associated chest trauma (OR: 1.727 [1.192-2.501], p < 0.001).

CONCLUSION

Patients admitted to the ICU for TBI were younger and had worse prognostic scores, longer hospital stays and higher mortality than those admitted to the ICU for other traumas. The independent predictors of mortality were older age, high APACHE II score, low GCS score, number of brain injuries and association with chest trauma.

Understanding Head Injury Risks During Car-to-Pedestrian Collisions Using Realistic Vehicle and Detailed Human Body Models

Traumatic brain injury (TBI) is the leading cause of death and long-term disability in road traffic accidents (RTAs). Researchers have examined the effect of vehicle front shape and pedestrian body size on the risk of pedestrian head injury. On the other hand, the relationship between vehicle front shape parameters and pedestrian TBI risks involving a diverse population with varying body sizes has yet to be investigated. Thus, the purpose of this study was to comprehensively study the effect of vehicle front shape parameters and various pedestrian bodies ranging from 95th percentile male (AM95) to 6 years old (YO) child on the dynamic response of the head and the risk of TBIs during primary (vehicle) impact. At three different collision speeds (30, 40, and 50 km/h), a total of 36 car-to-pedestrian collisions (CPCs) were reconstructed using three different vehicle types (Subcompact passenger sedan, mid-sedan, and sports utility vehicle (SUV)) and four distinct THUMS pedestrian finite element (FE) models (AM50, AM95, AF05, and 6YO). We assessed skull stress and brain strains besides head linear and rotational kinematics. Our findings indicate that vehicle shape parameters especially bonnet leading edge height (BLEH), when being divided by the height of the Center of Gravity of the human body, correlated positively to head kinematics. The data from this study using realistic vehicle structures and detailed human body models showed that smaller BLEH/CG ratios reduced head injury criteria (HIC) and brain injury criteria (BrIC) values for the car center to mid-stance walking pedestrian impacts but with low-to-moderate R squared values between 0.2 to 0.5. Smaller BLEH/CG reduced head lateral bending velocities with R squared values of 0.57 to 0.63 for all impact velocities, and reduced HIC with R squared value of 0.62 for 50 km/h cases. In the future, simulations with realistic car structures and detailed human body models will be further used to simulate impacts at different locations and with various body shapes/postures.

Clinical and epidemiological characteristics of road traffic accidents patients received at 2 intensive care units in Saudi Arabia-A cross-sectional study

Background

Road traffic accidents (RTAs) lead to major trauma, which is the greatest cause of morbidity and mortality worldwide. The purpose of the study was to determine the clinical epidemiological profiles of the patients received in intensive care units (ICU) with road traffic injuries (RTIs).

Methods

The study, which included 300 patients, was conducted at emergency departments and two reference ICUs in Saudi Arabia. The patients were of varying ages and genders from different demographic backgrounds with different modes of injuries, varying degrees of shock, and multiple types of injury. Study variables included demographics, clinical presentations, and the types of fractures and lacerations.

Results

Most of our study population was male (n = 273; 91%). Car accidents were found to be the prevalent cause of injury (n = 267; 89.0% cases). Only 21.7% of the study population (n = 65) needed ICU admission compared to non-ICU patients (n = 235; 78.3%). Injuries to the chest (P = 0.0001), abdomen (P = 0.0001), upper limbs (P = 0.022), and spine (P = 0.001) significantly contributed to ICU admissions.

Conclusion

The burden on ICUs due to RTIs can be reduced in Saudi Arabia by adopting strict preventive measures against RTAs.

Epidemiology and clinical characteristics of patients discharged from the ICU in a vegetative or minimally conscious state

Purpose

A significant percentage of patients are discharged from intensive care units (ICU) with disorders of counciousness (DoC). The aim of this retrospective, case-control study was to compare patients discharged from the ICU in a vegetative state (VS) or minimally conscious state (MCS) and the rest of ICU survivors, and to identify independent predictors of DoC among ICU survivors.

Methods

Data from 14,368 adult ICU survivors identified in a Silesian Registry of Intensive Care Units (active in the Silesian Region of Poland between October 2010 and December 2019) were analyzed. Patients discharged from the ICU in a VS or MCS were compared to the remaining ICU survivors. Pre-admission and admission variables that independently influence ICU discharge with DoC were identified.

Results

Among the 14,368 analyzed adult ICU survivors, 1,064 (7.4%) were discharged from the ICU in a VS or MCS. The percentage of patients discharged from the ICU with DoC was similar in all age groups. Compared to non- DoC ICU patients, they had a higher mean APACHE II and SAPS III score at admission. Independent variables affecting ICU discharge with DoC included unconsciousness at ICU admission, cardiac arrest and craniocerebral trauma as primary cause of ICU admission, as well as a history of previous chronic neurological disorders and cerebral stroke (p<0.001).

Conclusion

Discharge in a VS and MCS was relatively frequent among ICU survivors. Discharge with DoC was more likely among patients who were unconscious at admission and admitted to the ICU due to cardiac arrest or craniocerebral trauma.

Characterization of Traumatic Brain Injury Research in the Middle East and North Africa Region: A Systematic Review

OBJECTIVES

Traumatic brain injury (TBI) represents a major health concern worldwide with a large impact in the Middle East and North Africa (MENA) region as a consequence of protracted wars and conflicts that adversely affect the general population. Currently, systematic TBI studies in the MENA region are lacking, nonetheless they are immensely needed to enhance trauma management and increase survival rates among TBI patients. This systematic review aims to characterize TBI in the MENA region to guide future policy choices and research efforts and inform tailored guidelines capable of improving TBI management and patient treatment and outcome. Furthermore, it will serve as a road map to evaluate and assess knowledge of trauma impact on regional health systems that can be adopted by health-care providers to raise awareness and improve trauma care.

METHODS

We conducted a comprehensive search strategy of several databases including MEDLINE/Ovid, PubMed, Embase, Scopus, CINAHL, Google Scholar, and the grey literature in accordance with the PROSPERO systematic review protocol CRD42017058952. Abstracts were screened, and selected eligible studies were reviewed independently by 2 reviewers. We collected demographics information along with TBI characteristics, mortality rates, and regional distribution. Data were extracted using REDCap and checked for accuracy.

RESULTS

The search strategy yielded 23,385 citations; 147 studies met the eligibility criteria and were included in this review. Motor vehicle accident (MVA) was the leading cause of TBI (41%) in the MENA region, followed by the military- (15.6%) and fall- (8.8%) related TBI. Males predominantly suffer from TBI-related injuries (85%), with a high prevalence of MVA- and military-related TBI injuries. The TBI mortality rate was 12.9%. The leading causes of mortality were MVA (68%), military (20.5%), and assault (2.9%). The vast majority of reported TBI severity was mild (63.1%) compared to moderate (10.7%) and severe TBI (20.2%). Patients mainly underwent a Glasgow Coma Scale assessment (22.1%), followed by computed tomography scan (8.9%) and surgery (4.1%).

CONCLUSIONS

Despite its clinical, social, and economic burden, the evidence of TBI research in the MENA region is scarce. Further research and high-quality epidemiological studies are urgently needed to gain a deep understanding of the TBI burden in the region, facilitate the allocation of adequate resources, implement effective preventive and intervention strategies and advise on the TBI patient management as reflective on the TBI patterns and modes.

Comorbidity in traumatic brain injury and functional outcomes: a systematic review

INTRODUCTION

Comorbidities in people with traumatic brain injury (TBI) may negatively impact injury recovery course and result in long-term disability. Despite the high prevalence of several categories of comorbidities in TBI, little is known about their association with patients' functional outcomes. We aimed to systematically review the current evidence to identify comorbidities that affect functional outcomes in adults with TBI.

EVIDENCE ACQUISITION

A systematic search of Medline, Cochrane Central Register of Controlled Trials, Embase and PsycINFO was conducted from 1997 to 2020 for prospective and retrospective longitudinal studies published in English. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations.

EVIDENCE SYNTHESIS

Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes of patients with TBI. Cognitive and physical functioning were negatively affected by comorbidities, although the strength of association, even within the same categories of comorbidity and functional outcome, differed from study to study. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed.

CONCLUSIONS

Emerging evidence highlights the adverse effect of comorbidities on functional outcome in patients with TBI, so clinical attention to this topic is timely. Future research on the topic should emphasize time of comorbidity onset in relation to the TBI event, to support prevention, treatment, and rehabilitation. PROSPERO registration (CRD 42017070033).

Clinical predictors of prognosis in patients with traumatic brain injury combined with extracranial trauma

Objective: The purpose of this study was to investigate whether routine blood tests on admission and clinical characteristics can predict prognosis in patients with traumatic brain injury (TBI) combined with extracranial trauma. Methods: Clinical data of 182 patients with TBI combined with extracranial trauma from April 2018 to December 2019 were retrospectively collected and analyzed. Based on GOSE score one month after discharge, the patients were divided into a favorable group (GOSE 1-4) and unfavorable group (GOSE 5-8). Routine blood tests on admission and clinical characteristics were recorded. Results: Overall, there were 48 (26.4%) patients with unfavorable outcome and 134 (73.6%) patients with favorable outcome. Based on multivariate analysis, independent risk factors associated with unfavorable outcome were age (odds ratio [OR], 1.070; 95% confidence interval [CI], 1.018-1.124; p<0.01), admission Glasgow Coma Scale (GCS) score (OR, 0.807; 95% CI, 0.675-0.965; p<0.05), heart rate (OR, 1.035; 95% CI, 1.004-1.067; p<0.05), platelets count (OR, 0.982; 95% CI, 0.967-0.997; p<0.05), and tracheotomy (OR, 15.201; 95% CI, 4.121-56.078; p<0.001). Areas under the curve (AUC) of age, admission GCS, heart rate, tracheotomy, and platelets count were 0.678 (95% CI, 0.584-0.771), 0.799 (95% CI, 0.723-0.875), 0.652 (95% CI, 0.553-0.751), 0.776 (95% CI, 0.692-0.859), and 0.688 (95% CI, 0.606-0.770), respectively. Conclusions: Age, admission GCS score, heart rate, tracheotomy, and platelets count can be recognized as independent predictors of clinical prognosis in patients with severe TBI combined with extracranial trauma.

Risk Factors and Prognostic Value of Swirl Sign in Traumatic Acute Epidural Hematoma

Objective: Acute epidural hematoma (AEDH) is one of the deadliest lesions in patients after traumatic brain injury. AEDH with swirl sign progresses rapidly and requires timely surgical treatment. This study aims to investigate the risk factors for the occurrence of AEDH with swirl sign and its prognostic value.

Methods: Retrospective analysis was performed on 131 AEDH patients, who were divided into swirl sign group and non-swirl sign group based on the brain computed tomographic (CT) scan. Patient information, including gender, age, hypertension, mechanism of injury, Glasgow Coma Scale (GCS) score on admission, time from injury to CT scan, pupillary light reactivity on admission, midline shift, location of hematoma, hematoma volume on admission, oral anticoagulation, and Glasgow Outcome Scale (GOS) score at 3 months were collected. Univariate analysis was used to determine the risk factors for the occurrence of swirl sign. The factors with P < 0.05 were recruited into the multivariate logistic regression analysis and predictive receiver operating characteristic (ROC) curve model.

Results: Univariate analysis demonstrated that the GCS score on admission (P = 0.007), pupillary light reactivity (P = 0.003), location of hematoma (P < 0.0001), and GOS score at 3 months (P = 0.007) were risk factors for the occurrence of swirl sign. Multivariate logistic regression model revealed that the location of hematoma (OR = 0.121; 95% CI: 0.019–0.786; P = 0.027) was an independent risk factor for swirl sign, and the occurrence of swirl sign was a significant predictor of unfavorable neurological outcomes (OR = 0.100; 95% CI: 0.016–0.630; P = 0.014). ROC curves demonstrated that the GCS score on admission (AUC = 0.655; 95% CI: 0.506–0.804), pupillary light reactivity (AUC = 0.625; 95% CI: 0.474–0.777) and location of hematoma (AUC = 0.788; 95% CI: 0.682–0.893) can predict the occurrence of swirl sign, respectively. Remarkably, the combination of these three factors (AUC = 0.829; 95% CI: 0.753–0.906) provided a greater power to predict the swirl sign.

Conclusion: GCS score on admission, pupillary light reactivity, and location of hematoma are risk factors for the occurrence of swirl sign, respectively. The combination of these three factors might be used to predict whether there is swirl sign in AEDH after traumatic brain injury. Furthermore, swirl sign can be used as an effective predictor of poor prognosis in patients.

Combined trauma in craniomaxillofacial and orthopedic-traumatological patients: the need for proper interdisciplinary care in trauma units

Aim

The primary aim of this study was to analyze frequency and characteristics of combined facial and peripheral trauma with consecutive hospitalization and treatment.

Materials and methods

The study included all patients with concomitant orthopedic-traumatolgical (OT) and craniomaxillofacial (CMF) injuries admitted to our level I trauma center in 2018. The data were collected by analysis of the institution’s database and radiological reviews and included age, sex, injury type, weekday and time of presentation. All patients were examined and treated by a team of surgeons specialized in OT and CMF directly after presentation.

Results

A total number of 1040 combined OT and CMF patients were identified. Mean age was 33.0 ± 26.2 years. 67.3% (n = 700) were male patients. Primary presentation happened most frequently on Sundays (n = 199) and between 7 and 8 pm (n = 74). 193 OT fractures were documented, where cervical spine injuries were most frequent (n = 30). 365 facial and skull fractures were recorded. 10.8% of the 204 patients with fractures of the viscerocranium presented with at least one fracture of the extremity, 7.8% (16/204) with cervical spine fractures, 33.3% (68/204) with signs of closed brain trauma and 9.8% (20/204) with intracranial hemorrhage.

Discussion

The study shows a high frequency of combined facial with OT-injuries and brain damage in a predominantly young and male cohort. Attendance by interdisciplinary teams of both CMF and OT surgeons specialized in cervical spine trauma surgery is highly advisable for adequate treatment.

Conclusion

Diagnostics and treatment should be performed by a highly specialized OT and CMF team, with a consulting neurosurgeon in a level-1 trauma center to avoid missed diagnoses and keep mortality low.

Mortalidade de motociclistas com lesões traumáticas resultantes de acidentes de trânsito na cidade de São José dos Campos, em 2015: estudo de coorte

Resumo Objetivo: Analisar fatores associados à mortalidade por lesões traumáticas entre motociclistas. Métodos: Coorte prospectiva, conduzida no Hospital Municipal de São José dos Campos, Brasil, 2015. Foram incluídos motociclistas com lesões traumáticas, ≥14 anos de idade, hospitalizados. Analisaram-se as variáveis sociodemográficas do acidente e da hospitalização, por modelo de regressão de Poisson, apresentando-se risco relativo (RR) e intervalos de confiança de 95% (IC95%). Resultados: Entre 190 motociclistas, 161 (84,7%), jovens do sexo masculino, revelaram 422 (41,8%) lesões em extremidades inferiores e superiores. A incidência de óbito foi maior na medida do aumento da gravidade do trauma, fisiológica (RR=9,67 [IC95% 1,46;64,26]; e RR=4,71 [IC95% 1,36;16,26]) e anatômica (RR=31,49 [IC95% 3,72;266,38]); e mostrou-se menor em até uma semana de internação (RR=0,39 [IC95% 0,15;0,98]). Conclusão: A gravidade do trauma e o tempo de internação associaram-se ao óbito de motociclistas, mas novos estudos devem ser conduzidos para confirmar esses achados e analisar essas relações mais detalhadamente.

Indomethacin for intracranial hypertension secondary to severe traumatic brain injury in adults

BACKGROUND

Among people who have suffered a traumatic brain injury, increased intracranial pressure continues to be a major cause of early death; it is estimated that about 11 people per 100 with traumatic brain injury die. Indomethacin (also known as indometacin) is a powerful cerebral vasoconstrictor that can reduce intracranial pressure and, ultimately, restore cerebral perfusion and oxygenation. Thus, indomethacin may improve the recovery of a person with traumatic brain injury.

OBJECTIVES

To assess the effects of indomethacin for adults with severe traumatic brain injury.

SEARCH METHODS

We ran the searches from inception to 23 August 2019. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 8) in the Cochrane Library, Ovid MEDLINE, Ovid Embase, CINAHL Plus (EBSCO), four other databases, and clinical trials registries. We also screened reference lists and conference abstracts, and contacted experts in the field.

SELECTION CRITERIA

Our search criteria included randomised controlled trials (RCTs) that compared indomethacin with any control in adults presenting with severe traumatic brain injury associated with elevated intracranial pressure, with no previous decompressive surgery.

DATA COLLECTION AND ANALYSIS

Two review authors independently decided on the selection of the studies. We followed standard Cochrane methods.

MAIN RESULTS

We identified no eligible studies for this review, either completed or ongoing.

AUTHORS' CONCLUSIONS

We found no studies, either completed or ongoing, that assessed the effects of indomethacin in controlling intracranial hypertension secondary to severe traumatic brain injury. Thus, we cannot draw any conclusions about the effects of indomethacin on intracranial pressure, mortality rates, quality of life, disability or adverse effects. This absence of evidence should not be interpreted as evidence of no effect for indomethacin in controlling intracranial hypertension secondary to severe traumatic brain injury. It means that we have not identified eligible research for this review.

Benefits of the tranexamic acid in head trauma with no extracranial bleeding: a prospective follow-up of 180 patients

INTRODUCTION

Tranexamic acid (TXA) is one of the debated therapies in the management of traumatic brain injury (TBI). We conducted this study to evaluate the benefits of TXA in TBI on the mortality and its safety in these patients.

METHODS

This was a prospective randomized open-label trial including all patients, aged at 18 years or older, hospitalized in the emergency room during a 13-month period, for TBI. After the realization of the body CT scan, the patients were included if they had intracranial bleeding, and were then randomized according to their medical file number to receive or not the TXA. The eligibility criteria were based on the uncertainty principle, patients with significant extracranial bleeding were excluded since there was evidence that TXA improve their outcome.

RESULTS

We enrolled 180 patients aged at 42 ± 20 years, with an 88% men-proportion. Subarachnoid haemorrhage was the most frequent lesion in the brain CT-scan (67.5%). After randomization, 96 patients were in the TXA group (53%). Demographic data, clinical, biological and radiological features were statistically comparable in the two groups of patients ('TXA' and 'noTXA'). The needs of transfusion or neurosurgery, the mortality rate, the in-hospital length of stay and the dependency at 28-post-traumatic day were similar in the two groups of patients. However, pulmonary embolism was statistically more frequent in 'TXA' group (11.5 versus 2.4%, p = 0.02).

CONCLUSION

TXA is an interesting treatment in haemorrhagic shock. Its efficiency in head trauma is still debated and controversial. Its impact on the mortality and the needs of transfusion or surgery were not demonstrated in this study. Nevertheless, its safety worth to be studied in larger samples as we found a higher rate of pulmonary embolism in the treated group.