Back to basics: Practical strategies to reduce sensory overstimulation in the emergency department identified by adults and caregivers of children with autism spectrum disorder

INTRODUCTION

Sensory overstimulation of autistic patients of all ages during an ED visit can ultimately lead to care escalation, but few studies have evaluated patient perspectives on improving the ED sensory experience across the age continuum. The purpose of this study was to explore patient-centered perspectives on reducing adult and pediatric autistic patients' sensory stimulation during an ED visit.

METHODS

We used a qualitative descriptive design to explore how autistic patients experience sensory disruption and recommendations to improve care. Data were analyzed inductively using an overall categorization of 6 senses (visual, auditory, touch, smell, taste, and proprioception).

RESULTS

Fourteen adults and 30 caregivers of children provided written responses to open-ended interview questions (n = 44). Participants suggested strategies to minimize the sensory disruption they experienced; however, an overarching recommendation was for clinicians to ask about their or their child's preferences before delivering care or services.

CONCLUSION

Because people with autism are more likely to visit an ED than their neurotypical counterparts, ED clinicians should be proficient in "sensory-friendly care." A variety of evidence-based practical strategies and design approaches exist that can be leveraged to reduce the risk of care escalation; however, the most basic may be to prioritize asking patients and their caregivers about their preferences prior to providing care.

First measurements of an imaging heavy ion beam probe at the ASDEX Upgrade tokamak

The imaging heavy ion beam probe (i-HIBP) diagnostic has been successfully commissioned at ASDEX Upgrade. The i-HIBP injects a primary neutral beam into the plasma, where it is ionized, leading to a fan of secondary (charged) beams. These are deflected by the magnetic field of the tokamak and collected by a scintillator detector, generating a strike-line light pattern that encodes information on the density, electrostatic potential, and magnetic field of the plasma edge. The first measurements have been made, demonstrating the proof-of-principle of this diagnostic technique. A primary beam of 85/87Rb has been used with energies ranging between 60 and 72 keV and extracted currents up to 1.5 mA. The first signals have been obtained in experiments covering a wide range of parameter spaces, with plasma currents (Ip) between 0.2 and 0.8 MA and on-axis toroidal magnetic field (Bt) between 1.9 and 2.7 T. Low densities appear to be critical for the performance of the diagnostic, as signals are typically observed only when the line integrated density is below 2.0-3.0 × 1019 m-2 in the central interferometer chord, depending on the plasma shape. The strike line moves as expected when Ip is ramped, indicating that current measurements are possible. Additionally, clear dynamics in the intensity of the strike line are often observed, which might be linked to changes in the edge profile structure. However, the signal-to-background ratio of the signals is hampered by stray light, and the image guide degradation is due to neutron irradiation. Finally, simulations have been carried out to investigate the sensitivity of the expected signals to plasma density and temperature. The results are in qualitative agreement with the experimental observations, suggesting that the diagnostic is almost insensitive to fluctuations in the temperature profile, while the signal level is highly determined by the density profile due to the beam attenuation.

Spinal injury rates and specific causation in motor vehicle collisions

Motor vehicle collisions (MVCs) are a leading cause of acute spinal injuries. Chronic spinal pathologies are common in the population. Thus, determining the incidence of different types of spinal injuries due to MVCs and understanding biomechanical mechanism of these injuries is important for distinguishing acute injuries from chronic degenerative disease. This paper describes methods for determining causation of spinal pathologies from MVCs based on rates of injury and analysis of the biomechanics require to produce these injuries. Rates of spinal injuries in MVCs were determined using two distinct methodologies and interpreted using a focused review of salient biomechanical literature. One methodology used incidence data from the Nationwide Emergency Department Sample and exposure data from the Crash Report Sample System supplemented with a telephone survey to estimate total national exposure to MVC. The other used incidence and exposure data from the Crash Investigation Sampling System. Linking the clinical and biomechanical findings yielded several conclusions. First, spinal injuries caused by an MVC are relatively rare (511 injured occupants per 10,000 exposed to an MVC), which is consistent with the biomechanical forces required to generate injury. Second, spinal injury rates increase as impact severity increases, and fractures are more common in higher-severity exposures. Third, the rate of sprain/strain in the cervical spine is greater than in the lumbar spine. Fourth, spinal disc injuries are extremely rare in MVCs (0.01 occupants per 10,000 exposed) and typically occur with concomitant trauma, which is consistent with the biomechanical findings 1) that disc herniations are fatigue injuries caused by cyclic loading, 2) the disc is almost never the first structure to be injured in impact loading unless it is highly flexed and compressed, and 3) that most crashes involve predominantly tensile loading in the spine, which does not cause isolated disc herniations. These biomechanical findings illustrate that determining causation when an MVC occupant presents with disc pathology must be based on the specifics of that presentation and the crash circumstances and, more broadly, that any causation determination must be informed by competent biomechanical analysis.

Breadth of use of The Abbreviated Injury Scale in The National Trauma Data Bank bank

OBJECTIVE

The Abbreviated Injury Scale (AIS) is an anatomic-based injury coding system that strives to provide sufficient detail to differentiate unique injuries for the purposes of research and quality assurance, while limiting the total number of codes to facilitate efficient use. It has been shown that a substantial portion of codes are unused in automotive-trauma specific databases. The goal of this study was to determine the percentage of codes utilized in a nationwide trauma registry that includes multiple mechanisms of injury. Secondary objectives were to examine unused codes and determine the number of codes that were most frequently utilized.

METHODS

Data were obtained from the National Trauma Data Bank (NTDB) years 2016 and 2017. All injury data were recorded using AIS version 2005 update 2008 (AIS08), which contains 1,999 distinct injury codes. The percentage of the total number of AIS08 codes used in NTDB were determined for each year individually and the combination of both years. The unused codes were then examined manually to identify common characteristics. Finally, the number of codes that provided 95% coverage of all recorded injuries was calculated.

RESULTS

There were 6,661,110 injuries recorded for 1,953,775 patients in NTDB over the two-year period. A small percentage of codes had an incorrect severity level (0.07%) or an incorrect injury code (0.0002%). There were 1,987 (99.4% of the entire AIS dictionary) unique AIS08 codes utilized in each year, with the unused codes varying between years. The unused codes tended to involve specific nerves, dural sinuses, or severe, bilateral injuries. During the combined two-year period, 1,996 (99.8% of the entire dictionary) unique AIS08 codes were used. Although almost every code was used at least once, 95% of the injuries in NTDB used only the 631 (31.6%) most frequent AIS08 codes.

CONCLUSIONS

In contrast to automotive specific databases, nearly all the AIS08 codes are used each year in the NTDB. Over a two-year period, only three AIS08 injuries were unused. However, less than a third of AIS08 codes encompass 95% of the injuries. Further research is necessary to determine if common codes should be separated into multiple distinct codes to enhance discriminatory ability of AIS.

Helium line ratio spectroscopy for high spatiotemporal resolution plasma edge profile measurements at ASDEX Upgrade (invited)

The thermal helium beam edge diagnostic has recently been upgraded at the ASDEX Upgrade (AUG) tokamak experiment. Line ratio spectroscopy on neutral helium is a valuable tool for simultaneous determination of the electron temperature and density of plasmas. The diagnostic now offers a temporal resolution of 900 kHz with a spatial resolution of up to 3 mm at 32 lines of sight (LOS) simultaneously. The LOS covers a radial region of 8.5 cm, starting at the limiter radius and reaching into the confined region beyond the separatrix. Two components are of particular importance for the aforementioned hardware improvements. The first is the optical head, which collects the light from the experiment. Equipped with an innovative clamping system for optical fiber ends, an arbitrary distribution pattern of LOS can be achieved to gain radial and poloidal profiles. The second major development is a new polychromator system that measures the intensity of the 587 nm, 667 nm, 706 nm, and 728 nm helium lines simultaneously for 32 channels with filter-photomultiplier tube arrays. Thus, the thermal helium beam diagnostic supplements the AUG edge diagnostics, offering fast and spatially highly resolved electron temperature and density profile measurements that cover the plasma edge and scrape-off layer region. Plasma fluctuations, edge localized modes, filaments, and other turbulent structures are resolved, allowing analysis of their frequency and localization or their propagation velocity.

GLASS Clinical Decision Rule Applied to Thoracolumbar Spinal Fractures in Patients Involved in Motor Vehicle Crashes

INTRODUCTION

There are established and validated clinical decision tools for cervical spine clearance. Almost all the rules include spinal tenderness on exam as an indication for imaging. Our goal was to apply GLASS, a previously derived clinical decision tool for cervical spine clearance, to thoracolumbar injuries. GLass intact Assures Safe Spine (GLASS) is a simple, objective method to evaluate those patients involved in motor vehicle collisions and determine which are at low risk for thoracolumbar injuries.

METHODS

We performed a retrospective cohort study using the National Accident Sampling System-Crashworthiness Data System (NASS-CDS) over an 11-year period (1998-2008). Sampled occupant cases selected in this study included patients age 16-60 who were belt-restrained, front- seat occupants involved in a crash with no airbag deployment, and no glass damage prior to the crash.

RESULTS

We evaluated 14,191 occupants involved in motor vehicle collisions in this analysis. GLASS had a sensitivity of 94.4% (95% CI [86.3-98.4%]), specificity of 54.1% (95% CI [53.2-54.9%]), and negative predictive value of 99.9% (95% CI [99.8-99.9%]) for thoracic injuries, and a sensitivity of 90.3% (95% CI [82.8-95.2%]), specificity of 54.2% (95% CI [53.3-54.9%]), and negative predictive value of 99.9% (95% CI [99.7-99.9%]) for lumbar injuries.

CONCLUSION

The GLASS rule represents the possibility of a novel, more-objective thoracolumbar spine clearance tool. Prospective evaluation would be required to further evaluate the validity of this clinical decision rule.

Fast piezoelectric valve offering controlled gas injection in magnetically confined fusion plasmas for diagnostic and fuelling purposes

In magnetically confined fusion plasmas controlled gas injection is crucial for plasma fuelling as well as for various diagnostic applications such as active spectroscopy. We present a new, versatile system for the injection of collimated thermal gas beams into a vacuum chamber. This system consists of a gas pressure chamber, sealed by a custom made piezo valve towards a small capillary for gas injection. The setup can directly be placed inside of the vacuum chamber of fusion devices as it is small and immune against high magnetic fields. This enables gas injection close to the plasma periphery with high duty cycles and fast switch on/off times ≲ 0.5 ms. In this work, we present the design details of this new injection system and a systematic characterization of the beam properties as well as the gas flowrates which can be accomplished. The thin and relatively short capillary yields a small divergence of the injected beam with a half opening angle of 20°. The gas box is designed for pre-fill pressures of 10 mbar up to 100 bars and makes a flowrate accessible from 10¹⁸ part/s up to 10²³ part/s. It hence is a versatile system for both diagnostic as well as fuelling applications. The implementation of this system in ASDEX Upgrade will be described and its application for line ratio spectroscopy on helium will be demonstrated on a selected example.

Small female rib cage fracture in frontal sled tests

OBJECTIVES

The 2 objectives of this study are to (1) examine the rib and sternal fractures sustained by small stature elderly females in simulated frontal crashes and (2) determine how the findings are characterized by prior knowledge and field data.

METHODS

A test series was conducted to evaluate the response of 5 elderly (average age 76 years) female postmortem human subjects (PMHS), similar in mass and size to a 5th percentile female, in 30 km/h frontal sled tests. The subjects were restrained on a rigid planar seat by bilateral rigid knee bolsters, pelvic blocks, and a custom force-limited 3-point shoulder and lap belt. Posttest subject injury assessment included identifying rib cage fractures by means of a radiologist read of a posttest computed tomography (CT) and an autopsy. The data from a motion capture camera system were processed to provide chest deflection, defined as the movement of the sternum relative to the spine at the level of T8.  A complementary field data investigation involved querying the NASS-CDS database over the years 1997-2012. The targeted cases involved belted front seat small female passenger vehicle occupants over 40 years old who were injured in 25 to 35 km/h delta-V frontal crashes (11 to 1 o'clock).

RESULTS

Peak upper shoulder belt tension averaged 1,970 N (SD = 140 N) in the sled tests. For all subjects, the peak x-axis deflection was recorded at the sternum with an average of -44.5 mm or 25% of chest depth. The thoracic injury severity based on the number and distribution of rib fractures yielded 4 subjects coded as Abbreviated Injury Scale (AIS) 3 (serious) and one as AIS 5 (critical). The NASS-CDS field data investigation of small females identified 205 occupants who met the search criteria. Rib fractures were reported for 2.7% of the female occupants.

CONCLUSIONS

The small elderly test subjects sustained a higher number of rib cage fractures than expected in what was intended to be a minimally injurious frontal crash test condition. Neither field studies nor prior laboratory frontal sled tests conducted with 50th percentile male PMHS predicted the injury severity observed. Although this was a limited study, the results justify further exploration of the risk of rib cage injury for small elderly female occupants.

Classifying and Standardizing Panfacial Trauma With a New Bony Facial Trauma Score

Importance

The practice of facial trauma surgery would benefit from a useful quantitative scale that measures the extent of injury.

Objective

To develop a facial trauma scale that incorporates only reducible fractures and is able to be reliably communicated to health care professionals.

Design and Setting

A cadaveric tissue study was conducted from October 1 to 3, 2014. Ten cadaveric heads were subjected to various degrees of facial trauma by dropping a fixed mass onto each head. The heads were then imaged with fine-cut computed tomography. A Bony Facial Trauma Scale (BFTS) for grading facial trauma was developed based only on clinically relevant (reducible) fractures. The traumatized cadaveric heads were then scored using this scale as well as 3 existing scoring systems. Regression analysis was used to determine correlation between degree of incursion of the fixed mass on the cadaveric heads and trauma severity as rated by the scoring systems. Statistical analysis was performed to determine correlation of the scores obtained using the BFTS with those of the 3 existing scoring systems. Scores obtained using the BFTS were not correlated with dentition (95% CI, -0.087 to 1.053; P = .08; measured as absolute number of teeth) or age of the cadaveric donor (95% CI, -0.068 to 0.944; P = .08).

Main Outcome Measures

Facial trauma scores.

Results

Among all 10 cadaveric specimens (9 male donors and 1 female donor; age range, 41-87 years; mean age, 57.2 years), the facial trauma scores obtained using the BFTS correlated with depth of penetration of the mass into the face (odds ratio, 4.071; 95% CI, 1.676-6.448) P = .007) when controlling for presence of dentition and age. The BFTS scores also correlated with scores obtained using 3 existing facial trauma models (Facial Fracture Severity Scale, rs = 0.920; Craniofacial Disruption Score, rs = 0.945; and ZS Score, rs = 0.902; P < .001 for all 3 models). In addition, the BFTS was found to have excellent interrater reliability (0.908; P = .001), which was similar to the interrater reliability of the other 3 tested trauma scales. Scores obtained using the BFTS were not correlated with dentition (odds ratio, .482; 95% CI, -0.087 to 1.053; P = .08; measured as absolute number of teeth) or age of the cadaveric donor (odds ratio, .436; 95% CI, -0.068 to 0.944; P = .08).

Conclusions and Relevance

Facial trauma severity as measured by the BFTS correlated with depth of penetration of the fixed mass into the face. In this study, the BFTS was clinically relevant, had high fidelity in communicating the fractures sustained in facial trauma, and correlated well with previously validated models.

Level of Evidence

NA.

Mass gathering medicine: event factors predicting patient presentation rates

This study was conducted to identify the event characteristics of mass gatherings that predict patient presentation rates held in a southeastern US university community. We conducted a retrospective review of all event-based emergency medical services (EMS) records from mass gathering patient presentations over an approximate 23 month period, from October 24, 2009 to August 27, 2011. All patrons seen by EMS were included. Event characteristics included: crowd size, venue percentage filled seating, venue location (inside/outside), venue boundaries (bounded/unbounded), presence of free water (i.e., without cost), presence of alcohol, average heat index, presence of climate control (i.e., air conditioning), and event category (football, concerts, public exhibitions, non-football athletic events). We identified 79 mass gathering events, for a total of 670 patient presentations. The cumulative patron attendance was 917,307 persons. The patient presentation rate (PPR) for each event was calculated as the number of patient presentations per 10,000 patrons in attendance. Overdispersed Poisson regression was used to relate this rate to the event characteristics while controlling for crowd size. In univariate analyses, increased rates of patient presentations were strongly associated with outside venues [rate ratio (RR) = 3.002, p < 0.001], unbounded venues (RR = 2.839, p = 0.001), absence of free water (RR = 1.708, p = 0.036), absence of climate control (RR = 3.028, p < 0.001), and a higher heat index (RR = 1.211 per 10-unit heat index increase, p = 0.003). The presence of alcohol was not significantly associated with the PPR. Football events had the highest PPR, followed sequentially by public exhibitions, concerts, and non-football athletic events. In multivariate models, the strong predictors from the univariate analyses retained their predictive significance for the PPR, together with heat index and percent seating. In the setting of mass event medical care, we note that several factors are strongly associated with an increased patient census, including outside (external) or unbounded venues, the absence of fee water (i.e., without cost), no climate control, percent (occupied) seating, and increasing heat index. Although the presence of alcohol is noted to increase patient needs, it does not do so significantly. Regarding event type, collegiate football games have the highest patient census among the range of other events studied. These findings should be considered during the process of EMS resource planning for mass gatherings.

[Enzalutamide and Abiraterone in the Treatment of Metastatic Castration-resistant Prostate Cancer after Chemotherapy]

AIM

Enzalutamide and abiraterone represent new therapeutical options in the treatment of metastatic castration-resistant prostate cancer (mCRPC). The aim of the presented study was retrospective analysis of clinical experience and efficacy of enzalutamide or abiraterone in the postchemo indication in patients with mCRPC.

PATIENTS AND METHODS

A total of 32 mCRPC patients were evaluated. All patients received one or more lines of chemotherapy. Twenty-three patients were treated by enzalutamide, nine patients were treated by abiraterone. We defined two parameters: over all survival and progression-free survival.

RESULTS

The median follow-up was 6.5 months. A total of 10 patients treated by enzalutamide progressed (43.47%) and eight patients died (34.78%). A total of five patients treated by abiraterone progressed (55.56%) and one patient died (11.11%). We did not observe any statistical difference in over all survival (HR 0.2362, 95% CI 0.0295- 1.8942; p = 0.102) and in progression-free survival (HR 0.9853, 95% CI 0.2934- 3.308; p = 0.939) between enzalutamide and abirateron.

CONCLUSION

Our retrospective study demonstrated similar efficacy of enzalutamide and abiraterone in mCRPC patients previously treated by chemotherapy.

[Management of chronic and acute pain in patients with cancer diseases]

Pain is one of the most important and most frequent symptoms of malignancy. Its intensity and prevalence is growing with disease status. Pain should be present in early stage cancer patients also. Pain is, together with other symptoms (anorexia, nausea, depression, anxiety, sleep disturbances), factor of patients quality-of-life and proper therapy is responsible for overall patient satisfaction and activity. Right pain management is always multidimensional and pain should be assessed at each contact. In review article we would like to bring some alerts of pain context in complexity of cancer and we would like to stress some forms of acute pain management.

Occupant Kinematics in Laboratory Rollover Tests: PMHS Response

The objective of the current study was to characterize the whole-body kinematic response of restrained PMHS in controlled laboratory rollover tests. A dynamic rollover test system (DRoTS) and a parametric vehicle buck were used to conduct 36 rollover tests on four adult male PMHS with varied test conditions to study occupant kinematics during the rollover event. The DRoTS was used to drop/catch and rotate the test buck, which replicated the occupant compartment of a typical mid-sized SUV, around its center of gravity without roof-to-ground contact. The studied test conditions included a quasi-static inversion (4 tests), an inverted drop and catch that produced a 3 g vertical deceleration (4 tests), a pure dynamic roll at 360 degrees/second (11 tests), and a roll with a superimposed drop and catch produced vertical deceleration (17 tests). Each PMHS was restrained with a three-point belt and was tested in both leading-side and trailing-side front-row seating positions. Whole-body kinematics were measured using a 3D motion capture system that quantified occupant displacement relative to the vehicle buck for the X-axis (longitudinal), Y-axis (lateral), and Z-axis (vertical) directions. Additionally the spine was divided into five segments to describe intrasegmental kinematics of the spine, including segment rotations as well as spinal extension and compression. The reported data represent the most complete set of kinematic response targets for a restrained occupant in a variety of dynamic rollover conditions, and are immediately useful for efforts to evaluate and improve existing ATDs and computational models for use in the rollover crash environment.

Nonurgent commercial air travel after acute coronary syndrome: a review of 288 patient events

OBJECTIVES

We studied a population of individuals who experienced an acute coronary syndrome (ACS) event while traveling abroad and required nonurgent commercial air travel to the home region.

METHODS

This retrospective study gathered data from 288 patients enrolled in a travel-based medical assistance program. Interventions, complications, and travel home were assessed for trends. Descriptive and comparison statistical analyses were performed.

RESULTS

Two hundred eighty-eight patients were identified and entered into the review. Of the patients in this study, 77.1% were male with an average age of 67.7 years. One hundred sixteen (40.3%) patients were diagnosed with unstable angina pectoris (USAP), whereas the remaining 172 (59.7%) patients experienced acute myocardial infarction (AMI). Regarding inpatient complications during the initial admission, 121 (42.0%) patients experienced 1 or more adverse event. The average number of days after an ACS event that a patient began to travel home was 10.5 days for the entire patient population (USAP patients = 8.8 days, AMI patients = 11.8 days). Two hundred twenty (76.4%) patients traveled with a medical escort, and 48 (16.7%) patients received supplemental oxygen during air travel. Four (1.4%) in-flight adverse events occurred in the following ACS diagnostic groups: 2 in the complicated AMI group, 1 in the uncomplicated USAP group, and 1 in the uncomplicated AMI group. No in-flight deaths occurred. Nine (3.1%) deaths were noted within 2 weeks after returning to the home region. The deaths after returning to the home region occurred in the following ACS diagnostic groups: 2 in the complicated USAP group, 1 in the uncomplicated USAP group, and 6 in the complicated AMI group. None of the patients who experienced in-flight events died after returning to their home region.

CONCLUSIONS

Upon discharge, the vast majority of ACS patients who travel to their home region via commercial air do not experience adverse events in-flight; when such adverse events occur in-flight, these events do not result in a poor outcome. No in-flight deaths occurred; death occurred in a minority of patients after returning to their home region, particularly in the complicated USAP and AMI groups, who were planned readmissions to the hospital.

Training Emergency Medicine Residents—the Skill of Endotracheal Intubation: Comparison of Human Cadavers vs Mannequins

Introduction and objectives

There are multiple approaches to teach residents the skill of endotracheal intubation, including classroom teaching, cadaveric specimens, and simulation mannequins. The hypothesis of our study is training in the technique of intubation is equally mastered (resident confidence and competency) in training on human cadavers or simulation mannequins.

Materials and methods

Emergency medicine interns were asked to voluntarily enroll in the study prior to the beginning of intern year and randomized into two groups. The first group practiced intubation using mannequins. The second group practiced intubation using human cadavers. Both groups were given the same brief introductory lecture on the basics of endotracheal intubation. One week later, all the interns returned and attempted to intubate cadavers and mannequins. Competency assessment was based on the number of successful intubations, number of attempts, and use of adjunctive techniques. Interns were also surveyed after their anesthesia rotation with a Likert scale on confidence of being able to perform intubation.

Results

The overall average number of attempts was 1.67 in the mannequin group and 1.85 in the cadaver group. Mannequin trained interns had a total of 24 poor techniques noted over the 2 years. The cadaver trained group had a total of 35 poor techniques over the 2 years. Adjunct use was nearly identical in the two groups. Intubation success rate during anesthesia rotation and preparation ratings were nearly identical in the two groups. However, the cadaver-trained group reported feeling slightly more confident.

Conclusion

Overall, mannequins require fewer attempts to intubate and being mannequin trained results in fewer attempts. Adjunct use is independent of training type. The mannequintrained group had less episodes of poor technique than the cadaver-trained group. A mannequin training appears to be equivalent or better than cadaveric training for securing an airway, although cadaver trained interns reported slightly more confidence.

How to cite this article

Rothstein J, Gullo J, Cuningham L, Murphy P, Sochor M. Training Emergency Medicine Residents— the Skill of Endotracheal Intubation: Comparison of Human Cadavers vs Mannequins. Panam J Trauma Crit Care Emerg Surg 2014;3(1):8-10.

Occupant kinematics and shoulder belt retention in far-side lateral and oblique collisions: a parametric study

In far-side impacts, head contact with interior components is a key injury mechanism. Restraint characteristics have a pronounced influence on head motion and injury risk. This study performed a parametric examination of restraint, positioning, and collision factors affecting shoulder belt retention and occupant kinematics in far-side lateral and oblique sled tests with post mortem human subjects (PMHS). Seven PMHS were subjected to repeated tests varying the D-ring position, arm position, pelvis restraint, pre-tensioning, and impact severity. Each PMHS was subjected to four low-severity tests (6.6 g sled acceleration pulse) in which the restraint or position parameters were varied and then a single higher-severity test (14 g) with a chosen restraint configuration (total of 36 tests). Three PMHS were tested in a purely lateral (90° from frontal) impact direction; 4 were tested in an oblique impact (60° from frontal). All subjects were restrained by a 3-point seatbelt. Occupant motion was tracked with a 3D optoelectric high speed motion capture system. For all restraint configurations, the 60° oblique impact angle was associated with greater lateral head excursion than the 90° impact angle. This unexpected result reflects the increased axial rotation of the torso in the oblique impacts, which allowed the shoulder to displace more relative to the shoulder belt and thus the head to displace more relative to the sled buck. Restraint engagement of the torso and shoulder was actually greater in the purely lateral impacts than in the oblique impacts. Pretensioning significantly reduced lateral head excursion (175 mm average in the low-severity tests across all restraint configurations).

[Management of infections in palliative and terminal cancer care]

BACKGROUND

Patients with cancer are highly susceptible to infections. There is a lack of evidencebased guidelines or protocols for their management in palliative and endoflife care.

PURPOSE

To define an optimal dia-gnostic approach and therapeutic management of infections in patients with palliative and terminal cancer care. Along with thromboembolic disease and cancer progression, infections are the most frequent causes of death in oncology. Besides the impact on mortality, they are accompanied with a myriad of symptoms decreasing the quality of life. High incidence of infectons is due to a malignancy itself, the oncolgical therapy and host factors. There is a lack of evidencebased guidelines and protocols for the therapy of infections in palliative and terminal cancer care. Most of available studies are retrospective in nature, with diverse methods and cohorts. Incidence of infections in these patient oscillates between 16- 55% in specialized palliative units, and rises up to 83% in acute care hospitals. From the epidemiologic viewpoint, urinary (39- 42%) and respiratory infections (22- 36%) are the most frequent cases, followed by soft tissue and skin infections (6- 12%) and bacteremias (5- 14%). At present, the antibio-tic treatment does not seem to have a positive impact on the survival rate. Symptom control antibio-tic therapy as a means of symptom control still remains controversial, since it meets this purpose only in a few percents of studies. The most successful is the symtom control in urinary tract infections (60- 79%), in contrast to other sites of infection (30- 43%). In the last week of life there the symptom control is achieved only in 10% of patient. One should always consider the prognosis, actual preformance status and patients preferences when it comes to the management of dia-gnostics and therapy of infections. If the prognosis counts in weeks or months the dia-gnostics and therapy should not differ from the approach to any other oncological patient. In terminal cancer care the antibio-tics should be spared strictly for the purpose of symptom control and with a palliative intent. This article reviews current knowledge of dia-gnostics and therapy of infections in palliative cancer care and includes an algorithm for their management.

[Antiangiogenic biotherapy and chemotherapy in breast cancer: review of literature and case report]

Breast cancer incidence is 120/100,000 women and thus, it is the most frequent malignant disease in women. Despite the ever-increasing incidence, mortality has stayed stable; this is due to screening with detection of early breast cancers, adjuvant treatment and advances in targeted therapy. Currently, we perceive breast cancer as a phenotypically different subunits, influenced by genetic and epigenetic changes. All 5 basic subgroups (luminal A, B, basal-like, HER-2 positive and claudin-low) vary significantly in their prognosis and therapeutic options. The subgroup of basal-like tumors without hormone receptors positivity and HER-2 antigen (triple-negative breast cancer) is prognostically and therapeutically a very unfavorable group. Hormonal and anti-HER-2 therapy is excluded, and the effect of chemotherapy is limited and short-lived. Research for this sub-group of breast tumors in recent years focused on the influence of angiogenesis and DNA repair systems. Therapeutic manipulation of angiogenesis is based on the concept of its influence in the development and maintenance of the malignant process. The longest used and in terms of studies and clinical practice explored treatment is the main path of angiogenesis, the vascular endothelial growth factor. In the last few years, the real effect in the metastatic breast cancer is discussed. The initial positive results of pilot clinical trials showing a significant extension of the progression free survival bring disappointment since they were not translated into prolongation of overall survival. The following case-report presents a patient with metastatic triple-negative breast cancer with combined chemobiotherapy (capecitabine + bevacizumab). In the second part of the article, we discuss possible causes of inconsistent outcomes with antiangiogenic therapy in breast cancer, new directions in scientific research and today knowledge of prediction of its therapeutic effect.

GLass intact Assures Safe cervical Spine protocol

BACKGROUND

Selective cervical spine immobilization performed by Emergency Medical Services (EMS) is being utilized with increasing frequency. These protocols, although very sensitive, still include subjective data such as "mild cervical discomfort." The aim of this study is to create an objective clinical decision rule that would enhance the selective approach for cervical spine immobilization in patients aged 16-60 years.

STUDY OBJECTIVE

It is hypothesized that, in a motor vehicle crash, the integrity of the involved vehicle's glass window and airbag status is an excellent objective measure for the amount of energy a vehicle occupant has experienced during the crash. GLass intact Assures Safe Spine (GLASS) is an easy and objective method for evaluation of the need for prehospital cervical spine immobilization.

METHODS

A retrospective cohort study was performed with sample motor vehicle crash cases to evaluate the performance of the GLASS rule. The National Accident Sampling System-Crashworthiness Data System (NASS-CDS) was utilized to investigate tow-away motor vehicle crashes, including their glass damage characteristics and occupant injury outcomes, over an 11-year period (1998-2008). Sample occupant cases selected for this study were patients aged 16-60 years, who were belt-restrained front seat occupants involved in a crash with no airbag deployment, and no glass damage before the crash.

RESULTS

A total of 14,191 occupants involved in motor vehicle crashes were evaluated in this analysis. The results showed that the sensitivity of the GLASS rule was 95.20% (95% confidence interval [CI] 91.45-98.95%), the specificity was 54.27% (95% CI 53.44-55.09%), and the negative predictive value was 99.92% (95% CI 99.86-99.98%).

CONCLUSION

The GLASS rule presents the possibility of a novel, more objective tool for cervical spine clearance. Prospective evaluation is required to further evaluate the validity of this clinical decision rule.

Biomechanical response targets for physical and computational models of the pediatric trunk

OBJECTIVES

This paper quantifies pediatric thoracoabdominal response to belt loading to guide the scaling of existing adult response data and to assess the validity of a juvenile porcine abdominal model for application to the development of physical and computational models of the human child.

METHODS

Table-top belt-loading experiments were performed on 6, 7, and 15 year-old pediatric post-mortem human subjects (PMHS). Response targets are reported for diagonal belt and distributed loading of the anterior thorax and for horizontal belt loading of the abdomen.

RESULTS

The pediatric PMHS exhibited abdominal response similar to the swine, including the degree of rate sensitivity. The thoraces of the PMHS were as stiff as, or slightly more stiff than, published adult corridors.

CONCLUSIONS

An assessment of age-related changes in thoracic stiffness suggests that the effective stiffness of the chest increases through the fourth decade of life and then decreases, resulting in stiffness values similar for children and elderly adults.

[Bloodstream infections of the intravascular access devices - case reports and review of the literature]

Long-term access devices (VAD) in oncology patients are the elemental procedure of contemporary treatment. Apart from their indisputable benefit they are linked with an increased risk of infectious complications, ranging between simple colonisation of a device to catheter related bloodstream infections. The decision to salvage or extract the VAD in case of bloodstream infection depends on patient's clinical state, localisation of infection (site of insertion, catheter or pocket), casual agent and complications (e.g. endocarditis, septic embolization, osteomyelitis and so on). Authors present 5 case reports of portacath sepsis in their oncology department in 2011 (i.e. 4.46% of 112 inserted ports). In the second part of the article they review current literature data about prevention and treatment of infectious complications of vascular devices in cancer patients.

Whole-body response to pure lateral impact

The objective of the current study was to provide a comprehensive characterization of human biomechanical response to whole-body, lateral impact. Three approximately 50th-percentile adult male PMHS were subjected to right-side pure lateral impacts at 4.3 ± 0.1 m/s using a rigid wall mounted to a rail-mounted sled. Each subject was positioned on a rigid seat and held stationary by a system of tethers until immediately prior to being impacted by the moving wall with 100 mm pelvic offset. Displacement data were obtained using an optoelectronic stereophotogrammetric system that was used to track the 3D motions of the impacting wall sled; seat sled, and reflective targets secured to the head, spine, extremities, ribcage, and shoulder complex of each subject. Kinematic data were also recorded using 3-axis accelerometer cubes secured to the head, pelvis, and spine at the levels of T1, T6, T11, and L3. Chest deformation in the transverse plane was recorded using a single chestband. Following the impact the subject was captured in an energy-absorbing net that provided a controlled non-injurious deceleration. The wall maintained nearly constant velocity throughout the impact event. One of the tested subjects sustained 16 rib fractures as well as injury to the struck shoulder while the other two tested subjects sustained no injuries. The collected response data suggest that the shoulder injury may have contributed to the rib fractures in the injured subject. The results suggest that the shoulder presents a substantial load path and may play an important role in transmitting lateral forces to the spine, shielding and protecting the ribcage. This characterization of whole-body, lateral impact response provides quantified subject responses and boundary condition interactions that are currently unavailable for whole-body, lateral impacts at impact speeds less than 6.7 m/s.

Pediatric thoracoabdominal biomechanics

No experimental data exist quantifying the force-deformation behavior of the pediatric chest when subjected to non-impact, dynamic loading from a diagonal belt or a distributed loading surface. Kent et al. (2006) previously published juvenile abdominal response data collected using a porcine model. This paper reports on a series of experiments on a 7-year-old pediatric post-mortem human subject (PMHS) undertaken to guide the scaling of existing adult thoracic response data for application to the child and to assess the validity of the porcine abdominal model. The pediatric PMHS exhibited abdominal response similar to the swine, including the degree of rate sensitivity. The upper abdomen of the PMHS was slightly stiffer than the porcine behavior, while the lower abdomen of the PMHS fit within the porcine corridor. Scaling of adult thoracic response data using any of four published techniques did not successfully predict the pediatric behavior. All of the scaling techniques intrinsically reduce the stiffness of the adult response, when in reality the pediatric subject was as stiff as, or slightly more stiff than, published adult corridors. An assessment of age-related changes in thoracic stiffness indicated that for both a CPR patient population and dynamic diagonal belt loading on a PMHS population, the effective stiffness of the chest increases through the fourth decade of life and then decreases, resulting in stiffness values approximately the same for children and for elderly adults. Additional research is needed to elucidate the generality of this finding and to assess its significance for scaling adult data to represent pediatric responses.

Fetal outcome in motor-vehicle crashes: effects of crash characteristics and maternal restraint

OBJECTIVE

This project was undertaken to improve understanding of factors associated with adverse fetal outcomes of pregnant occupants involved in motor-vehicle crashes.

STUDY DESIGN

In-depth investigations of crashes involving 57 pregnant occupants were performed. Maternal and fetal injuries, restraint information, measures of external and internal vehicle damage, and details about the crash circumstances were collected. Crash severity was calculated using vehicle crush measurements. Chi-square analysis and logistic regression models were used to determine factors with a significant association with fetal outcome.

RESULTS

Fetal outcome is most strongly associated with crash severity (P < .001) and maternal injury (P = .002). Proper maternal belt-restraint use (with or without airbag deployment) is associated with acceptable fetal outcome (odds ratio = 4.5, P = .033). Approximately half of fetal losses in motor-vehicle crashes could be prevented if all pregnant women properly wore seat belts.

CONCLUSION

Higher crash severity, more severe maternal injury, and lack of proper seat belt use are associated with a higher risk of adverse fetal outcome. These results strongly support recommendations that pregnant women use properly positioned seatbelts.

The interaction of 'occupant factors' on the lower extremity fractures in frontal collision of motor vehicle crashes based on a level I trauma center

BACKGROUND

To advance occupant protection through the improvement of safety countermeasures, it is necessary to understand the factors that affect human injury tolerance. This study investigated the effect of 'occupant factors' i.e. age, gender, height, weight, and body mass index (BMI) on the pattern of lower extremity injury after motor vehicle crashes (MVCs). The second objective was to identify factor(s) (including restraint systems and Delta V) that influence the severity of fractures (open versus close fractures) within the lower extremity area. The outcome of this study may have implications toward secondary prevention in MVCs.

METHODS

One-hundred and thirty-seven front-seat occupants involved in MVCs with frontal impact admitted to the University of Michigan trauma center as part of the Crash Injury Research and Engineering Network (CIREN) project were evaluated. Injuries were classified according to location (knee, thigh, hip [KTH]; lower leg [LL], foot and ankle [FA]). All the relevant variables mentioned above were analyzed.

RESULTS

KTH fractures were the most common region (49.5%) affected, followed by fractures to the FA (38.4%) and LL region (12.1%). Female occupants, being generally shorter than their male counterpart, sustained a significantly higher percentage of FA fractures (44% vs. 29.5%, p < 0.05). Male occupants sustained more KTH fractures (58.3% vs. 44%, p < 0.05). Results demonstrated that there were significantly higher percentages of 'open' fractures in the below knee area (FA [53.8%], LL [24.4%], and KTH [21.8%]; p < 0.05). Of all those variables tested (age, gender, height, weight, BMI, restraint systems, and Delta V), occupant's height had a significant effect on the severity of fractures sustained.

CONCLUSION

The interactive effect observed for height and gender on the pattern of lower extremity fracture is principally related to the body habitus and that gender may be a 'proxy' variable. The 'human factor' plays a vital role in influencing the pattern of injury in a MVC. This study strongly supports the fact that occupants with dissimilar body habitus interact differently with the interior cabin of the vehicle, thus, the performance of the active and passive safety systems.

The simplification of the muscle force prediction using sensitivity analyses

Today artificial neural networks can be trained to solve problems that are difficult for conventional computers or human beings. The big advantage of an artificial neural network is results obtained without knowledge of the algorithm procedure or without full and exact information. Therefore an artificial neural network was used to predict the muscle forces. The aim of the study was to simplify prediction of muscle forces which are difficult to determine, because many muscles act cooperatively. However, orthopeadists, biomechanical engineers and physical therapists need to take muscle forces into consideration because joint contact forces, as well as muscle forces, need to be estimated in order to understand the joint and bone loading. In terms of sensitivity of the muscle parameters to the results from the proposed neural network object, the muscle force prediction was simplified.

Biological properties of the intervertebral cages made of titanium containing a carbon-carbon composite covered with different polymers

Intervertebral cages are used in orthopaedics for stabilization of injured lumbar parts of vertebral columns. Our study provides preliminary results of tests of the biological properties of titanium cages with a variously modified carbon/carbon composite (C/C) core. This core was produced from a C/C composite modified by hydrogel materials based on poly(2-hydroxyethyl methacrylate) (HEMA) enriched with 1% collagen or 35% methylmethacrylate or 30% terc-butylmethacrylamide. We evaluated the adhesion of the cells to the tested material coating using an in vitro study of the metabolic activity and cytokine production of the cells (TNF-alpha, IL-8). We studied the biocompatibility of intervertebral cages coated with different copolymers under in vivo condition and in an implantation experiment in the porcine femurs. Both in vitro and in vivo results revealed favourable biotolerance of the use system. Modification of the composite HEMA with the use of collagen seems to have a more positive effect on the new bone tissue formed around the implanted devices than HEMA copolymerized with methylmethacrylate or terc-butylmethacrylamide.