[Societals costs of trauma]. / Maatschappelijke kosten van trauma.

BACKGROUND: Knowing the costs of trauma aids in making informed decisions about investments to prevent and treat trauma. AIM: To provide an overview of the potential societal costs of psychological problems caused by traumatic experiences. METHOD: Using a narrative review based on the available literature on PTSD and adverse childhood events (ACEs), we estimated the possible societal costs for the Netherlands. We used literature on the domains of wellbeing, healthcare, education and labour, crime and justice, and intergenerational transfers. RESULTS: We estimated that costs due to loss of wellbeing may span from tens of millions to several billion euros annually for the Netherlands. Healthcare costs and costs due to lower educational attainment and reduced labor productivity were likely to amount to hundreds of millions of euros annually. Other domains were not quantifiable given current knowledge. CONCLUSION: Although societal costs cannot completely reliably be determined with current literature, there are reasons to assume that these costs can be significant. Investments in prevention and effective treatment could therefore lead to significant savings.

Clinical Predictors of Pseudohypoxia-Type Pheochromocytomas.

INTRODUCTION: Pheochromocytomas (PCCs) are rare tumors of neural crest origin with divergent transcriptional and metabolic profiles associated with mutational cluster types. Pseudohypoxia-type (PHT) PCCs have a poor prognosis; however diagnostic genetic testing is not always available. We aimed to investigate clinical parameters predictive of PHT PCCs. METHODS: Patients who underwent resection and genetic testing for PCC at two academic centers from 2006-2020 were retrospectively studied. Patients with PHT mutations (SDH-AF2/B/C/D, VHL) were compared to non-pseudohypoxia-type (nonPHT) PCCs to identify widely available clinical parameters predictive of PHT PCCs. Demographic, clinical, and pathologic characteristics were compared using student's T and ANOVA tests. Operative hemodynamic instability was defined as systolic blood pressure (SBP) > 200 mmHg, SBP increase of > 30% relative to baseline, and/or heart rate (HR) > 110 bpm. Mann-Whitney U test was used to assess area under the curve (AUC), sensitivity, and specificity. Recursive partitioning was used to model predictive thresholds for PHT PCC and develop a predictive score. RESULTS: Of the 79 patients included in the cohort, 17 (22%) had PHT and 62 (78%) had nonPHT PCCs. PCC patients with > 2 of the examined predictive clinical parameters (preoperative weight loss [> 10% body weight], elevated preoperative hematocrit [> 50%], normal baseline heart rate [< 100 bpm], and normal plasma metanephrines [< 0.60 nmol/L]) were more likely to have PHT PCCs (AUC = 0.831, sensitivity = 0.882, specificity = 0.694, all p < 0.001). CONCLUSIONS: Widely available preoperative clinical parameters including indicators of erythropoiesis (hemoglobin, hematocrit, and red blood cell count), baseline heart rate, plasma metanephrines, and weight loss may be useful predictors of PHT PCCs and may help guide management of PCCs when genetic testing is unavailable/delayed.

Understanding tissue-engineered endochondral ossification; towards improved bone formation.

Endochondral ossification (EO) is the process by which the long bones of the body form and has proven to be a promising method in tissue engineering for achieving cell-mediated bone formation. The present review centred on state-of-the-art research pertaining to mesenchymal stem cells (MSCs)-mediated endochondral bone formation, focusing on the role of donor cells, extracellular matrix and host immune cells during tissue-engineered bone formation. Possible research avenues to improve graft outcome and bone output were highlighted, as well as emerging research that, when applied to tissue-engineered bone grafts, offers new promise for improving the likelihood of such grafts transition from bench to bedside.

Initiation of osteoporosis assessment in the fracture clinic results in improved osteoporosis management: a randomised controlled trial.

UNLABELLED: Osteoporosis management post fragility fracture has traditionally been deficient with up to 60-90 % of patients remaining untreated for osteoporosis in some studies. Efforts have been made to address this deficiency with some successes reported. INTRODUCTION: The aim of this study was to assess the efficacy of two different models of screening for osteoporosis in a community fracture clinic setting. METHODS: A prospective randomised clinical trial was conducted to assess the DXA scan and treatment rates in patients with fragility fractures when assessment for osteoporosis had been initiated in the fracture clinic compared with the "usual care" of assessment initiation by the participant's general practitioner. RESULTS: Sixty-six patients were enrolled in the study. Thirty-three patients each were in the control and intervention groups. The assessment rate (DXA scan rate) was significantly better in the intervention group where participants were referred for assessment from fracture clinic compared to the control group where participants were referred for assessment by their general practitioner (68 vs 36 %, respectively; p < 0.05). For patients who were assessed for osteoporosis, treatment rates were similar in both the control and intervention groups (100 vs 88 %, p > 0.05). CONCLUSION: This study demonstrates that screening for osteoporosis initiated in fracture clinic results in improved osteoporosis management compared to screening initiated in primary care. Orthopaedic surgeons and other specialists need to be more active in managing osteoporosis in patients who present with fragility fractures and should at the very least initiate assessment in the fracture clinic setting.

Trauma assessment clinic: Virtually a safe and smarter way of managing trauma care in Ireland.

INTRODUCTION: The Trauma Assessment Clinic [TAC], also referred to as Virtual Fracture Clinic, offers a novel care pathway for patients and is being increasingly utilised across the Irish and UK health care systems. The provision of safe, patient centred, efficient and cost-effective treatment via a multidisciplinary team [MDT] approach is the primary focus of TAC. The Trauma and Orthopaedic unit at Tullamore Hospital was the first centre to introduce a TAC in Ireland and this overview outlines the experiences of this pilot. METHODS AND PATIENTS: Patients arriving to the Emergency Department with injuries that were TAC appropriate were treated as per a recognised protocol. They were given information regarding their injury and a removable splint or cast and told to expect a follow up phone call from the orthopaedic team. Within 24 h the patient's clinical notes and x-rays were assessed by the TAC MDT and patients were called immediately to be advised as to their planned treatment. RESULTS: To date the TAC pilot in Tullamore Hospital has reviewed 2704 patients. 35% of patients were discharged at the TAC review stage, 27% were referred to an appropriate clinic (e.g. Shoulder injuries referred to an upper limb specialist) or a general trauma follow-up clinic, and 38% were referred onto physiotherapy services local and community based for follow-up. A survey of patients reviewed in the TAC revealed that 97% of respondents agreed or strongly agreed that they were satisfied with their recovery. The cost of each TAC consultation was €28 versus €129 for a traditional fracture clinic appointment. CONCLUSION: Our experience of the TAC is that it provides a very safe, patient focused and cost-effective means of delivering trauma care. It provides a more streamlined and improved patient journey in select patients with certain fracture patterns, allowing for patient empowerment without compromising clinical care and marries current available technology with up to date best clinical practice.

Allogeneic chondrogenically differentiated human bone marrow stromal cells do not induce dendritic cell maturation.

Bone marrow stromal cell (BMSC)-mediated endochondral bone formation may be a promising alternative to the current gold standards of autologous bone transplantation, in the development of novel methods for bone repair. Implantation of chondrogenically differentiated BMSCs leads to bone formation in vivo via endochondral ossification. The success of this bone formation in an allogeneic system depends upon the interaction between the implanted constructs and the host immune system. The current study investigated the effect of chondrogenically differentiated human bone marrow stromal cell (hBMSC) pellets on the maturation and function of dendritic cells (DCs) by directly coculturing bone forming chondrogenic hBMSC pellets and immature or lipopolysaccharide (LPS)-matured DCs in vitro. Allogeneic chondrogenic hBMSC pellets did not affect the expression of CD80, CD86, or HLADR on immature or LPS-matured DCs following 24, 48, or 72 hr of coculture. Furthermore, they did not induce or inhibit antigen uptake or migration of the DCs over time. IL-6 was secreted by allogeneic chondrogenic hBMSC pellets in response to LPS-matured DCs. Overall, this study has demonstrated that maturation of immature DCs was not influenced by allogeneic chondrogenic hBMSC pellets. This suggests that allogeneic chondrogenic hBMSC pellets do not stimulate immunogenic responses from DCs in vitro and are not expected to indirectly activate T cells via DCs. For this reason, allogeneic chondrogenic bone marrow stromal cell pellets are promising candidates for future tissue engineering strategies utilising allogeneic cells for bone repair.

Interaction of ambient temperature with the effects of delta 9-tetrahydrocannabinol on brain catecholamine synthesis and plasma corticosterone levels.

The effects of delta 9-tetrahydrocannabinol (THC) on body temperature, catecholamine synthesis and plasma corticosteroid levels were examined in the mouse at ambient temperatures of 31 degrees, 20 degrees and 10 degrees C in order to study the role of hypothermia in the THC's other actions. THC produced hypothermia at 10 degrees and 20 degrees C, but not at 31 degrees C. Dose related increases in dopamine and norepinephrine synthesis rates and plasma corticosterone levels were produced by THC at both 31 degrees and 20 degrees C. The effects of THC at 10 degrees C were biphasic. These data indicate that the effects of THC on brain catecholamines are not a result of drug induced hypothermia and may be a result of a direct action on neurons.

Dichotic listening of verbal and non verbal material by Down's syndrome children and children of normal intelligence.

In an attempt to resolve the conflicting findings of earlier research on the direction of dichotic ear preferences in Down's Syndrome, two verbal and one nonverbal dichotic tests were administered to a group of Down's Syndrome subjects and a group of nursery school children of similar MA. The expected patterns of ear advantage emerged for the normal sample. Overall levels of lateralisation for the Down's group were not significant but the group was characterised by a high level of subjects with reversed ear advantages for verbal material. This reversal was not found for the nonverbal material. On the basis of earlier findings on the general mentally handicapped population it was concluded that reversal of ear advantage for verbal material was not characteristic of Down's Syndrome but may be associated with level of language ability.

A strategy for research on the use of nonvocal systems of communication.

This paper discusses problems with current research on the use of nonvocal communication systems with special reference to the severely and profoundly mentally retarded. A strategy for research, designed to provide a method whereby critical practical and theoretical issues can be isolated, is described. The approach involves surveys of use, development of procedures for assessment and program monitoring, the development of teaching methods for use with neglected groups, and experimental investigations of the interaction of system variables and subject characteristics. The strategy is illustrated with examples from ongoing research.

Effect of dietary insoluble fiber on control of glycemia in dogs with naturally acquired diabetes mellitus.

OBJECTIVE: To evaluate the effect of a high insoluble-fiber (HF) diet containing 12% cellulose in dry matter and a low insoluble-fiber (LF) diet on control of glycemia in dogs with naturally acquired insulin-dependent diabetes mellitus. DESIGN: Prospective randomized crossover controlled trial. ANIMALS: 11 dogs with naturally acquired diabetes mellitus. PROCEDURE: Dogs were fed HF and LF diets for 8 months each in 1 of 2 randomly assigned diet sequences. Caloric intake and insulin treatment were adjusted as needed to maintain stable body weight and control of glycemia, respectively. After a 2-month adaptation period, control of glycemia was evaluated every 6 weeks for 6 months. Variables assessed included serum glucose concentration measured during the preprandial state, blood glycosylated hemoglobin concentration, serum glucose concentration measured every 2 hours for 24 hours beginning at the time of the morning insulin injection, 24-hour mean serum glucose concentration, mean serum glucose concentration fluctuation from the 24-hour mean serum glucose concentration, and 24-hour urinary excretion of glucose. RESULTS: Significant differences in mean daily caloric intake, body weight, or daily insulin dosage among dogs fed HF and LF diets were not found. Mean preprandial serum glucose concentration, most postprandial serum glucose concentrations, 24-hour mean serum glucose concentration, and 24-hour urinary excretion of glucose were significantly lower in dogs fed the HF diet, compared with the LF diet. CLINICAL IMPLICATIONS: Results of this study support feeding of commercially available insoluble fiber diets to dogs with naturally acquired diabetes mellitus.

Effect of dietary insoluble fiber on control of glycemia in cats with naturally acquired diabetes mellitus.

OBJECTIVE: To evaluate effects of dietary insoluble fiber on control of glycemia in cats with naturally acquired diabetes mellitus. DESIGN: Randomized controlled crossover trial. ANIMALS: 16 cats with naturally acquired diabetes mellitus. PROCEDURE: Cats were fed a diet high in insoluble fiber (HF) containing 12% cellulose (dry-matter basis) or a diet low in insoluble fiber (LF) for 24 weeks; they were fed the other diet for the subsequent 24 weeks. Caloric intake and insulin treatment were adjusted to maintain stable body weight and control of glycemia, respectively. Cats were allowed an adaptation period of 6 weeks after initiation of a diet, after which control of glycemia was evaluated at 6-week intervals for 18 weeks. Variables assessed included serum glucose concentration measured during the preprandial state, blood glycated hemoglobin concentration, serum glucose concentration measured at 2-hour intervals for 12 hours beginning at the time of the morning insulin injection, 12-hour mean serum glucose concentration, and mean fluctuation in serum glucose concentration from the 12-hour mean serum glucose concentration. RESULTS: Mean daily caloric intake, body weight, or daily insulin dosage did not differ significantly between cats when fed HF and LF diets. Mean preprandial serum glucose concentration, most post-prandial serum glucose concentrations, and the 12-hour mean serum glucose concentration were significantly lower when cats consumed the HF diet, compared with values when cats consumed the LF diet. CONCLUSIONS AND CLINICAL RELEVANCE: These results support feeding a commercially available diet containing approximately 12% insoluble fiber (dry-matter basis) to cats with naturally acquired diabetes mellitus.

Predicting the persistence of severe self-injurious behavior.

Information was collected on 95 people with mental retardation who had been identified seven years previously as showing severe self-injurious behavior. At follow up 71% of participants were still showing self-injurious behavior of a severity which presented a management problem for care staff. The occurrence of specific topographies of self-injury was extremely stable among the group showing persistent self-injury. Finally, self-injury status at follow-up was predicted with 76% accuracy by a logistic regression model containing three variables: site of injury (higher persistence being shown by people exhibiting head directed self-injury); reported (greater) stability of self-injury when first identified; and (younger) age.

The prevalence of challenging behaviors: a total population study.

A total population study was undertaken in two areas of England to identify the situation and characteristics of people reported to exhibit challenging behaviors. We found that: (1) challenging behaviors are shown by 10-15% of people with mental retardation who are in contact with educational, health or social care services for people with mental retardation; (2) the most common forms of challenging behaviors reported were 'other' behavior (shown by 9%-12% of all people screened), aggression (7%), destructive behavior (4%-5%) and self-injury (4%); (3) the majority of people identified showed two or more of these four general forms of challenging behavior; (4) approximately two-thirds of the people identified were boys/men; (5) close to two-thirds of the people identified were adolescents or young adults; (6) approximately 50% of the people identified as showing more demanding challenging behavior were living with their families; (7) people who showed more demanding challenging behavior were more likely to need greater levels of assistance in eating, dressing and washing, be incontinent and have more restricted expressive and receptive communication.

Staff stressors and staff outcomes in services for adults with intellectual disabilities: the Staff Stressor Questionnaire.

This paper reports on the development, psychometric properties, and validity of a self-report measure designed to assess potential stressors among staff in services for people with intellectual disabilities, the 33-item Staff Stressor Questionnaire (SSQ). A questionnaire including the SSQ and scales measuring staff outcomes was administered to 512 staff across seven services for people with intellectual disabilities. The SSQ was factor analyzed to produce seven subscales reflecting different potential stressors for staff: user challenging behavior; poor user skills; lack of staff support; lack of resources; low-status job; bureaucracy; and work-home conflict. The SSQ subscales showed adequate internal reliability in terms of Cronbach's alpha and mean inter-item correlations. Associations between SSQ subscale scores and different staff groups, and patterns of associations between SSQ subscales and a range of staff outcomes, provided evidence suggestive of the face-, construct-, and criterion-related validity of the questionnaire. The SSQ shows promise as a measure for assessing potential stressors for staff in services for people with intellectual disabilities. Further studies to examine the reliability, validity, and utility of the SSQ are recommended.

The cost utility of a multi-disciplinary foot protection clinic (MDFPC) in an Irish hospital setting.

BACKGROUND: Foot ulceration which may result in lower limb amputation is one of the most feared complications among patients with diabetes and the prevention of both ulceration and amputation is a major challenge facing the health service. Many studies have proposed dedicated diabetic foot teams as the future of diabetic foot care. AIMS: We aimed to quantify the cost benefit and sustainability of a multi-disciplinary foot protection clinic (MDFPC) in an Irish university hospital setting. METHODS: A dedicated bi-weekly consultant-led MDFPC including Vascular Surgery, Endocrinology, Orthopaedic Surgery, Podiatry, Orthotics and Tissue Viability was established in June 2008. RESULTS: Between 2006 and 2010, a total of 221 lower limb procedures (major/minor amputations and debridement) were performed. The number of major amputations decreased from 12 during the control period (2 years before the clinic) to 7 in the study period (2 years after the clinic). After costing all activity associated with the clinic, there was an overall saving of €114,063 per year associated with the introduction of the MDFPC. CONCLUSION: This is the first study in an Irish context, and one of few international studies, to demonstrate that an aggressive-coordinated approach to diabetic foot care is both cost effective and clinically efficient in reducing the burden of foot-related complications in a diabetic population.

Toward a curriculum for the profoundly retarded, multiply handicapped child.

An approach to formulating programmes for the profoundly retarded child is described. It is suggested that the basis for programming should be an analysis of the child's ability to operate on, and find out about, his environment. This analysis can be approached by asking questions about blocks to development, needs and preferences, socialization and communication and play and sensori-motor coordination.

The use of nonvocal communication techniques with autistic individuals.

Studies reporting the use of sign languages and symbol systems with autistic children and young people are reviewed. The studies suggest that signs and symbols can be used in communication by individuals who are above and below the age of five, mute and mentally handicapped. The communication skills developed may, in some cases, be complex, and speech may develop in the context of sign or symbol programmes. However, problems concerned with the description of subjects, methods and outcome of studies mean that many conclusions can only be supported tentatively by existing data.

Spoken words and manual signs as encoding categories in short-term memory for mentally retarded children.

The release from proactive inhibition paradigm was used to test differential encoding of manual signs and spoken words by six severely retarded children. Scores for shift conditions were significantly different from scores for nonshift conditions on the last trial, indicating that manual signs were encoded differently from spoken words for short-term memory storage. Implications of separate encoding categories for the investigation of language processes were discussed.

Free recall of lists of word and sign labels by severely handicapped children.

Two experiments are reported which tested short-term recall of lists of four sign or four word labels by severely handicapped children. The findings suggest that the subjects were more efficient at processing words than signs in short-term memory, and that their organization of sign and word lists were affected by the length of time the material had to be held in short-term store. Both of these effects were influenced by whether or not the subjects had to use the stimuli as labels when making a response.