A systematic review of otologic injuries sustained in civilian terrorist explosions

PURPOSE

Determine the prevalence of otological symptoms and tympanic membrane perforation, healing rates of tympanic membrane perforation with surgical and conservative management, and hearing function in civilian victims of terrorist explosions.

METHODS

A systematic review was conducted with searches on Medline, Embase, EMCare and CINAHL for publications between the 1st January 1945 and 26th May 2023. Studies with quantitative data addressing our aims were included. This review is registered with PROSPERO: CRD42020166768. Among 2611 studies screened, 18 studies comprising prospective and retrospective cohort studies were included.

RESULTS

The percentage of eardrums perforated in patients admitted to hospital, under ENT follow up and attending the emergency department is 69.0% (CI 55.5-80.5%), 38.7% (CI 19.0-63.0%, I2 0.715%) and 21.0% (CI 11.9-34.3%, I2 0.718%) respectively. Perforated eardrums heal spontaneously in 62.9% (CI 50.4-73.8%, I2 0.687%) of cases and in 88.8% (CI 75.9-96.3%, I2 0.500%) of cases after surgery. Common symptoms present within one month of bombings are tinnitus 84.7% (CI 70.0-92.9%, I2 0.506%), hearing loss 83.0% (CI 64.5-92.9%, I2 0.505%) and ear fullness 59.7% (CI 13.4-93.4%, I2 0.719). Symptomatic status between one and six months commonly include no symptoms 57.5% (CI 46.0-68.3%), hearing loss 35.4% (CI 21.8-51.8%, I2 0.673%) and tinnitus 15.6% (CI 4.9-40.0%, I2 0.500%). Within one month of bombings, the most common hearing abnormality is sensorineural hearing loss affecting 26.9% (CI 16.9-40.1%, I2 0.689%) of ears 43.5% (CI 33.4-54.2%, I2 0.500) of people.

CONCLUSION

Tympanic membrane perforation, subjective hearing loss, tinnitus, ear fullness and sensorineural hearing loss are common sequelae of civilian terrorist explosions.

A review of signal processing and machine learning techniques for interictal epileptiform discharge detection

Brain interictal epileptiform discharges (IEDs), as one of the hallmarks of epileptic brain, are transient events captured by electroencephalogram (EEG). IEDs are generated by seizure networks, and they occur between seizures (interictal periods). The development of a robust method for IED detection could be highly informative for clinical treatment procedures and epileptic patient management. Since 1972, different machine learning techniques, from template matching to deep learning, have been developed to automatically detect IEDs from scalp EEG (scEEG) and intracranial EEG (iEEG). While the scEEG signals suffer from low information details and high attenuation of IEDs due to the high skull electrical impedance, the iEEG signals recorded using implanted electrodes enjoy higher details and are more suitable for identifying the IEDs. In this review paper, we group IED detection techniques into six categories: (1) template matching, (2) feature representation (mimetic, time-frequency, and nonlinear features), (3) matrix decomposition, (4) tensor factorization, (5) neural networks, and (6) estimation of the iEEG from the concurrent scEEG followed by detection and classification. The methods are compared quantitatively (e.g., in terms of accuracy, sensitivity, and specificity), and their general advantages and limitations are described. Finally, current limitations and possible future research paths related to this field are mentioned.

Assessing the strengths and limitations of quantitative micromorphometry for the forensic examination of small arms propellant towards brand identification

Smalls arms propellants (SAP) also known as canister powders are readily accessible and cost-effective materials that firearms enthusiasts can acquire for the legitimate assembly of ammunition. These attributes also make SAPs advantageous for the construction of improvised explosive devices (IEDs). Thus, there is a need to develop robust metrics for the characterization of propellants to provide investigative leads as well as for comparisons between known and recovered residues. The goal of this research was to investigate the utility of a high-throughput, non-destructive, and low-cost quantitative automated image analysis routine for the characterization and discrimination of SAP. For this project, 204 one-pound canisters of smokeless propellant (powder) were acquired from local and online sources. These samples represent nine manufacturers and 154 unique brands. From this set, five brands were selected to assess the intra- and inter-lot variability. Eight parameters, which encompass size- and shape-dependent metrics were measured for each sample. A total of ∼85,000 granules (∼680,000 measurements) were analyzed using linear discriminant analysis. A detailed assessment of the variables shows that the size-dependent metrics provide the greatest amount of sample discrimination. Overall accuracy of the method to correctly classify a test subset of data to the brand level is ∼84.72%. The results from this study provide a framework in which to interpret smokeless propellant micromorphometry in the context of intelligence purposes for initial stages of criminal investigations, and for traditional comparisons between known and unknown samples.

Pitfalls in scalp EEG: Current obstacles and future directions

Although electroencephalography (EEG) serves a critical role in the evaluation and management of seizure disorders, it is commonly misinterpreted, resulting in avoidable medical, social, and financial burdens to patients and health care systems. Overinterpretation of sharply contoured transient waveforms as being representative of interictal epileptiform abnormalities lies at the core of this problem. However, the magnitude of these errors is amplified by the high prevalence of paroxysmal events exhibited in clinical practice that compel investigation with EEG. Neurology training programs, which vary considerably both in the degree of exposure to EEG and the composition of EEG didactics, have not effectively addressed this widespread issue. Implementation of competency-based curricula in lieu of traditional educational approaches may enhance proficiency in EEG interpretation amongst general neurologists in the absence of formal subspecialty training. Efforts in this regard have led to the development of a systematic, high-fidelity approach to the interpretation of epileptiform discharges that is readily employable across medical centers. Additionally, machine learning techniques hold promise for accelerating accurate and reliable EEG interpretation, particularly in settings where subspecialty interpretive EEG services are not readily available. This review highlights common diagnostic errors in EEG interpretation, limitations in current educational paradigms, and initiatives aimed at resolving these challenges.

High risk and low prevalence diseases: Blast injuries

INTRODUCTION

Blast injury is a unique condition that carries a high rate of morbidity and mortality, often with mixed penetrating and blunt injuries.

OBJECTIVE

This review highlights the pearls and pitfalls of blast injuries, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Explosions may impact multiple organ systems through several mechanisms. Patients with suspected blast injury and multisystem trauma require a systematic evaluation and resuscitation, as well as investigation for injuries specific to blast injuries. Blast injuries most commonly affect air-filled organs but can also result in severe cardiac and brain injury. Understanding blast injury patterns and presentations is essential to avoid misdiagnosis and balance treatment of competing interests of patients with polytrauma. Management of blast victims can also be further complicated by burns, crush injury, resource limitation, and wound infection. Given the significant morbidity and mortality associated with blast injury, identification of various injury patterns and appropriate management are essential.

CONCLUSIONS

An understanding of blast injuries can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Salivary cortisol awakening levels are reduced in human subjects with intermittent explosive disorder compared with controls

BACKGROUND

The role of the hypothalamic-pituitary-adrenal (HPA) axis in human aggressive behavior is poorly characterized, though some studies report that, unlike depression, circulating or salivary levels of cortisol are low compared with controls.

METHODS

In this study, we collected three salivary cortisol levels (two in the morning and one in the evening) on three separate days in 78 adult study participants with (n = 28) and without (n = 52) prominent histories of impulsive aggressive behavior. Plasma C-Reactive Protein (CRP) and Interleukin-6 (IL-6) were also collected in most study participants. Aggressive study participants meet DSM-5 criteria for Intermittent Explosive Disorder (IED) while non-aggressive participants either had a history of a psychiatric disorder or no such history (Controls).

RESULTS

Morning, but not evening, salivary cortisol levels were significantly lower in IED (p < 0.05), compared with control, study participants. In addition, salivary cortisol levels correlated with measures of trait anger (partial r = -0.26, p < 0.05) and aggression (partial r = -0.25, p < 0.05) but not with measures of impulsivity, psychopathy, depression, history of childhood maltreatment, or other tested variables that often differ in individuals with IED. Finally, plasma CRP levels correlated inversely with morning salivary cortisol levels (partial r = -0.28, p < 0.05); plasma IL-6 levels showed a similar, though not statistically significant (rp = -0.20, p = 0.12) relationship with morning salivary cortisol levels.

CONCLUSION

The cortisol awakening response appears to be lower in individuals with IED compared with controls. In all study participants, morning salivary cortisol levels correlated inversely with trait anger, trait aggression, and plasma CRP, a marker of systemic inflammation. This suggests the present of a complex interaction between chronic-low level inflammation, the HPA axis, and IED that warrants further investigation.

Hippocampal ripples correlate with memory performance in humans

Memory performance evaluation has generally been based on behavioral tests in the past decades. However, its neural correlates remain largely unknown, particularly in humans. Here we addressed this question using intracranial electroencephalography in patients with refractory epilepsy, performing an episodic memory test. We used the presurgical Wechsler Memory Scale (WMS) test to assess the memory performance of each patient. We found that hippocampal ripples significantly exhibited a transient increase during visual stimulation or before verbal recall. This increase in hippocampal ripples positively correlated with memory performance. By contrast, memory performance is negatively correlated with hippocampal interictal epileptic discharges (IEDs) or epileptic ripples in the memory task. However, these correlations were not present during quiet wakefulness. Thus, our findings uncover the neural correlates of memory performance in addition to traditional behavioral tests.

Identification and classification of pathology and artifacts for human intracranial cognitive research

Intracranial electroencephalography (iEEG) presents a unique opportunity to extend human neuroscientific understanding. However, typically iEEG is collected from patients diagnosed with focal drug-resistant epilepsy (DRE) and contains transient bursts of pathological activity. This activity disrupts performances on cognitive tasks and can distort findings from human neurophysiology studies. In addition to manual marking by a trained expert, numerous IED detectors have been developed to identify these pathological events. Even so, the versatility and usefulness of these detectors is limited by training on small datasets, incomplete performance metrics, and lack of generalizability to iEEG. Here, we employed a large annotated public iEEG dataset from two institutions to train a random forest classifier (RFC) to distinguish data segments as either 'non-cerebral artifact' (n = 73,902), 'pathological activity' (n = 67,797), or 'physiological activity' (n = 151,290). We found our model performed with an accuracy of 0.941, specificity of 0.950, sensitivity of 0.908, precision of 0.911, and F1 score of 0.910, averaged across all three event types. We extended the generalizability of our model to continuous bipolar data collected in a task-state at a different institution with a lower sampling rate and found our model performed with an accuracy of 0.789, specificity of 0.806, and sensitivity of 0.742, averaged across all three event types. Additionally, we created a custom graphical user interface to implement our classifier and enhance usability.

Childhood and parental characteristics of adults with DSM-5 intermittent explosive disorder compared with healthy and psychiatric controls

BACKGROUND

Intermittent Explosive Disorder (IED) is a disorder primarily of aggression, defined by recurrent behavioral outbursts out of proportion to provocations or stressors. IED first appears in childhood and adolescence. This study examines the underlying childhood environment of those with IED, particularly familial and school-related factors.

METHODS

Adult participants from a larger study completed diagnostic assessments and a battery of self-report measures. Group assignment was based on the assessment: 1) IED diagnosis; 2) non-IED psychiatric diagnosis; and 3) no significant psychiatric history. Groups were compared on factors of parental demographics, intrafamilial aggression, lifetime syndromal and personality diagnoses, neurodevelopmental and learning difficulties, childhood peer relationships, and juvenile legal issues.

RESULTS

Significant patterns emerged specific to IED for not being raised by both parents, greater physical aggression to participant, and greater degree of fighting with peers by age ten.

LIMITATIONS

The retrospective, and cross-sectional, nature of the study, which prevent the making of causal inferences, and the basic nature of the questions asked of participants which limit a more nuanced interpretation of the data. A further limitation is bias associated with self-reported responses.

CONCLUSIONS

Results suggest the prevalence childhood adversaries may be linked with IED; the childhood environment of those with IED likely is substantially more tumultuous than individuals with or without other psychiatric disorders.

Implementation of and Experimentation with Ground-Penetrating Radar for Real-Time Automatic Detection of Buried Improvised Explosive Devices

This paper proposes the implementation of and experimentation with GPR for real-time automatic detection of buried IEDs. GPR, consisting of hardware and software, was implemented. A UWB antenna was designed and implemented, particularly for the operation of the GPR. The experiments were conducted in order to demonstrate the real-time automatic detection of buried IEDs using GPR with an R-CNN algorithm. In the experiments, the GPR was mounted on a pickup truck and a maintenance train in order to find the IEDs buried under a road and a railway, respectively. B-scan images were collected using the implemented GPR. R-CNN-based detection for the hyperbolic pattern, which indicates the buried IED, was performed along with pre-processing, for example, using zero offset removal, and background removal and filtering. Experimental results in terms of detecting the hyperbolic pattern in B-scan images were shown and verified that the proposed GPR system is superior to the conventional one using region analysis processing-based detection. Results also showed that pre-processing is required in order to improve and/or clean the hyperbolic pattern before detection. The GPR can automatically detect IEDs buried under roads and railways in real time by detecting the hyperbolic pattern appearing in the collected B-scan image.

Profile of explosives's use in ATMs/cash safes robberies in Brazil

This retrospective study reports data obtained by the Federal Police's National Institute of Criminalistics (INC-PF) relating to chemical analysis aimed at identifying explosives used in Automated teller machines (ATMs)/cash safes robberies between 2014 and 2020 in Brazil. 93 Real cases were studied and, based on the analysis carried out on the materials related to these cases, focusing on the type of explosive used, the following distribution profile was obtained: I) explosive mixtures based on chlorates and/or perchlorates (53%); explosive emulsion (22%); black gunpowder (13%); negative/inconclusive (11%) and organic - pentaerythritol tetranitrate (PETN) (1%). These results can contribute to investigations related to diversion/loss of explosives for criminal purposes, indicating, for example, through relationships between prevalence in the use of a certain type of explosive with a certain location, its possible origin (mining industry, explosive industries, fireworks factories, among others). The profile observed in the results can guide the selection of explosives to be studied in future research, as the possibilities are vast. Furthermore, despite the expressive number of occurrences in Brazil in the period of interest of this study, only a small fraction of samples was sent to the forensic chemistry laboratory to identify the explosive involved, which suggests that expanding chemical analysis should be encouraged in this field. In combination with an increase in professional training and collaboration trials between the laboratories, these activities can improve the chemical explosive's profile in Brazil, enabling the search for correlations between occurrences and contributing to the growth and development of this area.

Mapping the neurocircuitry of impulsive aggression through the pharmacologic review of anti-impulsive aggressive agents

Impulsive aggression, in contradistinction to premeditated aggression in humans or predatory aggression in animals, corresponds to defensive aggression in animal models. At the core of the neurocircuitry of impulsive aggression, from murine to feline to human species, it is the medial amygdala-mediobasal hypothalamus-dorsal periaqueductal gray pathway. Here, we update current knowledge on the neurocircuitry of impulsive aggression by placing the neurocircuitry and its neurophysiological substrates into the top-down/bottom-up hypothesis of impulsive aggression. We then reverse the neurotranslational approach, which applies neuroscience to developing therapeutic drugs, and apply current understanding of potential mechanisms of anti-impulsive aggression agents to further clarify, at least heuristically and hypothetically, the dynamic biochemical components of the neurocircuitry of impulsive aggression. To do this, we searched the medical literature for studies attempting to clarify the neurobiological and neurochemical effects of the five most widely studied anti-impulsive aggressive agents, particularly as they pertain to the top-down/bottom-up hypothesis. Multiple different mechanisms are discussed, all of which fitting in the hypothesis by way of either promoting the "top-down" part (i.e., enhancing inhibitory neurotransmitters), or suppressing the "bottom-up" part (i.e., decreasing excitatory neurotransmitters). The hypothesis appears consistent with the current psychopharmacological understanding of these agents, as well as to account for the likely multifactorial etiology of the condition. Limitations of the hypothesis and future directions are finally discussed.

Gene expression in peripheral blood mononuclear cells in impulsive aggression: Intermittent explosive disorder compared with non-aggressive healthy and psychiatric controls

Evidence of chronic, systemic, low levels of inflammation is present in several stress-related psychiatric conditions including schizophrenia, depression, and intermittent explosive disorder (IED). We analyzed leukocyte gene expression (mRNA) to quantify the activity of pro and anti-inflammatory signaling pathways. Work performed in non-aggressive populations has uncovered a Conserved Transcriptional Response to Adversity (CTRA) characterized by an upregulation of pro-inflammatory gene transcription in chronically stressed individuals. We used pathway-based bioinformatic analyses of genome-wide transcriptional profiles of peripheral blood leukocyte samples from IED study participants (N = 45) and controls [healthy (n = 45) and psychiatric (n = 34)], with analyses focusing on the pro-inflammatory transcription control pathway mediated by the NF-kB family of transcription factors (typically upregulated in CTRA) and the antiviral transcription control pathway mediated by anti-viral response (IRF) family transcription factors (typically downregulated in CTRA). Compared with both healthy and psychiatric controls, individuals with IED had upregulated transcriptional activity of the antiviral response (IRF), but no evidence of pro-inflammatory NF-kB activation. Analyses implicated CD4 + T cells, CD8 + T cells, and B lymphocytes in IED-related transcriptional alterations, but showed no significant indication of monocyte involvement. This suggests that the inflammatory profile of IED differs substantially from that observed previously in other stress-related disorders, and may involve a pathogen-driven adaptive immune etiology.

Characterization and differentiation of aluminum powders used in improvised explosive devices. Part 2: Micromorphometric method refinement and preliminary statistical analysis

Aluminum (Al) powder is commonly encountered in improvised explosive devices (IEDs) as a metallic fuel due to its availability and low cost. Although available commercially in powder form, amateur bomb-makers also produce their own Al powder via simple methods found online. In order to provide investigative leads and forensic intelligence, it is important to evaluate not only the composition of homemade devices, but also to distinguish between the various forms of Al powder they contain. To achieve this goal, a method using automated microscopy in combination with statistical techniques has been demonstrated to have the potential to provide source discrimination and investigative leads in source attribution of Al powders in IEDs. The present research refined this method and investigated 59 industrially and amateurly produced Al powder sources with seven subsamples per source using two traditional linear discriminant analyses (LDA), one with a standard data split for training and testing, and another using leave-one-out cross-validation. Averaging the classification accuracies for the two LDA-based analyses, LDA has the ability to correctly classify 59.26%, 83.35%, and 80.69% of the samples based on their powder source, type, and production method, respectively. This classification accuracy represents a 3407%, 317%, and 61.38% increase in accuracy from random class assignment, respectively. Further, in most instances of incorrect data attribution to a particular source, the subsample has been misidentified with another sample of the same powder type or production method.

Influence of ink and smoke ATM security systems on dactyloscopy and subsequent DNA analysis after detonation

Automated Teller Machine bombings are an increasing societal problem that are often committed using Improvised Explosive Devices. The evolution in IEDs and the negative consequences for society require new security measures to prevent these crimes. Ink staining and security smoke devices are added to cash cassettes, in order to protect ATMs and prevent ATM bombings. Traces found at crime scenes, such as fingerprints and DNA, can contribute to the identification of perpetrators. However, the effect of ink staining and security smoke devices on dactyloscopy and DNA profiling is still unknown. In the current study, we demonstrate that procedures using Citrus Cleaner or sulfosalicylic acid were successful in removing ink and security smoke deposited on plastic plates but did result in the massive loss of fingerprint information as only a low number (4%) of good quality fingerprints were recovered after smoke contamination. Secondly, security ink Sun Blue ES2, but not SICPA Green and Sun Blue ES1, had a significant impact on DNA profiling success. DNA concentrations obtained from blood spiked swabs decreased with increasing ink concentration resulting in a complete loss of genotype information with the addition of ≥10 μl Sun Blue ES2. No noticeable PCR inhibition or DNA degradation was detected during quantification, but a decreased efficiency of DNA extraction could not be excluded. Security smoke, on the other hand, does not seem to have a significant influence on DNA analysis. Precautions must therefore be taken in order to avoid contaminating DNA swabs with ink during sampling. Thirdly, only a single negative impression of a glove in ink and a single glove print were able to be visualized with white fingerprint powder on detonated cash cassettes. In conclusion, the detection of glove prints and fingerprints is limited and security ink, contrary to smoke, after detonation can have a negative influence on downstream DNA analysis procedures.

Localization of Epileptic Foci Based on Simultaneous EEG-fMRI Data

Combining functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) enables a non-invasive investigation of the human brain function and evaluation of the correlation of these two important modalities of brain activity. This paper explores recent reports on using advanced simultaneous EEG–fMRI methods proposed to map the regions and networks involved in focal epileptic seizure generation. One of the applications of EEG and fMRI combination as a valuable clinical approach is the pre-surgical evaluation of patients with epilepsy to map and localize the precise brain regions associated with epileptiform activity. In the process of conventional analysis using EEG–fMRI data, the interictal epileptiform discharges (IEDs) are visually extracted from the EEG data to be convolved as binary events with a predefined hemodynamic response function (HRF) to provide a model of epileptiform BOLD activity and use as a regressor for general linear model (GLM) analysis of the fMRI data. This review examines the methodologies involved in performing such studies, including techniques used for the recording of EEG inside the scanner, artifact removal, and statistical analysis of the fMRI signal. It then discusses the results reported for patients with primary generalized epilepsy and patients with different types of focal epileptic disorders. An important matter that these results have brought to light is that the brain regions affected by interictal epileptic discharges might not be limited to the ones where they have been generated. The developed methods can help reveal the regions involved in or affected by a seizure onset zone (SOZ). As confirmed by the reviewed literature, EEG–fMRI provides information that comes particularly useful when evaluating patients with refractory epilepsy for surgery.

Emotion attribution in intermittent explosive disorder

BACKGROUND

Accurate recognition of the emotions of others is an important part of healthy neurological development and promotes positive psychosocial adaptation. Differences in emotional recognition may be associated with the presence of emotional biases and can alter one's perception, thus influencing their overall social cognition abilities. The present study aims to extend our collective understanding of emotion attribution abnormalities in individuals with Intermittent Explosive Disorder (IED).

METHODS

Two-hundred and forty-two adults participated, separated into groups of those diagnosed with IED according to DSM 5 criteria, Psychiatric Controls (PC), and Healthy Controls (HC). Participants completed a modified version of the Emotional Attribution Task wherein they attributed an emotion to the main character of a short vignette.

RESULTS

Participants with IED correctly identified anger stories and misattributed anger to non-anger stories significantly more often than PC and HC participants. They were also significantly less likely than HC participants to correctly identify "sad stories."

LIMITATIONS

We utilized self-report assessments in a community-recruited sample. Replication in a clinical is suggested.

CONCLUSIONS

Findings from this study support the validity of IED as a diagnostic entity and provide important information about how individuals with psychiatric disorders perceive and experience emotional cues.

Topography-Related EEG-fMRI in Surgically Confirmed Epileptic Foci: A Comparison to Spike-Related EEG-fMRI in Clinical Practice

EEG-fMRI has gained increasing importance in epilepsy pre-surgical diagnosis. However, 40-70% of EEG-fMRI recordings in patients lack interictal epileptiform discharges (IEDs) during the scan, which could be overcome by detecting matching topography maps. We tried to validate this method in clinical settings taking various electroclinical factors into consideration. Eleven patients who had undergone EEG-fMRI during pre-surgical evaluation for drug-resistant epilepsy and who had had clinical long-term video-EEG were studied. Spike-related blood oxygen level-dependent (BOLD) maps were created using IEDs occurring during the EEG-fMRI scan. Separate maps were then generated from IEDs marked on the clinical long-term EEG recordings, which were averaged to produce topographical IED maps and correlated with the EEGs recorded inside the scanner yielding a correlation coefficient time course. Epileptogenic zones were defined by an expert panel during pre-surgical evaluation and validated by an epilepsy surgery resulting in a good outcome. Both techniques' performance was evaluated according to factors including arousal during IED recording, IED topography and lateralization, lesion type, and localization. Topography-related EEG-fMRI yielded more specific results compared to the spike-related method. Superficial lesion location and ipsilateral IED seem to result in a higher concordance of BOLD maps. The polarity of BOLD responses may be lesion-dependent, and both positive and negative BOLD changes may be associated with the irritative zone. Topography-related EEG-fMRI may show improved specificity especially for superficial lesions producing ipsilateral spikes. This method can be used as an alternative either in the absence of spikes during the simultaneous EEG-fMRI acquisition or to sharpen a diffusely activated BOLD-map.

Postmortem CT and autopsy findings in nine victims of terrorist attack

In a foreign country, a religious terrorist group raided a restaurant, using pipe bombs, sharp-edged weapons, and various types of firearms (handguns, submachine guns, and AK-47 assault rifles) loaded with normal and prohibited bullets to kill foreigner customers, some of whom were Italian tourists. Local pathologists performed forensic autopsies on the bodies, but we were asked to perform additional external examinations, postmortem computed tomography (PMCT) scans, and then a second round of complete autopsies on nine victims (5 females and 4 males). Four victims had slash wounds inflicted by sharp-edged weapons, mostly localized in the head and neck. All but two victims had gunshot wounds. Finally, three casualties had injuries caused by the explosion of improvised explosive devices. In all cases, PMCT was a reliable source of information and provided strategic guide during autopsies, helping identify and describe the injuries and thus reconstruct the events. Therefore, in these cases, we suggest integrating the autopsy findings with the postmortem radiological data.

Development of a finite element biomechanical whole spine model for analyzing lumbar spine loads under caudocephalad acceleration

Background:Spine injury risk due to military conflict is an ongoing concern among defense organizations throughout the world. A better understanding of spine biomechanics could assist in developing protection devices to reduce injuries caused by caudocephalad acceleration (+Gz) in under-body blasts (UBB). Although some finite element (FE) human models have demonstrated reasonable lumbar spine biofidelity, they were either partial spine models or not validated for UBB-type loading modes at the lumbar functional spinal unit (FSU) level, thus limiting their ability to analyze UBB-associated occupant kinematics.Methods:An FE functional representation of the human spine with simplified geometry was developed to study the lumbar spine responses under +Gz loading. Fifty-seven load curves obtained from post mortem human subject experiments were used to optimize the model.Results:The model was cumulatively validated for compression, flexion, extension, and anterior-, posterior-, and lateral-shears of the lumbar spine and flexion and extension of the cervical spine. The thoracic spine was optimized for flexion and compression. The cumulative CORrelation and Analysis (CORA) rating for the lumbar spine was 0.766 and the cervical spine was 0.818; both surpassed the 0.7 objective goal. The model's element size was confirmed as converged.Conclusions:An FE functional representation of the human spine was developed for +Gz lumbar load analysis. The lumbar and cervical spines were demonstrated to be quantitatively biofidelic to the FSU level for multi-directional loading and bending typically experienced in +Gz loading, filling the capability gap in current models.

Characterization and differentiation of aluminum powders used in improvised explosive devices - Part 1: Proof of concept of the utility of particle micromorphometry

Aluminum (Al) powders are commonly used in improvised explosive devices as metallic fuels, a component of explosive mixtures. These powders can be obtained readily from industrial-scale and consumer products, and produced using unsophisticated "kitchen chemistry" techniques. This research demonstrates the potential of automated particle micromorphometry for comparisons between known source and questioned Al powders recovered from IEDs, as well as for insight into the method of Al powder manufacture. Al powder samples were obtained from legitimate manufacturers, and 56 samples were produced "in-house" from Al-containing spray paints and ball-milled Al foils. Transmitted light microscope images of Al powder particles were acquired using an automated stage with automated z-focus; 17 size and shape parameters were measured for all particles. Approximately 37,000-2,500,000 particles/sample were analyzed using an open-source statistical package with customized code. Dimensionality reduction was required for processing the large datasets: eight of the 17 measured variables were selected based on inspection of the correlation matrix. Data from four subsamples from each of the 56 samples produced using "in-house" methods were analyzed using ANOVA to assess the within- and between-sample variation. High within-sample variation was noted; however, ANOVA and post-hoc Tukey's honestly significant difference (HSD) tests demonstrated that the between-sample variation was substantially larger than the within-sample variation. Each sample could be differentiated from all other samples in the test set. Future experiments will focus on ways to reduce the within-sample variation, and additional statistical and microanalytical methods to classify sources and confidently constrain the method of Al powder manufacture.

The recovery of touch DNA from RDX-C4 evidences

RDX (Royal Demolition Explosive) is the organic compound with the formula (O2NNCH2)3. It is a white solid material without smell or taste, widely used as an explosive. It is more energetic explosive than TNT, and it was used widely in World War II. The estimated number of RDX-C4 cases in Bahrain ranged between the years 2015–2018 (May) with a total quantity of 370.72 KG in a total number of 38 cases. The effect of explosive RDX-C4 is very massive and can cause many causalities and fatalities among civilians and policemen. These cases consisted of adhesive film with tapes wrapped around RDX-C4 substance (Demolition Charge M112), black batteries, pipes, black bag contained RDX-C4, and in magnetic improvised explosive device (IED). Touch DNA recovery utilized different collection methods, such as nylon swabbing, tape lifting, and direct cutting of certain parts of the samples that were positive of RDX-C4 through DXR Raman Spectrometer. Samples were extracted and purified with magnetic beads chemistry and quantified. Low copy DNA extracts were subjected to a concentration step. DNA extracts were amplified and processed for detection to obtain reliable results using GlobalFiler Amplification PCR kit and run through ABI 3500xL Genetic Analyzer for fragment length determination. We have discovered that RDX-C4 cannot bind to the DNA nor to the solutions used in DNA typing. Thus, it does not cause DNA inhibition or degradation. From this point of view, we were successful in obtaining acceptable and fit results using advanced techniques. This study will be very useful and informative to assist the forensic community in terrorism case applications worldwide as terrorists do not respect geographical boundaries nor ethnicities of the victims, and the use of DNA profiling technology is the most suitable way to identify the terrorists and keep an end to their violence.

Response of hybrid III and Mil-Lx ATD legs to explosively driven vehicle floor loading

Results are reported of small-scale explosive experiments with Hybrid III and Mil-Lx anthropomorphic test device (ATD) legs. The legs were subject to loadings from deforming metallic plates, driven by explosive loadings to replicate the movement of the floor of a protected vehicle subject to a land-mine strike. The forces measured by the legs are reported and compared between the two different leg types. The benefits of protective measures, including false-floors and commercially available footpads, are compared for their ability to reduce the forces measured in each leg type. It is concluded that the two leg types respond differently to different protective measures and hence cannot be used interchangeably.

Psychiatric comorbidity in Intermittent Explosive Disorder

This study examined aspects of psychiatry comorbidity in Intermittent Explosive Disorder (IED) in order to explore the validity of IED in the context of other psychiatric disorders. Data from the National Comorbidity Study - Revised (NCS-R: n = 9,282 adults) and its Adolescent Supplement (NCS-AS: n = 10,148 adolescents) and a large clinical research data set (n = 1640) were analyzed in this study. Mean number of comorbid disorders among current IED participants was similar to that among other Non-IED disorders and comorbidity of IED with Non-IED disorders was similar to comorbidity among Non-IED disorders. When examined together, current IED was significantly comorbid with current bipolar, depressive, anxiety, substance use, and post-traumatic stress disorder, and age of onset of IED generally preceded that of the comorbid disorders. Finally, mean aggression scores were generally highest among those with IED and the comorbid disorder while scores among those with the comorbid disorder alone were generally less than that with IED or with IED and the comorbid disorder. Comorbidity in IED is similar to that in other, more established, Non-IED disorders. The observation that the development of IED precedes the onset of most comorbid disorders and that aggression scores in those with IED and a comorbid disorder are often higher than those with IED alone supports the rationale that a diagnosis of both IED and the comorbid disorder should be made when both are present.

fMRI functional connectivity as an indicator of interictal epileptic discharges

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Functional connectivity to successful EEG/fMRI response indicates higher IED rates.

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The results hold when correcting for distance to maximum EEG-fMRI and laterality.

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Intracranial IED rates correlate with functional connectivity to EEG/fMRI maxima.

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Results suggest it is feasible to non-invasively infer the brain regions with IEDs.

Objective

To explore the relationship between functional connectivity and presence of interictal epileptic discharges (IEDs) in different brain regions in intracranial EEG (iEEG).

Methods

We studied 38 focal epilepsy patients who underwent simultaneous EEG/fMRI scanning and subsequent intracerebral stereo-EEG investigation. In EEG/fMRI analysis, IEDs with different spatial distributions were considered independent studies and IED-related maximal BOLD responses were evaluated. Studies with iEEG electrodes inside the maximal responses were selected and divided into three groups: Studies with 1. distinct maximal BOLD highly concordant with seizure-onset-zone (SOZ); 2. Moderate maximal BOLD concordant with SOZ; 3. maximal BOLD discordant with SOZ. Using maximal BOLD as seed, its functionally connected zone (FCZ) was determined. IED rates in iEEG channels inside and outside the FCZ were compared in the three groups. The effect of laterality and distance between channels and maximal BOLD, and correlation between functional connectivity values and IED rates were analyzed.

Results

Thirty-six studies in 25 patients were included. IED rates of intracranial EEG channels inside the FCZ were significantly higher than outside in Group 1 (p = 2.6×10−6) and Group 2 (p = 1.2×10−3) and the inside-outside difference remained after regressing distance and laterality factors. In Group 1, connectivity values were significantly correlated with IED rates in channels inside the FCZ (p < 0.05).

Significance

Our results indicate a higher probability of finding intracranial IEDs in the FCZ of SOZ-concordant maximal BOLD responses than in other regions, regardless of distance and laterality. In studies with distinct maximal BOLD, connectivity values can partially predict IED rates in intracranial EEG. It is thus feasible to non-invasively delineate brain regions that are likely to have high IED rates.

BOLD mapping of human epileptic spikes recorded during simultaneous intracranial EEG-fMRI: The impact of automated spike classification

OBJECTIVES

Simultaneous intracranial EEG and functional MRI (icEEG-fMRI) can be used to map the haemodynamic (BOLD) changes associated with the generation of IEDs. Unlike scalp EEG-fMRI, in most patients who undergo icEEG-fMRI, IEDs recorded intracranially are numerous and show variability in terms of field amplitude and morphology. Therefore, visual marking can be highly subjective and time consuming. In this study, we applied an automated spike classification algorithm, Wave_clus (WC), to IEDs marked visually on icEEG data acquired during simultaneous fMRI acquisition. The motivation of this work is to determine whether using a potentially more consistent and unbiased automated approach can produce more biologically meaningful BOLD patterns compared to the BOLD patterns obtained based on the conventional, visual classification.

METHODS

We analysed simultaneous icEEG-fMRI data from eight patients with severe drug resistant epilepsy, and who subsequently underwent resective surgery that resulted in a good outcome: confirmed epileptogenic zone (EZ). For each patient two fMRI analyses were performed: one based on the conventional visual IED classification and the other based on the automated classification. We used the concordance of the IED-related BOLD maps with the confirmed EZ as an indication of their biological meaning, which we compared for the automated and visual classifications for all IED originating in the EZ.

RESULTS

Across the group, the visual and automated classifications resulted in 32 and 24 EZ IED classes respectively, for which 75% vs 83% of the corresponding BOLD maps were concordant. At the single-subject level, the BOLD maps for the automated approach had greater concordance in four patients, and less concordance in one patient, compared to those obtained using the conventional visual classification, and equal concordance for three remaining patients. These differences did not reach statistical significance.

CONCLUSION

We found automated IED classification on icEEG data recorded during fMRI to be feasible and to result in IED-related BOLD maps that may contain similar or greater biological meaning compared to the conventional approach in the majority of the cases studied. We anticipate that this approach will help to gain significant new insights into the brain networks associated with IEDs and in relation to postsurgical outcome.

Social desirability, deceptive reporting, and awareness of problematic aggression in intermittent explosive disorder compared with non-aggressive healthy and psychiatric controls

Individuals with DSM-5 Intermittent Explosive Disorder (IED) are often suspected of minimizing the nature of their recurrent, problematic, impulsive aggressive behavior due to the social undesirability of these behaviors. Our first study involved 400 study participants categorized as Healthy Controls (HC), Psychiatric Controls (PC) and as having IED and included the Crowne-Marlowe Social Desirability Scale (SDS), the Lie Scale from the Eysenck Personality Questionnaire-Revised (EPQ-R Lie), and the Readiness to Change (Anger) Questionnaire (RTC). IED study participants had lower SDS and lower EPQ-R Lie scores, while having higher RTC scores, compared with both HC and PC study participants. Thus, when studied in a clinical research setting, IED study participants do not provide socially desirable answers to questions and do not engaging in deceptive reporting; likely because they have recognized their need/interest in reducing their own impulsive aggressive behavior. The second study, part of a family study of 70 probands and their first-degree relatives revealed a very high positive (96.3%), but substantially lower negative (55.8%), predictive power for IED based on informant report. This suggests that, while interview of close informants can confirm the diagnosis of IED, informant interviews cannot rule out IED when such informants provide a negative report.

The co-occurrence and correlates of anxiety disorders among adolescents with intermittent explosive disorder

We examined the lifetime prevalence of anxiety disorders (ADs) among adolescents with lifetime intermittent explosive disorder (IED), as well as the impact of co-occurring ADs on anger attack frequency and persistence, additional comorbidity, impairment, and treatment utilization among adolescents with IED. IED was defined by the occurrence of at least three anger attacks that were disproportionate to the provocation within a single year. Data were drawn from the National Comorbidity Survey-Adolescent Supplement (N = 6,140), and diagnoses were based on structured lay-administered interviews. Over half (51.89%) of adolescents with IED had an AD, compared to only 22.88% of adolescents without IED. Compared to adolescents with IED alone, adolescents with IED and comorbid ADs: (a) were more likely to be female; (b) reported greater impairment in work/school, social, and overall functioning; (c) were more likely to receive an additional psychiatric diagnosis, a depressive or drug abuse diagnosis, or diagnoses of three or more additional disorders; and (d) had higher odds of receiving any mental/behavioral health treatment as well as treatment specifically focused on aggression. Adolescents with IED alone and those with comorbid ADs did not differ in the number of years experiencing anger attacks or the highest number of anger attacks in a given year. ADs frequently co-occur with IED and are associated with elevated comorbidity and greater impairment compared to IED alone. Gaining a better understanding of this comorbidity is essential for developing specialized and effective methods to screen and treat comorbid anxiety in adolescents with aggressive behavior problems.

Psychosocial impairment in DSM-5 intermittent explosive disorder

The purpose of this study was to document the functional severity of DSM-5 IED in a clinical research sample. IED and control groups were compared on psychosocial functioning, life satisfaction, and on a variety of cognitive and behavioral issues. IED study participants reported significantly worse psychosocial function, quality of life, and higher job dysfunction than both psychiatric and healthy control study participants. The presence of DSM-5 IED is associated with significant psychosocial and functional impairment. Early intervention may aid in minimizing the consequences of impulsive aggressive behavior, and improving psychosocial functioning and quality of life.

Genome-Wide DNA Methylation Changes Associated with Intermittent Explosive Disorder: A Gene-Based Functional Enrichment Analysis

BACKGROUND

Intermittent explosive disorder is defined as a recurrent, problematic, and impulsive aggression that affects 3% to 4% of the US population. While behavioral genetic studies report a substantial degree of genetic influence on aggression and impulsivity, epigenetic mechanisms underlying aggression and intermittent explosive disorder are not well known.

METHODS

The sample included 44 subjects (22 with a DSM-5 diagnosis of intermittent explosive disorder and 22 comparable subjects without intermittent explosive disorder). Peripheral blood DNA methylome was profiled using the Illumina Infinium HumanMethylation450 Beadchip. Intermittent explosive disorder-associated genome-wide DNA methylation changes were analyzed using the CpGassoc R package, with covariates age, sex, and race being adjusted. A gene-based functional enrichment analysis was performed to identify pathways that were overrepresented by genes harboring highly differentially methylated CpG sites.

RESULTS

A total of 27 CpG sites were differentially methylated in IED participants (P<5.0×10-5), but none reached genome-wide significant threshold. Functional enrichment analysis revealed that genes mapped by these CpG sites are involved in the inflammatory/immune system, the endocrine system, and neuronal differentiation.

CONCLUSIONS

Consistent with our previous studies showing an association of inflammatory response with aggressive behavior in intermittent explosive disorder subjects, our gene-based pathway analysis using differentially methylated CpG sites supports inflammatory response as an important mechanism involved in intermittent explosive disorder and reveals other novel biological processes possibly associated with intermittent explosive disorder.

Epileptic networks are strongly connected with and without the effects of interictal discharges

OBJECTIVE

Epilepsy is increasingly considered as the dysfunction of a pathologic neuronal network (epileptic network) rather than a single focal source. We aimed to assess the interactions between the regions that comprise the epileptic network and to investigate their dependence on the occurrence of interictal epileptiform discharges (IEDs).

METHODS

We analyzed resting state simultaneous electroencephalography-functional magnetic resonance imaging (EEG-fMRI) recordings in 10 patients with drug-resistant focal epilepsy with multifocal IED-related blood oxygen level-dependent (BOLD) responses and a maximum t-value in the IED field. We computed functional connectivity (FC) maps of the epileptic network using two types of seed: (1) a 10-mm diameter sphere centered in the global maximum of IED-related BOLD map, and (2) the independent component with highest correlation to the IED-related BOLD map, named epileptic component. For both approaches, we compared FC maps before and after regressing out the effect of IEDs in terms of maximum and mean t-values and percentage of map overlap.

RESULTS

Maximum and mean FC maps t-values were significantly lower after regressing out IEDs at the group level (p < 0.01). Overlap extent was 85% ± 12% and 87% ± 12% when the seed was the 10-mm diameter sphere and the epileptic component, respectively.

SIGNIFICANCE

Regions involved in a specific epileptic network show coherent BOLD fluctuations independent of scalp EEG IEDs. FC topography and strength is largely preserved by removing the IED effect. This could represent a signature of a sustained pathologic network with contribution from epileptic activity invisible to the scalp EEG.

Proposed Iraq/Afghanistan War-Lung Injury (IAW-LI) Clinical Practice Recommendations: National Academy of Sciences' Institute of Medicine Burn Pits Workshop

High rates of respiratory symptoms (14%) and new-onset asthma in previously healthy soldiers (6.6%) have been reported among military personnel post-deployment to Iraq and Afghanistan. The term Iraq/Afghanistan War-Lung Injury (IAW-LI) is used to describe the constellation of respiratory diseases related to hazards of war, such as exposure to burning trash in burn pits, improvised explosive devices, and sandstorms. Burnpits360.org is a nonprofit civilian website which voluntarily tracks medical symptoms among soldiers post-deployment to the Middle East. Subsequent to initiation of the Burnpits360.org website, the Department of Veterans Affairs started the Airborne Hazards and Open Burn Pit registry. This paper: (a) analyzes the latest 38 patients in the Burnpits360.org registry, validated by DD214 Forms; (b) compares strengths and weaknesses of both registries as outlined at the National Academy of Sciences Institute of Medicine Burn Pits Workshop;

Using patient-specific hemodynamic response function in epileptic spike analysis of human epilepsy: a study based on EEG-fNIRS

Functional near-infrared spectroscopy (fNIRS) can be combined with electroencephalography (EEG) to continuously monitor the hemodynamic signal evoked by epileptic events such as seizures or interictal epileptiform discharges (IEDs, aka spikes). As estimation methods assuming a canonical shape of the hemodynamic response function (HRF) might not be optimal, we sought to model patient-specific HRF (sHRF) with a simple deconvolution approach for IED-related analysis with EEG-fNIRS data. Furthermore, a quadratic term was added to the model to account for the nonlinearity in the response when IEDs are frequent. Prior to analyzing clinical data, simulations were carried out to show that the HRF was estimable by the proposed deconvolution methods under proper conditions. EEG-fNIRS data of five patients with refractory focal epilepsy were selected due to the presence of frequent clear IEDs and their unambiguous focus localization. For each patient, both the linear sHRF and the nonlinear sHRF were estimated at each channel. Variability of the estimated sHRFs was seen across brain regions and different patients. Compared with the SPM8 canonical HRF (cHRF), including these sHRFs in the general linear model (GLM) analysis led to hemoglobin activations with higher statistical scores as well as larger spatial extents on all five patients. In particular, for patients with frequent IEDs, nonlinear sHRFs were seen to provide higher sensitivity in activation detection than linear sHRFs. These observations support using sHRFs in the analysis of IEDs with EEG-fNIRS data.

Morphometric analysis of amygdla and hippocampus shape in impulsively aggressive and healthy control subjects

BACKGROUND

Impulsive aggressive behavior is thought to be facilitated by activation of the limbic brain, particularly the amygdala and hippocampus., Functional imaging studies suggest abnormalities in limbic brain activity during emotional information processing in impulsively aggressive subjects with Intermittent Explosive Disorder (IED). It is not known if IED is associated with altered amygdala and hippocampus volume and shape.

METHODS

We examined the volume and shape of the amygdala-hippocampal complex, using morphometric analysis of high resolution structural 3T MR scans in healthy control (HC: n = 73) subjects without history of Axis I or II psychiatric conditions and in subjects with IED (n = 67).

RESULTS

While no volume differences were observed between HC and IED subjects, a significant level of morphometric deformation, suggestive of cell loss, in both amygdala and hippocampal structures was observed bilaterally in IED subjects. Analysis of a canonical variable that used the first 10 eigenvectors from both sides of the brain revealed that these morphometric deformations in the IED subjects were not due the presence of confounding variables or to comorbidities among IED subjects.

CONCLUSIONS

These data reveal that IED is associated with a significant loss of neurons in both the amygdala and hippocampus. These changes may play a role in the functional abnormalities observed in previous fMRI studies and in the pathophysiology of impulsive aggressive behavior.

Emotional intelligence and impulsive aggression in Intermittent Explosive Disorder

Emotional intelligence (EI) relates to one's ability to recognize and understand emotional information and then, to use it for planning and self-management. Given evidence of abnormalities of emotional processing in impulsively aggressive individuals, we hypothesized that EI would be reduced in subjects with Intermittent Explosive Disorder (IED: n = 43) compared with healthy (n = 44) and psychiatric (n = 44) controls. The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) was used to assess both Experiential EI and Strategic EI. Strategic, but not Experiential, EI was lower in IED compared with control subjects. These differences were not accounted for demographic characteristics, cognitive intelligence, or the presence of clinical syndromes or personality disorder. In contrast, the relationship between IED and Strategic EI was fully accounted for by a dimension of hostile cognition defined by hostile attribution and hostile automatic thoughts. Interventions targeted at improving Strategic EI and reducing hostile cognition will be key to reducing aggressive behavior in individuals with IED.

Relationship between psychopathy, aggression, anger, impulsivity, and intermittent explosive disorder

Intermittent explosive disorder (IED) in DSM-5 represents a disorder of recurrent, problematic, reactive (i.e., affective or impulsive), aggressive behavior that, over the lifetime, affects about 5-6% of individuals in the United States. While aggression is also observed in those with psychopathic personality, aggression in this context is frequently proactive rather than reactive, and neurobiological study suggests important differences between those with proactive aggression/psychopathy and those with reactive aggression. In this paper, we conducted two sets of analyses. First, a phenomenologic study to explore the frequency of psychopathic personality defined by the Psychopathology Checklist-Screening Version (PCL-SV) among IED and comparator participants and to explore differences in measures of aggression, anger, and impulsivity as a function of IED and psychopathic personality. Second, we re-analyzed data from five published studies to determine if psychopathic personality accounted for differences between IED and comparator participants. The first study found that only a modest proportion of IED participants display clinically substantial features of psychopathy and that measures of trait aggression and anger, rather than those of psychopathy, are the strongest correlates of IED. The second study found little evidence for any impact of psychopathy on reported findings in IED compared with various control participants.

Lower limb injuries caused by improvised explosive devices: proposed 'Bastion classification' and prospective validation

BACKGROUND

Complex lower limb injury caused by improvised explosive devices (IEDs) has become the signature wounding pattern of the conflict in Afghanistan. Current classifications neither describe this injury pattern well, nor correlate with management. There is need for a new classification, to aid communication between clinicians, and help evaluate interventions and outcomes. We propose such a classification, and present the results of an initial prospective evaluation.

PATIENTS AND METHODS

The classification was developed by a panel of military surgeons whilst deployed to Camp Bastion, Afghanistan. Injuries were divided into five classes, by anatomic level. Segmental injuries were recognised as a distinct entity. Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs, which impact on clinical management and resources, were also accounted for.

RESULTS

Between 1 November 2010 and 20 February 2011, 179 IED-related lower limb injuries in 103 consecutive casualties were classified, and their subsequent vascular and musculoskeletal treatment recorded. 69% of the injuries were traumatic amputations, and the remainder segmental injuries. 49% of casualties suffered bilateral lower limb amputation. The most common injury was class 3 (involving proximal lower leg or thigh, permitting effective above-knee tourniquet application, 49%), but more proximal patterns (class 4 or 5, preventing effective tourniquet application) accounted for 18% of injuries. Eleven casualties had associated intraperitoneal abdominal injuries, 41 suffered genital or perineal injuries, 9 had pelvic ring fractures, and 66 had upper limb injuries. The classification was easy to apply and correlated with management.

CONCLUSIONS

The 'Bastion classification' is a pragmatic yet clinically relevant injury categorisation, which describes current injury patterns well, and should facilitate communication between clinicians, and the evaluation of interventions and outcomes. The validation cohort confirms that the injury burden from IEDs in the Helmand Province of Afghanistan remains high, with most casualties sustaining amputation through or above the knee. The rates of associated injury to the abdomen, perineum, pelvis and upper limbs are high. These findings have important implications for the training of military surgeons, staffing and resourcing of medical treatment facilities, to ensure an adequate skill mix to manage these complex and challenging injuries.

Resilience of developing brain networks to interictal epileptiform discharges is associated with cognitive outcome

The effects of interictal epileptiform discharges on neurocognitive development in children with medically-intractable epilepsy are poorly understood. Such discharges may have a deleterious effect on the brain's intrinsic connectivity networks, which reflect the organization of functional networks at rest, and in turn on neurocognitive development. Using a combined functional magnetic resonance imaging-magnetoencephalography approach, we examine the effects of interictal epileptiform discharges on intrinsic connectivity networks and neurocognitive outcome. Functional magnetic resonance imaging was used to determine the location of regions comprising various intrinsic connectivity networks in 26 children (7-17 years), and magnetoencephalography data were reconstructed from these locations. Inter-regional phase synchronization was then calculated across interictal epileptiform discharges and graph theoretical analysis was applied to measure event-related changes in network topology in the peri-discharge period. The magnitude of change in network topology (network resilience/vulnerability) to interictal epileptiform discharges was associated with neurocognitive outcomes and functional magnetic resonance imaging networks using dual regression. Three main findings are reported: (i) large-scale network changes precede and follow interictal epileptiform discharges; (ii) the resilience of network topologies to interictal discharges is associated with stronger resting-state network connectivity; and (iii) vulnerability to interictal discharges is associated with worse neurocognitive outcomes. By combining the spatial resolution of functional magnetic resonance imaging with the temporal resolution of magnetoencephalography, we describe the effects of interictal epileptiform discharges on neurophysiological synchrony in intrinsic connectivity networks and establish the impact of interictal disruption of functional networks on cognitive outcome in children with epilepsy. The association between interictal discharges, network changes and neurocognitive outcomes suggests that it is of clinical importance to suppress discharges to foster more typical brain network development in children with focal epilepsy.

Detection of residues from explosive manipulation by near infrared hyperspectral imaging: a promising forensic tool

In this study near infrared hyperspectral imaging (NIR-HSI) is used to provide a fast, non-contact, non-invasive and non-destructive method for the analysis of explosive residues on human handprints. Volunteers manipulated individually each of these explosives and after deposited their handprints on plastic sheets. For this purpose, classical explosives, potentially used as part of improvised explosive devices (IEDs) as ammonium nitrate, blackpowder, single- and double-base smokeless gunpowders and dynamite were studied. A partial-least squares discriminant analysis (PLS-DA) model was built to detect and classify the presence of explosive residues in handprints. High levels of sensitivity and specificity for the PLS-DA classification model created to identify ammonium nitrate, blackpowder, single- and double-base smokeless gunpowders and dynamite residues were obtained, allowing the development of a preliminary library and facilitating the direct and in situ detection of explosives by NIR-HSI. Consequently, this technique is showed as a promising forensic tool for the detection of explosive residues and other related samples.

Classification of EEG abnormalities in partial epilepsy with simultaneous EEG-fMRI recordings

Scalp EEG recordings and the classification of interictal epileptiform discharges (IED) in patients with epilepsy provide valuable information about the epileptogenic network, particularly by defining the boundaries of the "irritative zone" (IZ), and hence are helpful during pre-surgical evaluation of patients with severe refractory epilepsies. The current detection and classification of epileptiform signals essentially rely on expert observers. This is a very time-consuming procedure, which also leads to inter-observer variability. Here, we propose a novel approach to automatically classify epileptic activity and show how this method provides critical and reliable information related to the IZ localization beyond the one provided by previous approaches. We applied Wave_clus, an automatic spike sorting algorithm, for the classification of IED visually identified from pre-surgical simultaneous Electroencephalogram-functional Magnetic Resonance Imagining (EEG-fMRI) recordings in 8 patients affected by refractory partial epilepsy candidate for surgery. For each patient, two fMRI analyses were performed: one based on the visual classification and one based on the algorithmic sorting. This novel approach successfully identified a total of 29 IED classes (compared to 26 for visual identification). The general concordance between methods was good, providing a full match of EEG patterns in 2 cases, additional EEG information in 2 other cases and, in general, covering EEG patterns of the same areas as expert classification in 7 of the 8 cases. Most notably, evaluation of the method with EEG-fMRI data analysis showed hemodynamic maps related to the majority of IED classes representing improved performance than the visual IED classification-based analysis (72% versus 50%). Furthermore, the IED-related BOLD changes revealed by using the algorithm were localized within the presumed IZ for a larger number of IED classes (9) in a greater number of patients than the expert classification (7 and 5, respectively). In contrast, in only one case presented the new algorithm resulted in fewer classes and activation areas. We propose that the use of automated spike sorting algorithms to classify IED provides an efficient tool for mapping IED-related fMRI changes and increases the EEG-fMRI clinical value for the pre-surgical assessment of patients with severe epilepsy.

Testing the individual effective dose hypothesis

The assumption of the individual effective dose is the basis for the probit method used for analyzing dose or concentration-response data. According to this assumption, each individual has a uniquely innate tolerance expressed as the individual effective dose (IED) or the smallest dose that is sufficient to kill the individual. An alternative to IED, stochasticity suggests that individuals do not have uniquely innate tolerance; deaths result from random processes occurring among similar individuals. Although the probit method has been used extensively in toxicology, the underlying assumption has not been tested rigorously. The goal of the present study was to test which assumption, IED or stochasticity, best explained the response of Daphnia magna exposed to multiple pulses of copper sulfate (CuSO4 ) over 24 d. Daphnia magna were exposed to subsequent age-dependent 24-h median lethal concentrations (LC50s) of copper (Cu). Age-dependent 24-h LC50 values and Cu depuration test were determined prior to the 24-d bioassay. The LC50 values were inversely related to organism age. The Cu depuration of D. magna did not depend on age or Cu concentration, and 5 d was sufficient recovery time. Daphnia magna were exposed to 4 24-h Cu exposures, and surviving organisms after each exposure were transferred to Cu-free culture media for recovery before the next exposure. Stochasticity appropriately explained the survival and reproduction response of D. magna exposed to Cu.

Military trauma care in Birmingham: observational study of care requirements and resource utilisation

BACKGROUND

The Royal Centre for Defence Medicine is located at University Hospitals Birmingham (UHB). Since 2001 all UK military casualties injured on active duty have been repatriated here for their initial treatment. This service evaluation was performed to quantify the work undertaken, with the aim of providing a snapshot of a year's military trauma work in order to inform the delivery of trauma care in both the military and civilian setting.

METHODS

Military patients admitted with traumatic injuries over a 12-month period were identified and the hospital notes and electronic records reviewed. Data were collected focusing on three areas - the details of the injury, information about the in-patient admission, and surgical interventions performed.

RESULTS

A total of 388 patients were used in the analysis. Median total length of stay was 10.5 days (IQR: 4-26, range: 0-137 days), and a median 6.0 days (IQR: 3.0-11.0, range: 1-49 days) was spent on intensive care by 125 patients. Surgical intervention was required for 278 (71.6%) patients, with a median of 2.0 operations (IQR: 1.0-4.0, range: 1-27) or 170 min (IQR: 90.0-570.0, range 20-4735 min) operating time per patient. 77% of these patients had their first procedure within 24h of arrival. Improvised explosives accounted for 50.5% of injuries seen. Spearman rank correlation between New Injury Severity Score with length of stay demonstrated significant correlation (p<0.001), with a coefficient of 0.640. A model predicting length of stay based on New Injury Severity Score was devised for patients with battle injuries.

CONCLUSION

This report of 12 months work at UHB demonstrates the service commitment to these casualties, describing the burden of care and resource requirements for military trauma patients.

Influence of paroxysmal activity on background synchronization in epileptic recordings

BACKGROUND

The presence of spikes and sharp waves in recordings of epileptic patients contaminates background signal synchronization. When estimating functional connectivity between extended cortical areas, the influence of epileptic spikes in specific areas should be considered; however, this step is sometimes overlooked. We present a simple method for quantifying the influence of epileptic activity on background signal synchronization.

METHOD

Standard synchronization measures were calculated for both pure correlated Gaussian signals and correlated Gaussian signals with different levels of epileptic spikes in order to determine the influence of epileptic activity on synchronization estimates.

RESULTS

Synchronization from invasive epileptic recordings (e.g., depth electrodes) displays a much higher bias due to epileptic activity than superficial electrodes. Moreover, statistical methods such as mutual information are more affected by spike presence than phase synchronization methods. The influence of spikes is far greater at low values of background synchronization.

CONCLUSIONS

The information provided by this procedure makes it possible to differentiate true background synchronization from spike synchronization. Thus, our procedure serves as a guide for analyzing synchronization and functional connectivity calculations in epileptic recordings.

Achieving convergence between a community-based measure of explosive anger and a clinical interview for intermittent explosive disorder in Timor-Leste

BACKGROUND

There is growing research interest in understanding and analyzing explosive forms of anger. General epidemiological studies have focused on the DSM-IV category of Intermittent Explosive Disorder (IED), while refugee and post-conflict research have used culturally-based indices of explosive anger. The aim of this study was to test the convergence of a culturally-sensitive community measure of explosive anger with a structured clinical interview diagnosis of IED in Timor-Leste, a country with a history of significant mass violence and displacement.

METHODS

A double-blind clinical concordance study was conducted amongst a stratified community sample in post-conflict Timor-Leste (n=85) to compare a community measure of anger against the Structured Clinical Interview (SCID) module for IED.

RESULTS

Clinical concordance between the two measures was high: the area under the curve (AUC) index was 0.90 (95% CI: 0.83-0.98); sensitivity and specificity were 93.3% and 87.5% respectively.

LIMITATIONS

Response rates were modest due to the participant's time commitments.

CONCLUSIONS

It is possible to achieve convergence between culturally-sensitive measures of explosive anger and the DSM-IV construct of IED, allowing comparison of findings across settings and populations.

Identifying future 'unexpected' survivors: a retrospective cohort study of fatal injury patterns in victims of improvised explosive devices

OBJECTIVES

To identify potentially fatal injury patterns in explosive blast fatalities in order to focus research and mitigation strategies, to further improve survival rates from blast trauma.

DESIGN

Retrospective cohort study.

PARTICIPANTS

UK military personnel killed by improvised explosive device (IED) blasts in Afghanistan, November 2007-August 2010.

SETTING

UK military deployment, through NATO, in support of the International Security Assistance Force (ISAF) mission in Afghanistan.

DATA SOURCES

UK military postmortem CT records, UK Joint Theatre Trauma Registry and associated incident data.

MAIN OUTCOME MEASURES

Potentially fatal injuries attributable to IEDs.

RESULTS

We identified 121 cases, 42 mounted (in-vehicle) and 79 dismounted (on foot), at a point of wounding. There were 354 potentially fatal injuries in total. Leading causes of death were traumatic brain injury (50%, 62/124 fatal injuries), followed by intracavity haemorrhage (20.2%, 25/124) in the mounted group, and extremity haemorrhage (42.6%, 98/230 fatal injuries), junctional haemorrhage (22.2%, 51/230 fatal injuries) and traumatic brain injury (18.7%, 43/230 fatal injuries) in the dismounted group.

CONCLUSIONS

Head trauma severity in both mounted and dismounted IED fatalities indicated prevention and mitigation as the most effective strategies to decrease resultant mortality. Two-thirds of dismounted fatalities had haemorrhage implicated as a cause of death that may have been anatomically amenable to prehospital intervention. One-fifth of the mounted fatalities had haemorrhagic trauma which currently could only be addressed surgically. Maintaining the drive to improve all haemostatic techniques for blast casualties, from point of wounding to definitive surgical proximal vascular control, alongside the development and application of novel haemostatic interventions could yield a significant survival benefit. Prospective studies in this field are indicated.

Imaging the interaction: epileptic discharges, working memory, and behavior

Interictal generalized epileptiform discharges may impair cognition. We used simultaneous video-electroencephalography and functional imaging to quantify changes, induced by epileptiform discharges, in the task-related activations during a spatial working-memory paradigm. The number of epileptiform discharges increased during the task with its level of complexity, but were not significantly associated with wrong responses during the task. We observed hemodynamic responses in working-memory related frontal-lobe-network, motor-cortex, precuneus, and parietal lobes in the absence of epileptiform discharges. In the presence of epileptiform discharges during the task, task-related hemodynamic changes were seen only in motor-cortex, precuneus, and parietal lobes. These findings suggest that generalized epileptiform discharges during a high demanding working memory task may change the working memory-related hemodynamic responses in frontal-lobe-network.

Physics of IED Blast Shock Tube Simulations for mTBI Research

Shock tube experiments and simulations are conducted with a spherical gelatin filled skull–brain surrogate, in order to study the mechanisms leading to blast induced mild traumatic brain injury. A shock tube including sensor system is optimized to simulate realistic improvised explosive device blast profiles obtained from full scale field tests. The response of the skull–brain surrogate is monitored using pressure and strain measurements. Fluid–structure interaction is modeled using a combination of computational fluid dynamics (CFD) simulations for the air blast, and a finite element model for the structural response. The results help to understand the physics of wave propagation, from air blast into the skull–brain. The presence of openings on the skull and its orientation does have a strong effect on the internal pressure. A parameter study reveals that when there is an opening in the skull, the skull gives little protection and the internal pressure is fairly independent on the skull stiffness; the gelatin shear stiffness has little effect on the internal pressure. Simulations show that the presence of pressure sensors in the gelatin hardly disturbs the pressure field.

Penetrating Blast Injury to the Knee of a United States Soldier Treated with Allograft Mosaicplasty

OBJECTIVE

This is the first report of successful allograft mosaicplasty treatment of a large osteochondral lesion of the knee caused by a blast fragment sustained during combat operations. The patient was able to return to active duty following rehabilitation.

METHODS

An active-duty infantryman sustained an osteochondral lesion of the medial femoral condyle caused by a metallic fragment of an explosively formed projectile. Initial treatment consisted of removal of the foreign body and primary closure. The patient continued to experience pain, mechanical symptoms, and repeated effusions after initial nonoperative treatment. Allograft mosaicplasty of the lesion utilizing two 18-mm-diameter fresh allograft osteochondral plugs was performed at 6 months post-injury.

RESULTS

At 2-year follow-up, the patient remains on active duty with marked improvement in symptoms. Two years postoperatively, his outcome scores are 72 of 100 on the Western Ontario and McMaster University osteoarthritis scoring index (WOMAC) and 60 of 100 on the Knee Injury and Osteoarthritis Outcome Score (KOOS). His follow-up x-rays and MRI demonstrate intact articular cartilage and subchondral bone incorporation.

CONCLUSION

Penetrating injuries to joints are commonplace in the battlefield environment. Combat injuries to the knee are frequently associated with articular cartilage injury. While numerous cartilage restoration techniques have been used with success for the treatment of osteochondral injuries to the femoral condyles, no published reports describe the use of allograft mosaicplasty in this location for open, penetrating injuries with focal cartilage loss. This is the first documented use of allograft mosaicplasty for a traumatic osteochondral defect of the medial femoral condyle caused by a metallic projectile. The patient was able to return to active duty following rehabilitation. We demonstrate a high level of functioning is possible following allograft mosaicplasty of a large osteochondral lesion caused by penetrating ballistic trauma.