A Multicenter Trial of Vena Cava Filters in Severely Injured Patients.

BACKGROUND: Whether early placement of an inferior vena cava filter reduces the risk of pulmonary embolism or death in severely injured patients who have a contraindication to prophylactic anticoagulation is not known. METHODS: In this multicenter, randomized, controlled trial, we assigned 240 severely injured patients (Injury Severity Score >15 [scores range from 0 to 75, with higher scores indicating more severe injury]) who had a contraindication to anticoagulant agents to have a vena cava filter placed within the first 72 hours after admission for the injury or to have no filter placed. The primary end point was a composite of symptomatic pulmonary embolism or death from any cause at 90 days after enrollment; a secondary end point was symptomatic pulmonary embolism between day 8 and day 90 in the subgroup of patients who survived at least 7 days and did not receive prophylactic anticoagulation within 7 days after injury. All patients underwent ultrasonography of the legs at 2 weeks; patients also underwent mandatory computed tomographic pulmonary angiography when prespecified criteria were met. RESULTS: The median age of the patients was 39 years, and the median Injury Severity Score was 27. Early placement of a vena cava filter did not result in a significantly lower incidence of symptomatic pulmonary embolism or death than no placement of a filter (13.9% in the vena cava filter group and 14.4% in the control group; hazard ratio, 0.99; 95% confidence interval [CI], 0.51 to 1.94; P = 0.98). Among the 46 patients in the vena cava filter group and the 34 patients in the control group who did not receive prophylactic anticoagulation within 7 days after injury, pulmonary embolism developed in none of those in the vena cava filter group and in 5 (14.7%) in the control group, including 1 patient who died (relative risk of pulmonary embolism, 0; 95% CI, 0.00 to 0.55). An entrapped thrombus was found in the filter in 6 patients. CONCLUSIONS: Early prophylactic placement of a vena cava filter after major trauma did not result in a lower incidence of symptomatic pulmonary embolism or death at 90 days than no placement of a filter. (Funded by the Medical Research Foundation of Royal Perth Hospital and others; Australian New Zealand Clinical Trials Registry number, ACTRN12614000963628.).

Severity and predictors of head injury due to bicycle accidents in Western Australia.

BACKGROUND: Head and face injuries are the second most frequently reported injuries among bicyclists. Recently, helmet usage has increased, and in some countries, helmet laws have been introduced. However, subsequent changes in the incidence and severity of traumatic brain injury (TBI) are unknown, and data on neurosurgical interventions are lacking. Therefore, we analyzed a cohort of bicyclists with TBI, in a state with an enforced helmet law, and compared our results with the available literature. METHODS: Patient data of bicycle accidents that occurred between January 2008 and January 2015 were extracted from the state trauma registry, and the corresponding patient files and CT scans were comprehensively reviewed. RESULTS: Of the 1019 patients admitted due to bicycle accidents, 187 patients suffered from TBI. Most cases were mild; however, 72 involved intracranial hemorrhages. Of the TBI patients, 113 were wearing helmets. CT scans were performed on 168 TBI patients, 120 of whom had a Rotterdam CT score of 1, with no difference between helmeted and non-helmeted patients. Open head injury (p < 0.05) and epidural hematomas were significantly less frequent among helmet wearers (p = 0.03). Ten patients required surgery; helmet use and neurosurgical involvement were not significantly correlated. CONCLUSIONS: Patients who wore helmets were significantly less likely to suffer from epidural hematomas and open head injuries. While TBI severity was not significantly different between helmeted and non-helmeted bicyclists, the overall occurrence of TBI and moderate to severe TBI among all admissions was lower than that seen in comparable studies from countries without helmet laws.

Are Medical Students Who Want to Become Surgeons Different? An International Cross-Sectional Study.

INTRODUCTION: Surgery is one of the most demanding and competitive medical specialities. This study aims to identify the characteristics that medical students who aspire to surgical specialisation possess. MATERIALS AND METHODS: In February 2010, an online survey comprised 36 questions was produced with the aid of the open source survey tool Limesurvey (Version 1.85 RC3). Deans' offices and student organisations in eight countries were contacted via e-mail with a link to the online survey for them to disseminate amongst the student population. Respondents were grouped into "Surgically inclined" and "non-surgically inclined". To compare the characteristics of these two groups, the Fisher Exact test was used for categorical data and non-parametric tests were used for continuous data. RESULTS: Between February and June 2010, we received 2907 responses; the majority from Australia, Austria, Germany, Switzerland and the UK. Of these, 2351 indicated what discipline they would like to pursue after graduation, with 383 (16.3 %) favouring surgery. The percentages of students interested in Surgery were similar across all participating countries. Those favouring Surgery were 1.5 times more likely to be male (*p = 0.01); however, Austria and Germany had significantly higher rates of female students interested in Surgery than all other countries surveyed. Students favouring Surgery were 20 % more likely to be single. Students favouring surgery were more likely to nominate "social prestige" and "remuneration" as their key motivation to become a doctor and were also prepared to work longer hours than respondents that were not surgically inclined. CONCLUSION: In this study, Medical students who aspire toward surgical careers were more likely to be male, less lifestyle orientated, and seeking social prestige and financial remuneration compared to other medical students.

Immunohistochemical and molecular characterization of the human periosteum.

PURPOSE: The aim of the present study was to characterize the cell of the human periosteum using immunohistological and molecular methods. METHODS: Phenotypic properties and the distribution of the cells within the different layers were investigated with immunohistochemical staining techniques and RT-PCR, focussing on markers for stromal stem cells, osteoblasts, osteoclasts and immune cells. RESULTS: Immunohistochemical results revealed that all stained cells were located in the cambium layer and that most cells were positive for vimentin. The majority of cells consisted of stromal stem cells and osteoblastic precursor cells. The density increased towards the deeper layers of the cambium. In addition, cells positive for markers of the osteoblast, chondrocyte, and osteoclast lineages were found. Interestingly, there were MHC class II-expressing immune cells suggesting the presence of dendritic cells. Using lineage-specific primer pairs RT-PCR confirmed the immunofluorescence microscopy results, supporting that human periosteum serves as a reservoir of stromal stem cells, as well as cells of the osteoblastic, and the chondroblastic lineage, osteoclasts, and dendritic cells. CONCLUSION: Our work elucidates the role of periosteum as a source of cells with a high regenerative capacity. Undifferentiated stromal stem cells as well as osteoblastic precursor cells are dominating in the cambium layer. A new outlook is given towards an immune response coming from the periosteum as MHC II positive immune cells were detected.

Medial thigh abscess mimicking septic arthritis of the knee: a report of two cases.

BACKGROUND: Septic arthritis of the knee joint requires prompt diagnosis and treatment for optimal outcomes. Pyomyositis with abscess formation is uncommon but may present with similar symptoms in the vicinity of a joint. OBJECTIVE: This report describes two cases of medial thigh abscess initially diagnosed and treated as septic arthritis, and highlights the need to make an accurate diagnosis. CASE REPORT: Two patients presenting with knee pain secondary to pyomyositis and abscess formation in the medial thigh were investigated with aspiration and treated subsequently with knee surgery, resulting in contamination of the knee joint in one case and delayed diagnosis with significant morbidity in both. CONCLUSION: Failure to identify a soft tissue infection may lead to delayed diagnosis, misdirected treatment, and contamination of a normal joint. Diagnosis is best confirmed with thorough physical examination and specific imaging where available.

Propeller and jet-ski injuries during Christmas and New Year in Western Australia.

This is the first published case series of patients with injuries from watercraft propellers and jet skis. Five patients presented to the level-one trauma centre of Western Australia with such injuries over 10 days during the 2010-2011 Christmas holidays; all required surgery, and all but one sustained multiple, severe injuries.

Reimplantation of a completely extruded talus 8 days following injury: a case report.

We present the case of a 28-year-old female with 45 months follow-up after reimplantation of a completely extruded talus 8 days following the injury. The extruded talus was recovered at the site of the motor vehicle accident, where it had been embedded in the wreckage and subsequently transported to hospital 3 hours later. Thereafter, the talus was washed in an iodine solution for 5 hours and frozen for a period of 8 days at -80 °C, after which reimplantation surgery was undertaken. Throughout the extended follow-up period, no evidence of infection ever developed. Three years following her injury, the patient underwent fusion of the subtalar and talonavicular joints. At 45 months postoperative, imaging revealed avascular necrosis of the talar dome without substantial collapse. The patient progressed to the point where, at last follow-up, she was working in an administrative job and was able to bear full weight on the involved foot, despite development of mild pain on physical exertion. Despite the pain, moreover, she remained able to snow ski and to regularly walk 2 kilometers for cardiovascular fitness. We believe this case demonstrates that, in the apparent absence of deep infection, the development of avascular necrosis need not necessarily lead to a poor clinical outcome. Furthermore, this case showed that even after a period of 8 days in the freezer, and following antiseptic cleansing, the extruded talus could be reimplanted with a reasonable degree of clinical success.

Open total talus dislocation: clinical and functional outcomes: a case series.

BACKGROUND: This case series reviews open total talar dislocations, the subsequent development of infection and avascular necrosis of the talar dome, and the clinical and functional outcomes associated with this injury. Open total talar dislocation is a relatively rare but debilitating injury. Techniques for managing such injuries include reimplantation of an extruded talus, open reduction internal fixation, and fusion (immediate or delayed). METHODS: An operating theater database search from 2002 to 2007 was conducted to identify cases of open total talar dislocations at a major trauma center in Western Australia. Forty-one cases were initially identified, and from these, a total of eight cases were selected, which represented open dislocations of the talus. Parameters measured include postinjury development of infection and avascular necrosis, and clinical and functional outcome measurements. RESULTS: Four of the eight patients achieved an overall good outcome, two had a fair outcome, one patient had a poor outcome, and one patient was lost to follow-up after 4 months. Five of the patients developed avascular necrosis, and two patients developed postoperative infections (one joint infection, one superficial infection around a K-wire site). CONCLUSIONS: Postinjury joint infection is the single most significant factor associated with poor clinical and functional outcome of open total talar dislocation. The impact of avascular necrosis on functional outcome cannot be fully demonstrated nor has its development with such injuries been proven inevitable.

Osteopetrosis--a challenge for the orthopaedic surgeon.

Osteopetrosis (OP) is a rare heterogeneous group of inherited skeletal dysplasias characterised by osteoclast dysfunction, impaired bone resorption and poor bone remodelling. Three groups can be categorised on the basis of clinical findings. These include neurological symptoms, haematological abnormalities and renal tubular acidosis in the first group. Increased bone density, osteomyelitis and frequent fractures are the clinical findings in the second group, and the third group have normal life expectancy but may develop cranial nerve compression and osteomyelitis. Fractures in patients with OP are common and require appropriate pre-, peri- and postoperative management. The long bones are most frequently affected, fractures of the femoral neck and proximal (upper third) shaft being particularly common. This case report proposes possible operative fracture treatment in a patient with OP and highlights the potential perioperative pitfalls in this rare surgical population.

From brain to bone: evidence for the release of osteogenic humoral factors after traumatic brain injury.

PRIMARY OBJECTIVE: The aetiology of the increased osteogenesis associated with severe traumatic brain injury (TBI) remains incompletely understood. The purpose of this article is to review the available evidence regarding the release of osteogenic humoral factors after TBI. RESEARCH DESIGN: This study is presented in the form of a literature review. METHODS AND PROCEDURES: To obtain suitable references, Pubmed was searched using keywords 'heterotopic ossification', 'brain', 'trauma', 'injury', 'aetiology'. MAIN OUTCOMES AND RESULTS: Evidence from both clinical and laboratory investigations points to centrally released osteogenic factor(s) that enter the systemic circulation following TBI. CONCLUSIONS: Further investigation into the identification of these putative osteogenic factor(s), using human tissues and new techniques, is indicated to better understand this phenomenon.

Earthquakes and trauma: review of triage and injury-specific, immediate care.

Earthquakes present a major threat to mankind. Increasing knowledge about geophysical interactions, progressing architectural technology, and improved disaster management algorithms have rendered modern populations less susceptible to earthquakes. Nevertheless, the mass casualties resulting from earthquakes in Great Kanto (Japan), Ancash (Peru), Tangshan (China), Guatemala, Armenia, and Izmit (Turkey) or the recent earthquakes in Bhuj (India), Bam (Iran), Sumatra (Indonesia) and Kashmir (Pakistan) indicate the devastating effect earthquakes can have on both individual and population health. Appropriate preparation and implementation of crisis management algorithms are of utmost importance to ensure a large-scale medical-aid response is readily available following a devastating event. In particular, efficient triage is vital to optimize the use of limited medical resources and to effectively mobilize these resources so as to maximize patient salvage. However, the main priorities of disaster rescue teams are the rescue and provision of emergency care for physical trauma. Furthermore, the establishment of transport evacuation corridors, a feature often neglected, is essential in order to provide the casualties with a chance for survival. The optimal management of victims under such settings is discussed, addressing injuries of the body and psyche by means of simple diagnostic and therapeutic procedures globally applicable and available.

Self-evaluation of present clinical skills by medical students in the years 3 to 6 - a pilot study in four European countries.

Background: Clinical training concepts of medical students differ in the various European countries. The goal of this paper is to study the differences at the beginning of medical practice in specific clinical skills on an international level. Methods: The data were collected by a publically accessible online questionnaire online from February to June 2010. The participants in the study were recruited through the official letter sent by deaneries and student organisations. Two thousand nine hundred and seven medical students participated in the online survey. From study years 1 to 6, 2406 valid data records (67.3 percent female; 32.7 percent male) from four different European countries were sent. The skills in the questionnaire included patient consultation and anamnesis, physical examination, auscultation, gypsum and bandage dressing, suture techniques, venepuncture, and laying of indwelling catheters. Results: One thousand six hundred and twenty-nine data records of medical students in their training years 3 to 6 were assessed. The average age of the students was 24.7 years. On a scale from 1 to 10, the average satisfaction of the students with their medical faculty was 6.47 (±2.07); the assessment of the preparation for the clinical activities was 4.72 (±2.13). By comparison, British students indicated most satisfaction with their training (6.70±1.85). With respect to the clinical skills, the students interviewed felt safest in patient consultation and anamnesis (7.63±2.13) followed by blood sampling (7.46±2.29). The topics of surgical suturing techniques (4.40±2.81) and the gypsum and bandaging techniques (2.63±2.23) were taught worst subjectively. Discussion: The training of medical students in basic clinical skills is an essential part of the studies. This study was able to demonstrate that the subjective trust of medical students in their personal skills positively correlated with the satisfaction with their own university. The results pointed out that future curricula of universities could profit from an increased focus on clinical skills.

Osteoinductive effect of cerebrospinal fluid from brain-injured patients.

Patients with traumatic brain injury (TBI) are predisposed to heterotopic ossification, which is believed to be due to osteoinductive factors released at the site of the brain injury. To date, little is known about the presence of such factors in human cerebrospinal fluid (CSF). This study investigated whether CSF of TBI patients is osteoinductive. In addition, known osteoinductive factors--such as bone morphogenetic protein (BMP)-2, BMP-4, and BMP-7, and S100B--were measured in CSF. Eighty-four consecutive patients were classified according to brain pathology: TBI (n = 11), non-traumatic brain pathology (NTBP) (n = 26), and no brain pathology (control group) (n = 47). The osteoinductive effect of CSF was measured repeatedly in proliferation assays using a fetal human osteoblast cell line. The mean proliferation rate (normalized to the internal negative control) of the TBI, NTBP, and control groups was 138.2% (SD 13.1), 110.0% (SD 22.1), and 118.8% (SD 16.9), respectively. The potentially confounding effect of age was investigated further by restricting the selection of patients for analysis to that of the oldest patient in the TBI group and use of multiple regression analysis. After implementation of both, it was shown that age is highly unlikely to account for the higher rates of proliferation observed among the TBI patients in this study. Of note, the TBI group had a significantly higher mean proliferation rate than the NTBP (p = 0.001) and the control group (p = 0.006). S100B and BMP-2, -4, or -7 concentrations were measured using enzyme-linked immunosorbent assay (ELISA). There was no correlation between proliferation rates and S100B (r = 0.023). Only three of 36 CSF samples had measurable levels of BMP-2 and -7, and none had detectable concentrations of BMP-4. Consequently, it is unlikely that S100B or BMP-2, -4, or -7 are the putative osteoinductive factors. The results indicate that CSF from TBI patients has an osteoinductive effect in vitro. However, the osteoinductive factor has still to be characterized.

Bone morphogenetic proteins in clinical applications.

The role of bone morphogenetic proteins (BMPs) in bone healing has been shown in numerous animal models. To date, at least 20 BMPs have been identified, some of which have been shown in vitro to stimulate the process of stem cell differentiation into osteoblasts in human and animal models. Having realized the osteoinductive properties of BMPs and having identified their genetic sequences, recombinant gene technology has been used to produce BMPs for clinical application - most commonly, as alternatives or adjuncts in the treatment of cases in which fracture healing is compromised. BMP-2 and BMP-7 are approved for clinical use in open fractures of long bones, non-unions and spinal fusion. However, despite significant evidence of their potential benefit to bone repair and regeneration in animal and preclinical studies, there is, to date, a dearth of convincing clinical trials. The purpose of this paper is to give a brief overview of BMPs and to critically review the clinical data currently available on the use of BMP-2 and BMP-7 in fracture healing.

A complete tear of the pectoralis major muscle from a seat belt injury.

Rupture of the pectoralis major muscle is a rare injury that can result in both functional and cosmetic deficiency, with fewer than 150 cases reported in the literature. To date, the injury has been reported exclusively in men and is most common among weight lifters and high-performance athletes. The treatment of partial rupture is conservative, whereas in cases of total rupture surgical repair is advocated, particularly in young active patients. Here, we report the case of a complete proximal tear of the pectoralis major muscle from a seat belt injury sustained in a motor vehicle accident. To the best of our knowledge, this is the first time such a case has been reported in the literature.

Postural tremor induced by paint sniffing.

Volatile substance abuse is the intentional inhalation of volatile solvents, aerosols, gases or nitrates for the purpose of intoxication. This practice is more common among young people, due, in part, to the low cost and ready availability of these inhalants. In this report, we present the case of a 22-year-old male with a seven-year history of chronic paint sniffing. The patient presented with vigorous postural and kinetic tremor in both hands. A neurological examination revealed a bilateral, non-fatiguing geotropic positional nystagmus and a mild ataxia together with dysdiadochokinesis. He also had a mild chronic encephalopathy. Following treatment with clonazepam, the tremors subsided, but were not completely controlled.

Detailed assessment of benefits and risks of retrievable inferior vena cava filters on patients with complicated injuries: the da Vinci multicentre randomised controlled trial study protocol.

INTRODUCTION: Retrievable inferior vena cava (IVC) filters have been increasingly used in patients with major trauma who have contraindications to anticoagulant prophylaxis as a primary prophylactic measure against venous thromboembolism (VTE). The benefits, risks and cost-effectiveness of such strategy are uncertain. METHODS AND ANALYSIS: Patients with major trauma, defined by an estimated Injury Severity Score >15, who have contraindications to anticoagulant VTE prophylaxis within 72 hours of hospitalisation to the study centre will be eligible for this randomised multicentre controlled trial. After obtaining consent from patients, or the persons responsible for the patients, study patients are randomly allocated to either control or IVC filter, within 72 hours of trauma admission, in a 1:1 ratio by permuted blocks stratified by study centre. The primary outcomes are (1) the composite endpoint of (A) pulmonary embolism (PE) as demonstrated by CT pulmonary angiography, high probability ventilation/perfusion scan, transoesophageal echocardiography (by showing clots within pulmonary arterial trunk), pulmonary angiography or postmortem examination during the same hospitalisation or 90-day after trauma whichever is earlier and (B) hospital mortality; and (2) the total cost of treatment including the costs of an IVC filter, total number of CT and ultrasound scans required, length of intensive care unit and hospital stay, procedures and drugs required to treat PE or complications related to the IVC filters. The study started in June 2015 and the final enrolment target is 240 patients. No interim analysis is planned; incidence of fatal PE is used as safety stopping rule for the trial. ETHICS AND DISSEMINATION: Ethics approval was obtained in all four participating centres in Australia. Results of the main trial and each of the secondary endpoints will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ACTRN12614000963628; Pre-results.