Dupilumab-associated ocular adverse events are predicted by low tear break-up time and correlate with high IL-33 tear concentrations in patients with atopic dermatitis

Dupilumab, blocking IL-4 and IL-13 signals, improves atopic dermatitis and Quality of Life but might be also associated with the occurrence of ocular adverse events (OAEs). The main objective of our prospective study was to characterize the cytokine and chemokine profile in the tear fluid of dupilumab-treated patients with moderate-to- severe atopic dermatitis and to identify biomarkers predicting the occurrence of ocular adverse events. Patients with moderate-to-severe AD underwent dermatological and ophthalmological evaluation at the baseline (T0) and week 16 or at the time of an eventual ocular adverse events (T1). A multiplex immunoassay measuring multiple cytokines and chemokines in the tear fluid extracted during ocular examination at both T0 and T1 was performed. Thirty-nine patients with moderate-to-severe AD and treated with dupilumab were included in the study. Baseline tear fluid levels revealed a significantly higher concentration of type 2 cytokines and chemokines in AD patients than healthy controls. The occurrence of ocular adverse events during dupilumab therapy was associated with a significant increase of IL-33 tear fluid levels and a significantly lower tear break-up time, this latter also identified as predictive factor. Our findings suggest that the ophthalmological examination should be considered a valid support to identify patients at risk of developing OAEs and to provide their appropriate management.

Does ABS ensure good performance in emergency braking for less skilled motorcyclists?

This study aims to investigate whether motorcyclists are able to use the full potential of anti-lock braking systems (ABS) in demanding braking situations that maintain the natural coupling of action and perception of emergency events, or whether instead the lack of braking skills in riders makes ABS almost ineffective and comparable to non-ABS brakes on dry pavement. Six experienced riders performed two experimental tests. First test included 12 emergency braking trials in a realistic scenario using a mock-up of an intersection conflict with a car initiating a left turn manoeuvre across the path (LTAP) of a motorcycle approaching from the opposite direction as an unpredicted moving hazard. Second test included three trials in a planned self-timed hard braking. The speed at the onset of braking was 35-45 km/h. The braking performance was measured from the initiation of brake pressure until the full stop of the vehicle. Front wheel ABS usage was determined by the pressure in the master cylinder and wheel callipers. The testing resulted in 85 data runs with full stop braking manoeuvres. Results revealed four categories of riders classified by their front wheel ABS usage during the emergency braking tests, which included two riders who underused front wheel ABS (9.6% and 27.4% of braking time on average). The worst case resulted in a significantly longer braking distance (braking deceleration of 5.2 m/s²). The highest skilled rider, who reached initial jerks close to 30 m/s³, used the ABS of the front wheel 93.7% of the braking time on average, resulting in a braking deceleration of 7.71 m/s². Overall, the best braking performance was achieved in trials where the front ABS was activated for more than 80% of the braking. In planned self-timed hard braking test, where riders have more time to plan the braking manoeuvre, the experience rider with lowest performance during the emergency braking test improved braking efficiency and was able to increase ABS activation from 9.6% to 26.8% of the time, achieving a deceleration of 6.24 m/s². ABS is demonstrated to reduce stopping distances and to improve stability under all braking conditions, but such features are not enough to guarantee a good braking performance in emergency events if the riders have not the skills to utilize the full braking power of the motorcycle. Less skilled riders, even with ABS, may not have the confidence to increase braking power further when reaching high decelerations that push them to the limit of their stabilisation control in emergency braking, thus increasing braking distance with potentially life-threatening consequences. Our results suggest that many experience riders still need knowledge and skill to make the ABS work to its optimum in emergency events to avoid crashes. Further research with larger sample sizes including the full diversity of the motorcyclist population is recommended to determine the actual proportion of motorcyclists underusing ABS.

Motorcycle emergency steering assistance: A systematic approach from system definition to benefit estimation and exploratory field testing

Braking assistance systems are already contributing to improving motorcyclists' safety, however, research on emergency systems acting on the steering is lacking. These systems, already available for passenger cars, could prevent or mitigate motorcycle crashes in which safety functions based only on braking are ineffective. The first research question was to quantify the safety impact of diverse emergency assistance systems acting on the steering of a motorcycle. For the most promising system, the second research question was to assess the feasibility of its intervention using a real motorcycle. Three emergency steering assistance systems were defined in terms of Functionality, Purpose, and Applicability: Motorcycle Curve Assist (MCA), Motorcycle Stabilisation (MS), and Motorcycle Autonomous Emergency Steering (MAES). Experts evaluated each system's applicability and effectiveness based on the specific crash configuration (using Definitions for Classifying Accidents - DCA), the Knowledge-Based system of Motorcycle Safety (KBMS), and the In-Depth Crash Reconstruction (IDCR). An experimental campaign was conducted with an instrumented motorcycle to assess the rider's reaction to external steering input. A surrogate method for an active steering assistance system imparted external steering torques in correspondence with a lane change to analyse the effect of the steering inputs on motorcycle dynamics and rider controllability. MAES globally got the best score for each assessment method. MS received better evaluations than MCA in two out of three methods. The union of the three systems covered a sizeable fraction of the crashes considered (maximum score in 22.8% of the cases). An estimation of the injury potential mitigation, based on injury risk functions for motorcyclists, was made for the most promising system (MAES). The field test data and video footage showed no instability or loss of control, despite the high intensity (>20Nm) of the external steering input. The rider interviews confirmed that the external action was intense but manageable. For the first time, this study presents an exploratory assessment of the applicability, benefits, and feasibility of motorcycle safety functions acting on the steering. MAES, in particular, was found applicable to a relevant share of crashes involving motorcycles. Remarkably, applying an external action to produce a lateral avoidance manoeuvre proved feasible in a real-world test setting.

Testing the acceptability of motorcycle-AEB system: Use of unanticipated interventions as a reliable surrogate of genuinely unexpected events

OBJECTIVE

Active safety systems such as motorcycle autonomous emergency braking (MAEB) capable of ensuring effectiveness and safe rider-vehicle interaction present many potential benefits to reduce road fatalities but also many challenges. The whole development cycle of MAEB requires research through extensive field tests that reproduce unexpected interventions or real-life driving situation before the system can be available to the end-user. This study aims to better understand the rider's kinematic response required to control the stability of the rider-motorcycle system, as well as the extent of unexpectedness perceived by participants under different degrees of awareness of automatic braking (AB) activation.

METHODS

We compared responses to AB in anticipated and (un)anticipated conditions and in a condition that was intended to be genuinely unexpected (Out of the Blue). Twenty men and women, wearing an inertial measurement unit on their upper-back, rode a scooter-type motorcycle with two front wheels simulating urban riding maneuvers on a closed test-track. Three automatic braking (AB) profiles were tested in different sessions, ranged from 3 to 5 m/s² deceleration and 15 to 25 m/s³ braking-jerk. Differences between AB conditions were analyzed using linear mixed models.

RESULTS

The unanticipated condition was perceived as fairly unexpected (rated between Quite Unexpected and Very Unexpected). Out of the Blue condition was on average close to the highest level of unexpectedness (Completely Unexpected). The exposure to unanticipated AB events resulted in upper-body response with larger peaks of pitch rate (0.20 to 0.77 rad/s higher) and acceleration (1.0 to 2.3 m/s² higher) than those of anticipated. Participants showed less postural stability during unanticipated events taking longer both to start correcting the initial forward lean and to fully stabilize balance. Unanticipated and Out of the Blue conditions did not differ in either the amplitude of the kinematic variables or the time-to-peak pitch rate.

CONCLUSIONS

The kinematic response of the rider's upper-body was found to be a reliable estimator of unexpectedness in AB. The findings suggest that unanticipated AB events while the rider engages in riding tasks can enable testing aimed at designing MAEB systems and assessing end-user acceptance in a reliable manner and within ethical safety limits.

V-034 IPOM PLUS: IS THERE ANY PLACE LEFT? WHY WE (STILL) DO IT

Aim

In this video, we want to share and discuss what we have learned from our 20-year experience in IPOM PLUS, for scheduled as emergencies

Material and Methods

We use only all 5 mm trocars, instruments, and 30-degree optics and we always use low intra-abdominal pressure - 10mmHg.

The technical trick is to carefully prepare and manage the abdominal wall context, to free all the hernia areas.

Results

Our experience is almost more than 500 cases, elective as an emergency. In the last years, we normally use a prosthesis, made with a monofilament macroporous mesh and transparent film(with the film versus the intestine), with a 5 cm overlap. Besides the well known needed physical characteristics of the mesh, on the surgeon's side, a mesh should be smooth, stiff, wide enough to cover all the possible defects, easy to handle, and, especially for its possible use in laparoscopy, with a certain degree of and thickness just what it is needed to let it pass through a 5 mm trocar once rolled up. We use to close the defect to avoid serosa and SS - Morbidity and we use to fix the mesh with absorbable tackers. Above all we do believe in the diagnostic value of the technique, cause allows us to better see and judge the intraabdominal context

Conclusions

The advantages of laparoscopy rely on the minimal access and the possibility to manage and examine the abdominal context, especially in emergencies, close the defect, and fix the mesh with tackers.

P-078 LAPAROSCOPIC TREATMENT OF UMBILICAL HERNIA IN A COMMUNITY HOSPITAL SETTING

Introduction

Umbilical Hernia is a common ventral hernia in the adult population. The classical approach was represented by open repair, but in recent years laparoscopic treatment is increasingly adopted and it can present some intraoperative and post-operative advantages.

Materials and methods

We prospectively analyzed a case series of 50 laparoscopic primary and incisional umbilical hernia repairs performed between January 1st, 2020, and December 31st, 2021. We collected data concerning age, sex, hernia defect size, operative time, and complications according to Clavien-DindoClassification, recurrence at 6 months, and 1-year follow-up.

Results

We performed laparoscopic umbilical hernia repairs in 50 patients (32males,18females);mean age52.1year-old(range30–82y.o.).Mean defect size was4.5cm(3–6.8cm).All procedures were performed under general anesthesia and with 5mm trocars and optic and under pneumoperitoneum pressure set until 10 mmHg as the maximum value. In all cases we applied a transparent, lightweight, ultra-thin, nonabsorbable surgical prosthesis in polypropylene, made by a monofilament macroporous mesh and a transparent film. and we performed closure of fascia with adsorbable stitches. Mean Operative time:40minutes(30–65min.).No complications and recurrences were reported.

Conclusions

Laparoscopic treatment of umbilical hernia is a safe and feasible procedure; indeed, we consider reducing hernia from the abdominal cavity generally better than the open approach and composite mesh positioning with direct fascial closure usually allows a satisfying repair of the defect.

P-051 TAPP IN A COMMUNITY HOSPITAL SETTING : AN EXPERIENCE OF OVER 1000 CASES

Aim

We want to share and discuss what we have learned from our 20-year experience in TAPP procedures

Material and Methods

We use only all 5 mm trocars, instruments, and 30-degree optics and we always use low intraabdominal pressure (10mmHg).

The major technical trick is to carefully prepare the peritoneum flap all around, like a cone, just in order to let the mesh perfectly lie down on the inguinal area.

Results

Our TAPP experience is almost more than 1000 cases, elective as an emergency. We use a 10×15 cm LW macroporous monofilament polypropylene mesh. Besides the well known needed physical characteristics of the mesh, on the surgeon's side, a mesh should be smooth, stiff, wide enough to cover all the possible defects, easy to handle, and, especially for its possible use in laparoscopy, with a certain degree of and thickness just what it is needed in order to let it pass through a 5 mm trocar once rolled up. We do not use to fix the mesh anymore because we do believe in the mesh pushed versus the abdominal wall by the intra-abdominal pressure, and in the exact size of the (10×15 cm). Only in case of huge direct hernia we do “lift” without tension the transversalis fascia.

Conclusions

Most of the advantages of laparoscopy rely on the minimal access and therefore the benefits of this technique will be greater as the access becomes smaller, together with a no fixed LW mesh.

Assessment of the effect of motorcycle autonomous emergency braking (MAEB) based on real-world crashes

Objective: Vehicles are increasingly being equipped with Autonomous Emergency Braking (AEB) and literature highlights the utility to fit a similar active safety system in Powered Two-Wheelers (PTWs). This research attempts to analyze the efficacy of PTW Autonomous Emergency Braking (MAEB) when functioning solely, and in the case where both the PTW and Opponent Vehicle (OV) have AEB installed.Methods: 23 crashes involving motorcyclists that occurred in metropolitan areas of Italy between 2009 and 2017 were selected. The "In-depth Study of road Accidents in FlorencE (InSAFE)" provides data for the study. Each crash was reconstructed in PC-Crash 12.1 software. The obtained simulation of the crash dynamics was then used to create the dataset of cases fitted with AEB and MAEB systems. A custom MAEB system was implemented with specifications based on literature.Results: The majority of crashes occurred on urban roads, at intersections, on dry asphalt, with clear visibility, and in daylight. The passenger vehicle was the most frequent opponent vehicle (70%). Almost half the sample involved the PTW rider traveling beyond the speed limit permitted on urban roads. MAEB was found to be applicable in 19 out of 23 real-world crashes allowing the avoidance of two crashes with the progressive triggering criteria (Time to Collision (TTC) - 1.0 s) and one crash in the case where both the PTW and OV have AEB installed with more conservative setups. MAEB simulations show important trends in the reduction of the PTW impact speed (ISR) from the conservative (TTC-0.6s) to standard (TTC-0.8s) to progressive (TTC-1.0s) triggering criteria. The mean impact speed reduction (ISR) becomes 8.6 km/h, 13.8 km/h, 19.1 km/h, respectively.Conclusions: The results suggested that MAEB may be extremely effective in the PTW impact speed reduction and that an earlier MAEB intervention is beneficial in achieving higher reductions in the PTW impact speed. Further, the effect of opponent vehicles also possessing AEB was studied, and it was found that this increased the likelihood of crash avoidance and greater reduction in crash severity in unavoidable circumstances.

Motorcycle curve assist: A novel approach based on active speed control for crash injury reduction

OBJECTIVE

Safely negotiating curves with a powered-two-wheeler (PTW) requires a high level of skill, and a significant proportion of PTW crashes have a curve involvement. This study aimed to estimate the applicability, potential benefits and feasibility of novel Motorcycle Curve Assist (MCA). The system is designed to operate an emergency control of the speed of a motorcycle approaching a bend at an inappropriate speed.

METHODS

First, the MCA system intervention was defined. Second, the applicability of the system and an estimate of its potential benefits was performed based on a PTW crash database. Motorcyclists' injury risk estimates, MCA working parameters and timing of intervention were employed to estimate the potential injury reduction of applicable crash types. Third, a field test campaign involving 29 common riders as participants was conducted to investigate the real-world applicability and acceptability among end-users of the system deployment in one relevant riding condition adopting a range of parameters of intervention.

RESULTS

In the crash database, 23% of cases had curve involvement and after detailed analysis, 14% resulted to be suitable for MCA (60% of cases with curve involvement). The potential relative injury risk reduction considering only the benefits due to crash speed reduction ranged from 3-9% for MAIS2+ to 9-27% for MAIS3+ injuries. Field tests were performed in corners approached at an average speed of 28.7 km/h and an average lean angle of 20°. The system provided a mean deceleration of 0.33 g reached with a fade-in jerk of 1.73 g/s, for an average total duration of 0.59 s. For the field test component, participants reported good controllability of the system, with no incipient loss of control recorded nor reported by participants.

CONCLUSIONS

The proposed approach for MCA implementation showed considerable potential benefits in terms of injury reduction. The intervention with the defined working parameters was considered feasible by a sample of end-users. When integrated with an intervention logic capable of predicting emergency situations while approaching curves, MCA will be a technology capable of assisting PTW riders in conditions where other available active safety systems do not.

Motorcycle Autonomous Emergency Braking (MAEB) employed as enhanced braking: Estimating the potential for injury reduction using real-world crash modeling

OBJECTIVE

Recent field-tests on Motorcycle Autonomous Emergency Braking system (MAEB) showed that higher levels of deceleration to improve its effectiveness were feasible. However, the potential of MAEB in mitigating rider injuries is not well understood, particularly in scenarios where the efficacy of standard MAEB is limited because the rider is manually braking. The purpose of this study was first, to assess the injury mitigation potential of MAEB and second, to test MAEB as an enhanced braking system applied in circumstances where the rider is braking before a crash.

METHODS

Data from previously investigated motorcycle injury crashes that occurred on public roads in Victoria, Australia were reconstructed using a 2D model. The intervention of MAEB was applied in the simulations to test both MAEB standard and MAEB working as enhanced braking system. The effects of MAEB in mitigating crashes were separated by crash configuration and evaluated based on the modeled reductions in impact speed and injury risk, employing injury risk functions available in the literature.

RESULTS

After modeling was applied, MAEB was found to be applicable in 30 cases (91% of those in which was estimated as "possibly applicable"). The modeled Impact Speed Reduction (ISR) among the 30 cases averaged 5.0 km/h. In the cases without manual braking, the mean ISR due to standard MAEB was 7.1 km/h, whereas the relative injury risk reduction ranged from 10% for MAIS2+ to 22% for fatal injuries. In the 14 cases with manual braking, the modeled application of MAEB as enhanced braking led to an average ISR ranging from 5.3 km/h to 7.3 km/h. This resulted in an injury risk reduction ranging from 9% to 12% for MAIS2+ and from 16% to 21% for fatal injuries, depending on the different modes of MAEB.

CONCLUSIONS

This study modeled the potential benefits of the highest levels of intervention for MAEB field-tested to date. The findings estimate the degree to which MAEB could mitigate motorcycle crashes and reduce injury risks for motorcyclists. New strategies for MAEB intervention as enhanced braking were modeled through crash simulations, and suggest improvements in the benefits of MAEB when riders are braking before the crash. This highlighted the requirement to perform new field-based tests to assess the feasibility of MAEB deployed as enhanced braking system.

Cardiac magnetic resonance in athletes with ventricular arrhythmias

Funding Acknowledgements

Type of funding sources: None.

Background

Ventricular arrhythmias in athletes represent an important issue in sport eligibility as they may be a marker of a concealed cardiomyopathy, potentially at risk of sudden cardiac death during sport activity.

Purpose

to assess the utility of cardiac magnetic resonance (CMR) to identify cardiac abnormalities in athletes with documented frequent premature ventricular beats (PVB) or complex ventricular arrhythmias (VA) undergoing competitive sport eligibility screening.

Methods

We enrolled 65 athletes with documented ventricular arrhythmias as follows: 1) frequent PVB at 24-hour ambulatory ECG monitoring (>100 PVB/24h); 2) polymorphic PVB; 3) repetitive PVB (couplets, triplets, or nonsustained ventricular tachicardia). All athletes were studied with rest ECG, exercise stress testing, 24-hour ambulatory ECG monitoring, transthoracic echocardiography and contrast-enhanced CMR.

Results

Sixty-five athletes (56 males, 9 females, age 30 ± 15years) underwent CMR with gadolinium contrast. In 55 patients (84.6%) CMR was normal, in 10 patients (15.4%) the following abnormalities were reported at CMR: four patients with isolated late gadolinium enhancement (LGE) of whom 3 patients with subepicardial LGE in the inferolateral wall and 1 patient with intramyocardial basal inferior LGE; 1 patient with hypertrophic cardiomyopathy with septal LGE; 1 patient with left ventricular non compaction; 3 patients with right ventricular abnormalities (a 13-year-old patient with dilated right ventricle and LGE located at the superior interventricular insertion point, 1 patient with a dilated and hypokinetic right ventricle, 1 patient with a focal right ventricular aneurysm). Transthoracic echocardiography was normal in 7/10 (70%) athletes with CMR abnormalities.

Conclusion

In athletes with frequent or complex ventricular arrhythmias cardiac magnetic resonance identifies cardiac abnormalities in a significant proportion of subjects and it may offer a diagnostic incremental value.

Motorcycle helmet selection and usage for improved safety: A systematic review on the protective effects of helmet type and fastening

OBJECTIVE

Motorcycle helmets are the most common and effective protective device to reduce head injuries and mortality in crashes among powered two-wheeler riders. Even if they are globally recognized as effective, there are still concerns regarding their correct use, which is necessary to achieve maximum head protection. The goal of this systematic review is to assess which characteristics of helmet design and use showed a positive influence on rider safety, in order to provide insights to improve end-user helmet usage.

METHODS

A literature search was carried out combining two sets of keywords, one related with either motorcycle or rider and the other referring to either protective equipment or injuries. After the exclusion of duplicates, 977 papers were screened by reviewers, thus identifying 32 papers that were analyzed in group discussions.

RESULTS

Among the papers included in this study, no strong conflicting conclusions emerged in their results. The studies focusing on the use of different types of helmets highlighted that full-face helmets, compared with other standard helmets, have a positive influence on head injuries and facial injuries. Correct fastening was clearly beneficial for head and facial injuries, induced injuries, and helmet ejection.

CONCLUSIONS

This systematic review provides important insights to improve the usage of helmets by end-users. Correct fastening is a crucial factor to avoid helmet roll-off during a crash. Most studies agreed that full-face helmets provide higher protection in comparison with other standard helmets, especially for facial injuries, and no negative influence with respect to neck and spinal injuries.

Human error in motorcycle crashes: A methodology based on in-depth data to identify the skills needed and support training interventions for safe riding

OBJECTIVE

Human error by either rider or other vehicle driver is the primary contributing factor in crashes involving powered-two-wheelers. A human-factor-based crash analysis methodology is key to enhancing the road safety effectiveness of rider training interventions. Our aim is to define a methodology that uses in-depth data to identify the skills needed by riders in the highest risk crash configurations to reduce casualty rates.

METHODS

The methodology is illustrated through a case study using in-depth data of 803 powered-two-wheeler crashes. Seven types of high-risk crash configuration based on pre-crash trajectories of the road-users involved were considered to investigate the human errors as crash contributors. Primary crash contributing factor, evasive maneuvers performed, horizontal roadway alignment and speed-related factors were identified, along with the most frequent crash configurations and those with the greatest risk of severe injury.

RESULTS

Straight Crossing Path/Lateral Direction was the most frequent crash configuration and Turn Across Path/Opposing Direction was identified as that with the highest risk of serious injury. Multi-vehicle crashes cannot be considered as a homogenous category of crashes to which the same human failure is attributed, as different interactions between motorcyclists and other road users are associated with both different types of human error and different rider reactions. Human error in multiple-vehicle crashes differed between those configurations related to crossroads and those related to rear-end and head-end crashes. Both single-vehicle crashes and multi-vehicle head-on crashes frequently occur along curves. The involved collision avoidance maneuvers of the riders differed significantly among the highest risk crash configurations. The most relevant lack of skills are identified and linked to their most representative context. In most cases a combination of different skills was required simultaneously to avoid the crash.

CONCLUSIONS

The results contribute to understand the motorcyclists' responses in high-risk crash scenarios. The findings underline the need to group accident cases, beyond the usual single-vehicle versus multi-vehicle collision approach. The different interactions with other road users should be considered to identify the competencies of the motorcyclists needed to reduce crash risks. Our methodology can be applied to increase the motorcyclists' safety by supporting preventive actions based on riders' training and eventually ADAS design.

Field testing the applicability of motorcycle autonomous emergency braking (MAEB) during pre-crash avoidance maneuver

OBJECTIVE

Autonomous Emergency Braking (AEB) is a promising technology for crash avoidance or pre-crash impact speed reduction through the automatic application of braking force. Implementation of AEB technology on motorcycles (MAEB) is still problematic as its interaction with the rider may compromise the safety. In previous studies, MAEB interventions at low decelerations were shown to be easily manageable by common riders in straight line condition, but they were not previously tested in lateral maneuvers such as lane change and swerving, which are common in pre-crash situations. The objective of this paper is to assess the applicability of MAEB activation during lateral avoidance maneuver and to estimate its benefits in this scenario.

METHODS

Field tests were carried out involving common riders as participants, using a test protocol developed on the experience of previous studies. The test vehicle was a sport-touring motorcycle equipped with an automatic braking system that could be activated remotely by researchers to simulate MAEB intervention. The motorcycle was equipped with outriggers to prevent capsizing. The Automatic Braking (AB) interventions using a nominal deceleration of 0.3 g were deployed at pseudo-random times in conditions of straight-line travel and a sharp lane-change maneuver emulating a pre-crash avoidance action. The straight-line trials were used as the reference condition for analysis.

RESULTS

Thirty-one participants experienced AB interventions in straight-line and lane-change at an average speed of 44.5 km/h. The automatic braking was deployed in all the key phases of the avoidance maneuver. The system reached a deceleration of 0.3 g for a time of intervention of approximately 1 s. The participants were consistently able to control the vehicle during the automatic braking interventions and were always able to complete the lane-change maneuver. The speed reductions obtained with the AB interventions during lane change were very similar to those obtained in the straight-line conditions.

CONCLUSIONS

MAEB interventions with decelerations up to 0.3 g can be easily managed by motorcycle riders not only in straight-line conditions but also during an avoidance maneuver. Further investigations using higher deceleration values are now possible.

Dietary supplements, drugs and doping in the sport society

Consumption of supplements and the use/abuse of drugs to support athletic performance is increasingly growing. The aim of this paper is to approach the phenomenon by providing a tool to develop critical awareness of these problems. By reviewing scientific articles, we collected information on the use of licit and illicit substances among professional and non-professional athletes, showing a widespread scenario also based on false myths. The use of supplements, drugs and doping substances represents a complex and still debated issue, that deserves greater consideration among both sportsmen and health operators. A more critical and informed approach to these topics can support empowerment and a conscious use of drugs by respecting eating habits, own health and healthy lifestyles.

The prevention of doping and the improper use of drugs and food supplements in sports and physical activities: a survey on the activity of the prevention departments of Italian local health authorities

INTRODUCTION

Doping is an important public health problem widespread not only among elite athletes, but also among amateur and recreational athletes and the general population. In Italy the introduction of doping prevention within the Essential Levels of Care (LEA) with the DPCM 12/1/2017 represents a crucial step towards the implementation of education and health promotion interventions. In this context, the Departments of Prevention (DP) of the Local Health Authorities (LHA) have to play a fundamental role, becoming the cultural and operational reference on this issue. As part of the "Doping prevention: development of a permanent educational tool coordinated by the National Health Service Prevention Departments" project, funded by the Italian Ministry of Health, a survey was conducted on the activities carried out by the DP regarding doping prevention and improper use and abuse of drugs and food supplements in sports and physical activities, as a basis for the harmonization of organizational structures and prevention programs and the creation of a collaboration network at a regional and national level.

METHODS

A semi-structured questionnaire consisting of 11 questions, prepared on an electronic platform, was sent to the DP of all the Italian LHA.

RESULTS

A total of 38 DP out of 131 (29%) completed the questionnaire, with representation from all regions. 42.1% of DP carried out or are still running programs for the prevention of doping, a percentage that decreases to 27% considering the programs for the prevention of misuse and abuse of drugs and food supplements in sports and in physical activities; in less than half of the DP, 37.5% and 41.7%, respectively, dedicated funds have been allocated. The professionals most involved in prevention of doping are the Specialists in Sport Medicine (81.3%) followed by Specialists in Hygiene (43.8%) and Psychologists (37.5%), while Health Care Assistants (50%) are the professionals most involved in the prevention of the improper use of drugs and food supplements, followed by Specialists in Hygiene and Specialists in Sport Medicine (40%). Most of the DP (71.9%) believe that the introduction of programs to prevent and counteract doping in the LEA will have repercussions on their approach against doping.

CONCLUSIONS

The survey, although conducted on a limited sample, has provided an important framework relating to programs for the prevention of doping and the misuse and abuse of drugs and food supplements in sports and in the physical activities carried out by DP. A remarkable heterogeneity has been highlighted, both at national and regional level. It is urgent to provide DP with homogeneous and effective organizational models and adequate operational tools, paying particular attention to the training of all the professionals involved. It is also essential to implement permanent monitoring tools.

Active safety systems for powered two-wheelers: A systematic review

Objective: Active safety systems, of which antilock braking is a prominent example, are going to play an important role to improve powered two-wheeler (PTW) safety. This paper presents a systematic review of the scientific literature on active safety for PTWs. The aim was to list all systems under development, identify knowledge gaps and recognize promising research areas that require further efforts.Methods: A broad search using "safety" as the main keyword was performed on Scopus, Web of Science and Google Scholar, followed by manual screening to identify eligible papers that underwent a full-text review. Finally, the selected papers were grouped by general technology type and analyzed via structured form to identify the following: specific active safety system, study type, outcome type, population/sample where applicable, and overall findings.Results: Of the 8,000 papers identified with the initial search, 85 were selected for full-text review and 62 were finally included in the study, of which 34 were journal papers. The general technology types identified included antilock braking system, autonomous emergency braking, collision avoidance, intersection support, intelligent transportation systems, curve warning, human machine interface systems, stability control, traction control, and vision assistance. Approximately one third of the studies considered the design and early stage testing of safety systems (n. 22); almost one fourth (n.15) included evaluations of system effectiveness.Conclusions: Our systematic review shows that a multiplicity of active safety systems for PTWs were examined in the scientific literature, but the levels of development are diverse. A few systems are currently available in the series production, whereas other systems are still at the level of early-stage prototypes. Safety benefit assessments were conducted for single systems, however, organized comparisons between systems that may inform the prioritization of future research are lacking. Another area of future analysis is on the combined effects of different safety systems, that may be capitalized for better performance and to maximize the safety impact of new technologies.

Erice 2018 Charter on the role of the National Health Service in the prevention of doping

The Erice 2018 Charter was unanimously approved at the conclusion of the 53rd Residential Course of the International School of Epidemiology and Preventive Medicine “Adapted Physical Activity in Sport, Wellness and Fitness; the role of the Departments of Prevention and of the National Health Service in doping prevention and health promotion”, held on 15-19 May 2018 in Erice, Italy, at the “Ettore Majorana” Foundation and Centre for Scientific Culture, and promoted by the Study Group on “Movement Sciences for Health” of the Italian Society of Hygiene, Preventive Medicine and Public Health. The event was part of a larger project supported by the Ministry of Health aimed at preventing doping in the general population involved in sport and physical activities. After an intense discussion the participants focused on ten statements involving the following critical issues: responsibility, priority, message, alphabetization, networks and alliances, school promoting health, player and opportunities, competences, know-how, programming and acting. These statements provide hints to approach doping within a public health frame and summarize the role of the Departments of Prevention and NHS in promoting and coordinating preventive actions with other institutions and stakeholders. Doping represents a complex phenomenon related to cultural, social, economic and legal issues. In addition to regulatory or repressive actions, education to health and legality is proposed as the fundamental strategy to contrast doping by promoting healthy lifestyles, based on scientific knowledge and respect for legality.

Peer Education strategies for promoting prevention of doping in different populations

BACKGROUND

In the field of doping prevention, alongside the traditional functions of repression and control of the phenomenon, educational aspects are becoming increasingly important. Article 18 of the World Anti doping Code obliges the signatories to invest in anti-doping education with the aim of preserving the spirit of sport. The educational commitment should involve young people in health promotion interventions for the prevention of risk behaviors. Therefore, our attention has focused on finding the mechanisms that lead people to make certain behavioral choices.

MATERIAL AND METHODS

In the context of preventive programs, to counter the doping phenomenon through health promotion programs, the most recognized method is peer education, particularly with adolescents. It is an educational method according to which some members of a group are empowered and trained to carry out specific activities with their peers. It is constituted as an example of equal relationship and finds its basis in cooperation and solidarity with the aim of increasing empowerment and a healthy development of the identity and collective dimension in young people.

RESULTS

Numerous experts - biologists / nutritionists, hygienists, sports coaches, psychologists, teachers of physical education in secondary schools and other stakeholders have actively participated in the co-construction of a training package aimed at activating cascade training processes on the knowledge and skills of peer education in contexts of youth aggregation, such as schools, gyms, sports associations, social gatherings of all kinds. The path allowed to define a peer education model capable of enabling the participants to activate health promotion interventions for the prevention of doping risk behaviors, each in their own setting.

CONCLUSIONS

In conclusion, we can say that prevention programs are the more effective the more they are addressed to young people and adolescents and provide interactive and action-oriented interventions. Successful initiatives aim to emphasize the development of life skills and to influence numerous determinants of behavior, including individual attitudes, knowledge, motivations, interpersonal relationships and social norms. If the aim is to act on the change of behavior, the efforts will be more successful if the content of the intervention will give due consideration to the context in which it applies and the target population, involving it and addressing its specific needs and values.

Motorcycle active safety systems: Assessment of the function and applicability using a population-based crash data set

Objective: Motorcycles and mopeds, often referred to as powered 2-wheelers (PTWs), play an important role in personal mobility worldwide. Despite their advantages, including low cost, space occupancy, and fuel efficiency, the risk of sustaining serious or fatal injuries is higher than that for occupants of passenger cars. The development of safety systems specific for PTWs represents a potential way to reduce casualties among riders. With the proliferation of new active and passive safety technologies, the question as to which might offer the most value is important. In this context, a prioritization process was applied to a set of PTW active safety systems to evaluate their applicability to crash scenarios alone and in combination. The systems included in the study were antilock braking (ABS), autonomous emergency braking (AEB), collision warning, curve warning, and curve assist. Methods: With the functional performance of the 5 safety systems established, the relevance of each system to specific crash configurations and vehicle movements defined by a standardized accident classification system used in Victoria, Australia, was rated by 2 independent reviewers, with a third reviewer acting as a moderator where disagreements occurred. Ratings ranged from 1 (definitely not applicable) to 4 (definitely applicable). Using population-based crash data, the number and percentage of crashes that each safety system could potentially influence, or be relevant for, was defined. Applying accepted injury costs permitted the derivation of the societal economic cost of PTW crashes and the potential reductions associated with each safety system given a theoretical crash avoidance effectiveness of 100%. Results: In the 12-year period 2000-2011, 23,955 PTW riders and 1292 pillion passengers were reported to have been involved in a road crash, with over 500 killed and more than 10,000 seriously injured; only 3.5% of riders/pillion passengers were uninjured. The total economic cost associated with these injured riders and pillion passengers was estimated to be AU$11.1 billion (US$7.70 billion; €6.67 billion). The 5 safety systems, as single solutions or in combination, were relevant to 57% of all crashes and to 74% of riders killed. Antilock braking was found to be relevant to the highest number of crashes, with incremental increases in coverage when combined with other safety systems. Conclusions: The findings demonstrate that ABS, alone and in combination with other safety systems, has the potential to mitigate or possibly prevent a high percentage of PTW crashes in the considered setting. Other safety systems can influence different crash scenarios and are also recommended. Given the high cost of motorcycle crashes and the increasing number of PTW safety technologies, the proposed approach can be used to inform the process of selection of the most suitable interventions to improve PTW safety.

Motorcycle That See: Multifocal Stereo Vision Sensor for Advanced Safety Systems in Tilting Vehicles

Advanced driver assistance systems, ADAS, have shown the possibility to anticipate crash accidents and effectively assist road users in critical traffic situations. This is not the case for motorcyclists, in fact ADAS for motorcycles are still barely developed. Our aim was to study a camera-based sensor for the application of preventive safety in tilting vehicles. We identified two road conflict situations for which automotive remote sensors installed in a tilting vehicle are likely to fail in the identification of critical obstacles. Accordingly, we set two experiments conducted in real traffic conditions to test our stereo vision sensor. Our promising results support the application of this type of sensors for advanced motorcycle safety applications.

Are automatic systems the future of motorcycle safety? A novel methodology to prioritize potential safety solutions based on their projected effectiveness

OBJECTIVE

Motorcycle riders are involved in significantly more crashes per kilometer driven than passenger car drivers. Nonetheless, the development and implementation of motorcycle safety systems lags far behind that of passenger cars. This research addresses the identification of the most effective motorcycle safety solutions in the context of different countries.

METHODS

A knowledge-based system of motorcycle safety (KBMS) was developed to assess the potential for various safety solutions to mitigate or avoid motorcycle crashes. First, a set of 26 common crash scenarios was identified from the analysis of multiple crash databases. Second, the relative effectiveness of 10 safety solutions was assessed for the 26 crash scenarios by a panel of experts. Third, relevant information about crashes was used to weigh the importance of each crash scenario in the region studied. The KBMS method was applied with an Italian database, with a total of more than 1 million motorcycle crashes in the period 2000-2012.

RESULTS

When applied to the Italian context, the KBMS suggested that automatic systems designed to compensate for riders' or drivers' errors of commission or omission are the potentially most effective safety solution. The KBMS method showed an effective way to compare the potential of various safety solutions, through a scored list with the expected effectiveness of each safety solution for the region to which the crash data belong. A comparison of our results with a previous study that attempted a systematic prioritization of safety systems for motorcycles (PISa project) showed an encouraging agreement.

CONCLUSIONS

Current results revealed that automatic systems have the greatest potential to improve motorcycle safety. Accumulating and encoding expertise in crash analysis from a range of disciplines into a scalable and reusable analytical tool, as proposed with the use of KBMS, has the potential to guide research and development of effective safety systems. As the expert assessment of the crash scenarios is decoupled from the regional crash database, the expert assessment may be reutilized, thereby allowing rapid reanalysis when new crash data become available. In addition, the KBMS methodology has potential application to injury forecasting, driver/rider training strategies, and redesign of existing road infrastructure.

Energy attenuation performance of impact protection worn by motorcyclists in real-world crashes

OBJECTIVE

Laboratory studies have demonstrated that impact protectors (IP) used in motorcycle clothing can reduce fracture severities. While crash studies have reported IP are associated with reduced likelihood of soft tissue injury, there is little evidence of their effectiveness in reducing fracture likelihood. This discrepancy might be related to IP quality. There are mandatory requirements for IP supplied with protective clothing in Europe, but not elsewhere. This study examines the energy attenuation performance of IP used by Australian riders.

METHODS

IP were harvested from clothing worn by crashed riders admitted to hospital. The IP were examined and energy attenuation properties were determined using EN 1621-1 test procedures. Impact injury was identified from medical records and defined as fractures, dislocations, and avulsions that occurred following impact to the rider's shoulders, elbows, hips, and/or knees. Fisher's exact test was used to examine the relationship between meeting the EN 1621-1 energy attenuation requirements and impact injury. The association between the average and maximum transmitted force, and impact injury was examined using generalized estimating equations. Motorcycle riders were recruited as part of an in-depth crash study through three hospitals in New South Wales, Australia, between 2012 and 2014. Riders were interviewed, and engineers conducted site, vehicle, and clothing inspections. Clothing was collected, or identical garments were purchased.

RESULTS

Clothing was inspected for 62 riders. Of these, 19 wore clothing incorporating 76 IP. Twenty-six of these were impacted in the crash event. Almost all impacted IP (96%) were CE marked, and most (83%) met Level 1 energy attenuation requirements of EN 1621-1 when tested. Of the 26 impacted IP, four were associated with impact injuries, including midshaft and distal clavicle fractures and a scapula and olecranon fracture. No associations between meeting EN 1621-1 requirements and impact injury were found (p = 0.5). There was no association between average force transmitted and impact injury (95% CI: 0.91-1.24); however, as maximum force transmitted increased, the odds of impact injury increased (95% CI: 1.01-1.2). These results indicate a high probability of impact injury at 50 kN, the limit of maximum transmitted force specified in EN 1621-1.

CONCLUSION

The allowable transmitted force of EN 1621-1 may be too high to effectively reduce the probability of impact injury. This is not surprising, given human tolerance levels that are reported in literature. Reducing the force limit below the reported fracture tolerance limits might be difficult with current technology. However, there is scope to reduce the EN 1621-1 maximum limit of 50 kN transmitted force. A reduction in the maximum force limit would improve rider protection and appears feasible, as 77% of tested IP recorded a maximum force <35 kN. This level of transmitted force is estimated to be associated with <20% probability of impact injury. While the performance of IP available to Australian riders is not regulated, most IP was CE marked. The results indicate a significant association between maximum transmitted force, tested according to EN 1621-1 procedures, and impact injury. Further investigation of the EN 1621-1 requirements may be warranted. This work will interest those targeting protective equipment for motorcyclists as a mechanism for reducing injury to these vulnerable road users.

Exploratory field trial of motorcycle autonomous emergency braking (MAEB): Considerations on the acceptability of unexpected automatic decelerations

OBJECTIVE

Autonomous emergency braking (AEB) acts to slow down a vehicle when an unavoidable impending collision is detected. In addition to documented benefits when applied to passenger cars, AEB has also shown potential when applied to motorcycles (MAEB). However, the feasibility of MAEB as practically applied to motorcycles in the real world is not well understood.

METHODS

In this study we performed a field trial involving 16 riders on a test motorcycle subjected to automatic decelerations, thus simulating MAEB activation. The tests were conducted along a rectilinear path at nominal speed of 40 km/h and with mean deceleration of 0.15 g (15% of full braking) deployed at random times. Riders were also exposed to one final undeclared brake activation with the aim of providing genuinely unexpected automatic braking events.

RESULTS

Participants were consistently able to manage automatic decelerations of the vehicle with minor to moderate effort. Results of undeclared activations were consistent with those of standard runs.

CONCLUSIONS

This study demonstrated the feasibility of a moderate automatic deceleration in a scenario of motorcycle travelling in a straight path, supporting the notion that the application of AEB on motorcycles is practicable. Furthermore, the proposed field trial can be used as a reference for future regulation or consumer tests in order to address safety and acceptability of unexpected automatic decelerations on a motorcycle.

A robust estimation of the effects of motorcycle autonomous emergency braking (MAEB) based on in-depth crashes in Australia

OBJECTIVE

Autonomous emergency braking (AEB) is a safety system that detects imminent forward collisions and reacts by slowing down the host vehicle without any action from the driver. AEB effectiveness in avoiding and mitigating real-world crashes has recently been demonstrated. Research suggests that a translation of AEB to powered 2-wheelers could also be beneficial. Previous studies have estimated the effects of a motorcycle AEB system (MAEB) via computer simulations. Though effects of MAEB were computed for motorcycle crashes derived from in-depth crash investigation, there may be some inaccuracies due to limitations of postcrash investigation (e.g., inaccuracies in preimpact velocity of the motorcycle). Furthermore, ideal MAEB technology was assumed, which may lead to overestimation of the benefits. This study sought to evaluate the sensitivity of the simulations to variations in reconstructed crash cases and the capacity of the MAEB system in order to provide a more robust estimation of MAEB effects.

METHODS

First, a comprehensive classification of accidents was used to identify scenarios in which MAEB was likely to apply, and representative crash cases from those available for this study were populated for each crash scenario. Second, 100 variant cases were generated by randomly varying a set of simulation parameters with given normal distributions around the baseline values. Variants reflected uncertainties in the original data. Third, the effects of MAEB were estimated in terms of the difference in the impact speed of the host motorcycle with and without the system via computer simulations of each variant case. Simulations were repeated assuming both an idealized and a realistic MAEB system. For each crash case, the results in the baseline case and in the variants were compared. A total of 36 crash cases representing 11 common crash scenarios were selected from 3 Australian in-depth data sets: 12 cases from New South Wales, 13 cases from Victoria, and 11 cases from South Australia.

RESULTS

The reduction in impact speed elicited by MAEB in the baseline cases ranged from 2.8 to 10.0 km/h. The baseline cases over- or underestimated the mean impact speed reduction of the variant cases by up to 20%. Constraints imposed by simulating more realistic capabilities for an MAEB system produced a decrease in the estimated impact speed reduction of up to 14% (mean 5%) compared to an idealized system.

CONCLUSIONS

The small difference between the baseline and variant case results demonstrates that the potential effects of MAEB computed from the cases described in in-depth crash reports are typically a good approximation, despite limitations of postcrash investigation. Furthermore, given that MAEB intervenes very close to the point of impact, limitations of the currently available technologies were not found to have a dramatic influence on the effects of the system.

Headache Treatment Before and After the Consultation of a Specialized Centre: A Pharmacoepidemiology Study

Our aim was to study and compare pharmacoepidemiology of headache treatment in two different settings: inside and outside a specialized Centre. We analysed the differences in headache treatment between 612 subjects admitted for the first visit (‘naive’) (F/M: 2.41; mean age = 37.31 ± 14.09 years) and 620 subjects admitted for a control visit (F/M: 3.18; mean age = 44.30 ± 15.37 years) to the Headache Centre of the University of Modena and Reggio Emilia. Most patients suffered from migraine. As acute treatment, on the first visit, 49.4% of them were taking drugs prescribed by a doctor; 41.5% were taking over-the-counter analgesics (OTCAs); 9.1% were not taking any drug. On the control visit, 81.3% of patients were taking prescription drugs; 15.8% OTCAs; 2.9% were not taking drugs (overall chi-square = 139.229, P < 0.001). Non-selective analgesics were the most-used drugs. Triptans were used by 9.1% of ‘naive’ patients and by 31.8% of patients attending for the control visit (Fisher's Z = 7.655, P < 0.001). Nimesulide was the most-used drug. A prophylactic treatment was made by 16.8% of ‘naive’ patients, and by 58.2% of patients admitted to the control visit (Fisher's Z = 12.135, P < 0.001). Antidepressants were the class of drugs most used for prophylaxis. Amitriptyline was the drug for prophylaxis most frequently used by patients attending the control visit, while flunarizine was the most frequently used by ‘naive’ patients. Before being examined in a specialized centre, few patients take prescription drugs, triptans, or prophylactic drugs; specialized care increases the proportion of patients taking prophylactic drugs, and changes the type of acute treatment used into disease-specific medication for headache.

Reconsidering the safety in numbers effect for vulnerable road users: an application of agent-based modeling

OBJECTIVE

Increasing levels of active transport provide benefits in relation to chronic disease and emissions reduction but may be associated with an increased risk of road trauma. The safety in numbers (SiN) effect is often regarded as a solution to this issue; however, the mechanisms underlying its influence are largely unknown. We aimed to (1) replicate the SiN effect within a simple, simulated environment and (2) vary bicycle density within the environment to better understand the circumstances under which SiN applies.

METHODS

Using an agent-based modeling approach, we constructed a virtual transport system that increased the number of bicycles from 9% to 35% of total vehicles over a period of 1,000 time units while holding the number of cars in the system constant. We then repeated this experiment under conditions of progressively decreasing bicycle density.

RESULTS

We demonstrated that the SiN effect can be reproduced in a virtual environment, closely approximating the exponential relationships between cycling numbers and the relative risk of collision as shown in observational studies. The association, however, was highly contingent upon bicycle density. The relative risk of collisions between cars and bicycles with increasing bicycle numbers showed an association that is progressively linear at decreasing levels of density.

CONCLUSIONS

Agent-based modeling may provide a useful tool for understanding the mechanisms underpinning the relationships previously observed between volume and risk under the assumptions of SiN. The SiN effect may apply only under circumstances in which bicycle density also increases over time. Additional mechanisms underpinning the SiN effect, independent of behavioral adjustment by drivers, are explored.

Atherosclerotic coronary plaque in subjects with diabetic neuropathy: the prognostic cardiovascular role of Charcot neuroarthropathy--a case-control study

The aim of this study was to investigate the severity of coronary artery disease (CAD) and the plaque composition in neuropathic type 2 diabetic subjects with and without Charcot neuroarthropathy (CN) undergoing multidetector computed tomography coronary angiography (MDCT-CA). The study was a single-center, observational, with unmatched case-control design. We selected 17 CN patients and 18 patients with diabetic neuropathy (DN) without CN. In all the patients, multidetector computed tomography was performed to assess the coronary artery calcium score (CACS) and degree of coronary artery stenosis. Patients were classified as positive in the presence of significant CAD if there was at least one stenosis >50 % on MDCT-CA. The invasive coronary angiography was performed in case of significant stenosis detected with MDCT-CA, both as reference to standard and eventually as treatment. Groups were matched for age, sex, and traditional CAD risk factors. As compared to DN individuals, CN exhibited higher rates of significant coronary stenoses (p = 0.027; OR 7.7 [1.3-43.5]). However, no significant differences were observed in the CACS, which reflects plaque burden, in the two groups (p = 0.759). No significant differences were observed comparing CACS distribution in all subjects for stenosis higher/equal or lower than 50 % (p = 0.320). Finally, no significant differences were observed comparing CACS distribution in CN and DN subjects for coronary stenoses higher/equal or lower than 50 %. Our results suggest that CN patients have a higher prevalence of severe coronary plaques compared to DN patients. Nevertheless, coronary plaques in CN patients did not exhibit an increased degree of calcification.

Further development of Motorcycle Autonomous Emergency Braking (MAEB), what can in-depth studies tell us? A multinational study

OBJECTIVE

In 2006, Motorcycle Autonomous Emergency Braking (MAEB) was developed by a European Consortium (Powered Two Wheeler Integrated Safety, PISa) as a crash severity countermeasure for riders. This system can detect an obstacle through sensors in the front of the motorcycle and brakes automatically to achieve a 0.3 g deceleration if the collision is inevitable and the rider does not react. However, if the rider does brake, full braking force is applied automatically. Previous research into the potential benefits of MAEB has shown encouraging results. However, this was based on MAEB triggering algorithms designed for motorcycle crashes involving impacts with fixed objects and rear-end crashes. To estimate the full potential benefit of MAEB, there is a need to understand the full spectrum of motorcycle crashes and further develop triggering algorithms that apply to a wider spectrum of crash scenarios.

METHODS

In-depth crash data from 3 different countries were used: 80 hospital admittance cases collected during 2012-2013 within a 3-h driving range of Sydney, Australia, 40 crashes with Injury Severity Score (ISS)>15 collected in the metropolitan area of Florence, Italy, during 2009-2012, and 92 fatal crashes that occurred in Sweden during 2008-2009. In the first step, the potential applicability of MAEB among the crashes was assessed using a decision tree method. To achieve this, a new triggering algorithm for MAEB was developed to address crossing scenarios as well as crashes involving stationary objects. In the second step, the potential benefit of MAEB across the applicable crashes was examined by using numerical computer simulations. Each crash was reconstructed twice-once with and once without MAEB deployed.

RESULTS

The principal finding is that using the new triggering algorithm, MAEB is seen to apply to a broad range of multivehicle motorcycle crashes. Crash mitigation was achieved through reductions in impact speed of up to approximately 10 percent, depending on the crash scenario and the initial vehicle pre-impact speeds.

CONCLUSIONS

This research is the first attempt to evaluate MAEB with simulations on a broad range of crash scenarios using in-depth data. The results give further insights into the feasibility of MAEB in different speed ranges. It is clear then that MAEB is a promising technology that warrants further attention by researchers, manufacturers, and regulators.

Analysis of the minimum swerving distance for the development of a motorcycle autonomous braking system

In the recent years the autonomous emergency brake (AEB) was introduced in the automotive field to mitigate the injury severity in case of unavoidable collisions. A crucial element for the activation of the AEB is to establish when the obstacle is no longer avoidable by lateral evasive maneuvers (swerving). In the present paper a model to compute the minimum swerving distance needed by a powered two-wheeler (PTW) to avoid the collision against a fixed obstacle, named last-second swerving model (Lsw), is proposed. The effectiveness of the model was investigated by an experimental campaign involving 12 volunteers riding a scooter equipped with a prototype autonomous emergency braking, named motorcycle autonomous emergency braking system (MAEB). The tests showed the performance of the model in evasive trajectory computation for different riding styles and fixed obstacles.

Intraorbital injection of rituximab: a new approach for active thyroid-associated orbitopathy, a prospective case series

AIM

The aim of this paper was to examine the efficacy and the safety of intraorbital administration of the monoclonal anti-CD20 antibody rituximab (RTX) to treat patients affected by thyroid-associated orbitopathy (TAO) unresponsive to conventional therapy.

METHODS

Five patients with active moderately-severe TAO unresponsive to systemic glucocorticoids were studied. After a complete ophthalmological examination, disease activity and severity were assessed by the clinical activity score (CAS) and the NO SPECS scoring system. Computed tomography scans were performed in all patients. Patients were treated with intraorbital injection of RTX 10 mg once a week for one month repeated once one month apart. The patients were followed every three months until 18 months.

RESULTS

In all patients treated with RTX, CAS was significantly reduced (p< 0,005), inactive phase of TAO was reached in four out of five patients. No patients experienced major side effects, minor side effects were reported in two patients.

CONCLUSION

Intraorbital injection of RTX is a safe and useful promising therapeutic option for active TAO.

Assessing the potential benefits of the motorcycle autonomous emergency braking using detailed crash reconstructions

OBJECTIVE

The aim of this study was to assess the feasibility and quantitative potential benefits of a motorcycle autonomous emergency braking (MAEB) system in fatal rear-end crashes. A further aim was to identify possible criticalities of this safety system in the field of powered 2-wheelers (PTWs; e.g., any additional risk introduced by the system itself).

METHODS

Seven relevant cases from the Swedish national in-depth fatal crash database were selected. All crashes involved car-following in which a non-anti-lock braking system (ABS)-equipped motorcycle was the bullet vehicle. Those crashes were reconstructed in a virtual environment with Prescan, simulating the road scenario, the vehicles involved, their precrash trajectories, ABS, and, alternatively, MAEB. The MAEB chosen as reference for the investigation was developed within the European Commission-funded Powered Two-Wheeler Integrated Safety (PISa) project and further detailed in later studies, with the addition of the ABS functionality. The boundary conditions of each simulation varied within a range compatible with the uncertainty of the in-depth data and also included a range of possible rider behaviors including the actual one. The benefits of the MAEB were evaluated by comparing the simulated impact speed in each configuration (no ABS/MAEB, ABS only, MAEB).

RESULTS

The MAEB proved to be beneficial in a large number of cases. When applicable, the benefits of the system were in line with the expected values. When not applicable, there was no clear evidence of an increased risk for the rider due to the system.

DISCUSSION AND LIMITATIONS

MAEB represents an innovative safety device in the field of PTWs, and the feasibility of such a system was investigated with promising results. Nevertheless, this technology is not mature yet for PTW application. Research in the field of passenger cars does not directly apply to PTWs because the activation logic of a braking system is more challenging on PTWs. The deployment of an autonomous deceleration would affect the vehicle dynamics, thus requesting an additional control action of the rider to keep the vehicle stable. In addition, the potential effectiveness of the MAEB should be investigated on a wider set of crash scenarios in order also to avoid false triggering of the autonomous braking.

Evaluation of an autonomous braking system in real-world PTW crashes

OBJECTIVES

Powered 2-wheelers (PTWs) are becoming increasingly popular in Europe. They have the ability to get around traffic queues, thus lowering fuel consumption and increasing mobility. The risk of rider injury in a traffic crash is however much higher than that associated with car users. The European project, Powered Two Wheeler Integrated Safety (PISa), identified an autonomous braking system (AB) as a priority to reduce the injury consequences of a PTW crash. The aim of this study was to assess the potential effectiveness of the AB system developed in PISa, taking into account the specific system characteristics that emerged during the design, development and testing phases.

METHODS

Fifty-eight PTW cases representing European crash configurations were examined, in which 43 percent of riders sustained a Maximum Abbreviated Injury Scale (MAIS) 2+ injury. Two of the most common crash types were a PTW impacting a stationary object (car following scenario) 16% and an object pulling across the PTW path (crossing scenario) 54%. An expert team analysed the in-depth material of the sample crashes and determined a posteriori to what extent the AB would have affected the crash. For those cases where the AB was evaluated as applicable, a further quantitative evaluation of the benefits was conducted by considering a set of different possible rider reactions in addition to that exhibited in the actual crash.

RESULTS

In 67 percent of cases, the application of AB could have mitigated the crash outcome. Analysis of those real crash cases showed the potential for an expert rider to avoid the collision. An early reaction of the rider, associated with a correct application of the brakes would have avoided 18 of the 37 car following/crossing scenarios. Conversely, according to the analysis, an expert rider would not have been able to avoid 19 of the 37 cases. In 14 of those 19 cases, the AB would have contributed to mitigating the crash outcome.

CONCLUSIONS

This study demonstrated significant potential for application of the autonomous braking system in car following and crossing scenarios. In addition, the theoretical benefit curves for the AB globally, were able to provide good quantitative indications of its benefits in real cases where the AB was considered applicable. Further analysis with larger databases is suggested in order to confirm the magnitude of benefits in the PTW crash population.

[Micromedullary thyroid carcinoma: school experience]

Medullary microcarcinomas occurrence are rare and fortuitous, it's usually related to the calcitonin measurement, that's the gold standard for the diagnosis. In other cases performing a thyroidectomy for a benign thyroid disease it's found a sub-centimeter tumor. Actually it's not clear the most appropriate surgical treatment for those kind of tumors because the number of cases in literature is limited and because there are different surgical approaches. In this study 17 patients were operated for medullary thyroid microcarcinoma and the Authors found central lymph node metastases in 33.3% of cases. The Authors, analyzing those results, think that total thyroidectomy with lymphadenectomy of the central compartement is the best choice in a sporadic microcarcinoma, while a total thyroidectomy without lymphadenectomy should be performed when the microcarcinomas are incidentals.

[Case-mix index and length of hospitalization]

The ACG (Adjusted Clinical Groups) case-mix system is a classification method of diseases of patients, focused on the person. Depending on the pattern of these morbid conditions, the ACG system assigns each patient to a single group (an ACG group), which allows to capture the effects of a group of diseases in estimates of resource use. Diseases are classified into a diagnostic group (ADG) according to 5 clinical dimensions: duration (acute, recurrent or chronic), severity (minor/major vs stable/unstable), diagnostic assessment (symptoms vs diseases), etiology (infectious, traumatic or other), specialty (medical, surgical, obstetric, ...). All diseases can be classified into these dimensions and into one of 32 groups. The ACG case-mix system uses an algorithm to classify each patient into one of 93 ACG categories. Each person is assigned to an ACG according to his ADG combination, his age and his gender. With the repayment system "case-mix", surgery has become central for all great hospitals in virtue of its great productive potential. The case-mix index is one of the factors which influence the duration of hospitalization. The case-mix system has emphasized the importance of the duration of hospitalization, encouraging the planning of programs in order to discharge patients early after surgical operations. It has also stimulated the surgical activity in operating units with "budget" forecasts in which resources are provided according to an expected level of specialist surgery.

[Medullary thyroid carcinoma: a study about 28 operated patients]

In this study on 28 operated patients, the Authors show that total thyroidectomy with elective central neck dissection and ipsilateral neck dissection is the most appropriate surgical treatment for medullary thyroid carcinoma. Pathologic study on lymph nodes removed in central and in latero-cervical compartments showed malignancy respectively in 75% and in 70% of the cases. However the role of elective ipsilateral lateral neck dissection remains controversial.

[Retroperitoneal giant mixed sarcoma. Case report]

The Authors present a rare case of voluminous retroperitoneal tumor in a 41 years old woman. CT scan showed a solid abdominal expansive mass, with compression and displacement of the left lobe of the liver, spleen, stomach, pancreas, and left kidney. The patient underwent surgery for excision of a giant retroperitoneal mass. Surgery was uneventful. The patients recovered well. Histology showed a mixed liposarcoma and angiosarcoma with high grade of malignancy and positivity for vimentin, factor VIII, CD34, CD31 and negativity for S-100, CD68, AMS, AML. The prognosis of these tumours is closely related to local recurrence, histological type, size and radical surgery. A low-grade malignancy tumor, small sized and completely resected leads to a good prognosis. Radiation therapy and chemotherapy do not seem to have a strong influence on the prognosis. An aggressive surgical approach is the first choice for the treatment of such tumors. The resection of adjacent organs may be required for radical surgery.

[Two cases of synchronous papillary and medullary thyroid carcinoma]

The Authors describe two cases of simultaneous association of papillary and medullary thyroid carcinoma. They emphasize the treatment of these cases stressing the correlation between the therapeutic criteria and the malignancy of medullary carcinoma.

64 slice cardiovascular CT in the emergency department: concepts and first experiences

PURPOSE

The purpose of this study was to evaluate contrast-enhanced electrocardiogram (ECG)-gated 64-slice computed tomography (CT) angiography of the thorax as a triage tool in patients with acute equivocal chest pain.

MATERIAL AND METHODS

Technical principles and diagnostic algorithms for using a single ECG-gated 64-slice CT scan for triple rule-out of acute pulmonary embolism, aortic dissection, acute coronary syndromes and other diseases of the chest are introduced. Our experience using this test in 23 patients are reviewed and exemplary cases are illustrated. The total length of hospitalisation and charges for Emergency Department care at the time of discharge were compared with a matched control population that underwent catheter angiography for emergent cardiac workup. Statistical analyses were performed with an independent Student's t test. Mann-Whitney rank sum test was also used on variables that did not have equal variance.

RESULTS

Of the 23 patients, 11 presented without pathological findings, two with extensive pulmonary embolism, two with definite coronary artery disease (CAD) but stenosis <50% and eight with significant CAD (>50% stenosis). Catheter angiography was performed in the latter group, confirming the CT findings in all cases. Nine patients without CT findings were discharged on the same day. In comparison with the control group, length of hospitalisation (p=0.009) and total hospital charges (p<0.001) were significantly reduced.

CONCLUSIONS

Our initial experience shows that ECG-gated 64- slice CT angiography of the entire thorax is technically feasible and enables rapid triage of patients to determine underlying cardiac and noncardiac reasons for chest pain. This test may thus help to significantly reduce costs and length of hospitalisation. Prospective studies involving larger groups of patients are required to confirm these findings.

Pharmacokinetics of a new extended-release nifedipine formulation following a single oral dose, in human volunteers

This study aimed to define the pharmacokinetics of nifedipine following oral administration of a new extended-release formulation. Twelve healthy volunteers of both sexes, aged 39 +/- 4 years, were treated with a single oral tablet of a new extended-release formulation containing 40 mg of nifedipine. Samples of venous blood were taken before dosing, after 30 min and at 1, 2, 4, 8, 12, 16, 20 and 24 h after administration. Nifedipine concentration was measured by means of a high-performance liquid chromatography method. Noncompartmental pharmacokinetics parameters were then calculated. The plasma concentration of nifedipine increased slowly and in seven subjects biphasic peaks occurred. The mean values were as follows: t(max): 8.5 +/- 1.2 h; C(max): 36.55 +/- 6.76 ng/ml; AUC: 347.06 +/- 51.61 ng/h/ml; AUC 409.99 +/- 61.08 ng/h/ml; A(half-life): 2.26 +/- 0.36 h; D(half-life): 2.43 +/- 0.44 h; E(half-life): 4.62 +/- 0.79 h. Twenty-four hours after administration nifedipine was still detectable (3.17 +/- 0.67 ng/ml). Arterial blood pressure decreased and heart rate increased concurrently and proportionally to the increase in nifedipine concentration. Extended-release nifedipine formulations have better tolerability profiles than immediate-release formulations, which are at present not recommended in the treatment of hypertension, hypertensive crises or myocardial infarction. This new extended-release formulation has interesting pharmacokinetic parameters and may be effective in conditions in which dihydropyridine calcium channel blockers are indicated.

Panax notoginseng (Burk.) effects on fibrinogen and lipid plasma level in rats fed on a high-fat diet

Several studies have shown that notoginsenoides improve diastolic function in hypertensive subjects, induce the fibrinolytic system in in vitro models and act as antiproliferative agents on vessel leiomyocytes. Our aim was to evaluate their effect on fibrinogen and lipid plasma levels compared with a well-known HMGCoA reductase inhibitor. Seventy Wistar male adult rats on a fat-enriched diet were treated orally with P. notoginseng pulverized root (43 mg/kg/day or 86 mg/kg/day; 20 animals per group), fluvastatin (3 mg/kg/day; 20 animals) or physiological saline (5 mL/kg/day; 10 animals). The ten rats on a normocaloric diet were also treated with 5 mL/kg/day of physiological saline. After a 28-day treatment, the rats were killed and their blood analysed with standard procedures. Treatment with 43 mg/kg/day of P. notoginseng or 3 mg/kg/day of fluvastatin showed similar activity in decreasing total cholesterol (-23.70%, -19.29%, respectively) and triglycerides (-21.59%, -18.55%). The most evident effect of P. notoginseng was the reduction of fibrinogenaemia in treated rats compared with the control values (-38.10%; p < 0.001), no dose-relationship being shown in this effect. Moreover, no significant variation in HDL cholesterol and glucose levels was observed nor did relevant behavioural changes occur in association with the root intake. Besides a moderate, non dose-related decrease in the plasma lipid levels, P. notoginseng appeared to induce a significant reduction in the rat fibrinogenaemia.