Inter-rater reliability in the radiological classification of renal injuries.

INTRODUCTION: Although many radiologists invoke the surgical classification of renal injury proposed by the American Association for Surgery in Trauma (AAST), there has been only limited work on the role of the AAST system as an imaging stratification. The aim was to determine the inter-rater reliability (IRR) amongst radiologists and urologists using the AAST system. METHODS: A 1-year retrospective study of consecutive patients with computed tomography (CT) evidence of renal trauma managed at a Level 1 trauma center. Three radiologists and three urologists independently stratified the presentation CT findings according to the AAST renal trauma classification. Agreement between independent raters and mutually exclusive groups was determined utilizing weighted kappa coefficients. RESULTS: One hundred and one patients were included. Individual inter-observer agreements ranged from 54/101 (53.4%) to 62/101 (61.4%), with corresponding weighted kappa values from 0.61 to 0.69, constituting substantial agreement. Urologists achieved intra-disciplinary agreement in 49 cases (48.5%) and radiologists in 36 cases (35.6%). Six-reader agreement was achieved in 24 cases (23.7%). The AAST grade I injuries had the highest level of agreement, overall. CONCLUSION: The finding of substantial IRR amongst radiologists and urologists utilizing the AAST system supports continued use of the broad parameters of the AAST system, with some modification in specific categories with lower agreement.

Homogeneity of Different Functional mRNA Indicators for Wound Age Estimation.

OBJECTIVES: To explore the homogeneity level of four different functional mRNA （PUM2, TAB2, Cx45 and CHRNA1） expressions in rats with skeletal muscle contusion. METHODS: The relative expressions of PUM2, TAB2, Cx45 and CHRNA1 mRNAs were detected by quantitative real-time reverse transcription-polymerase chain reaction （RT-qPCR）. The coefficient of variation （CV） of the relative expressions for different individuals in each injury group was calculated. The extreme value of CV, cumulative variability, and CVCV were compared. RESULTS: A high CV of PUM2 and TAB2 mRNAs appeared on several different time points. However, the CV of Cx45 and CHRNA1 mRNAs was relatively low. The cumulative variability from high to low was PUM2, CHRNA1, TAB2 and Cx45 mRNAs. The relative expression of PUM2 mRNA was significantly higher than that of TAB2, Cx45 and CHRNA1 mRNAs （ P<0.05）. There was no statistical significance （P>0.05） in the CVCV of the relative expression of TAB2, CHRNA1 and Cx45 mRNAs. CONCLUSIONS: As the mRNAs involving in biological process regulation, PUM2 and CHRNA1 mRNAs show a lowest individual homogeneity of the relative expression followed by TAB2 mRNA. As the mRNAs participating in the composition of cellular structure, Cx45 and CHRNA1 mRNAs show a high individual homogeneity of the relative expressions. The functional classification should be considered for the screening of the mRNA indicators used for wound age estimation.

The persistence of ligature marks: towards a new protocol for victims of abuse and torture.

One of the most frequently observed lesions in clinical forensic practice concerns the patterned abrasion on skin due to constriction by various types of ligature. Detection of ligature marks and their patterns may be fundamental for reconstructing events and supporting testimony of an aggression, sexual abuse, or maltreatment. But very little actually exists in literature concerning their detectability and how long they last. This study aims at evaluating the time of persistence and detectability of skin signs left by different types of ligatures in living persons: on the arms of three volunteers, eight different ligatures were applied; 123 tests were performed, with time of contact ranging between 1 min and 2 h and 45 min. In addition, the persistence of the shape and pattern of the ligature was evaluated 15, 30, and 60 min after a 5- and 15-min compression. Polyvinyl siloxane, applied by a gun dispenser, was used to perform a cast of the skin mark. The results show that the pattern was less distinguishable with the decrease of time of contact, going from 75 % after 10 and 15 min of contact, to 45.8 % after 1 min. Above 15 min, the specific pattern was always recognizable. In addition, a progressive decrease of the detectability of the pattern with time, respectively, up to 12.5 and 37.5 % in 5- and 15-min tests was observed. This study provides useful results for the assessment of patterned injuries in forensic pathology and clinical forensic medicine, both on dead and living persons: in addition, the use of silicone casts seems to be a reliable and cheap method for easily recording and preserving the morphological profile of skin lesions.

Terminology and classification of muscle injuries in sport: the Munich consensus statement.

OBJECTIVE: To provide a clear terminology and classification of muscle injuries in order to facilitate effective communication among medical practitioners and development of systematic treatment strategies. METHODS: Thirty native English-speaking scientists and team doctors of national and first division professional sports teams were asked to complete a questionnaire on muscle injuries to evaluate the currently used terminology of athletic muscle injury. In addition, a consensus meeting of international sports medicine experts was established to develop practical and scientific definitions of muscle injuries as well as a new and comprehensive classification system. RESULTS: The response rate of the survey was 63%. The responses confirmed the marked variability in the use of the terminology relating to muscle injury, with the most obvious inconsistencies for the term strain. In the consensus meeting, practical and systematic terms were defined and established. In addition, a new comprehensive classification system was developed, which differentiates between four types: functional muscle disorders (type 1: overexertion-related and type 2: neuromuscular muscle disorders) describing disorders without macroscopic evidence of fibre tear and structural muscle injuries (type 3: partial tears and type 4: (sub)total tears/tendinous avulsions) with macroscopic evidence of fibre tear, that is, structural damage. Subclassifications are presented for each type. CONCLUSIONS: A consistent English terminology as well as a comprehensive classification system for athletic muscle injuries which is proven in the daily practice are presented. This will help to improve clarity of communication for diagnostic and therapeutic purposes and can serve as the basis for future comparative studies to address the continued lack of systematic information on muscle injuries in the literature. WHAT ARE THE NEW THINGS: Consensus definitions of the terminology which is used in the field of muscle injuries as well as a new comprehensive classification system which clearly defines types of athletic muscle injuries. LEVEL OF EVIDENCE: Expert opinion, Level V.

[The magnitude and the structure of ENT sanitary losses in modern local armed conflicts].

The objective of the present study was to estimate the magnitude and the structure of ENT losses in modern local armed conflicts. We have considered characteristics of battle injuries inflicted in modern wars based on the materials collected during the armed conflicts in the Caucasus during 1999-2002 and stored in the Military Medical Museum (MMM) of the Russian Defense Ministry. A total of 5608 case records of the surgical treatment of mechanical injuries were analysed including 4002 gunshot wounds and 1606 closed injuries (contusions). ENT and neck wounds were the main and concomitant injuries in 102 and 107 subjects respectively who accounted for 2.5% and 2.7% of all the wounded servicemen. Fifty five (3.93%) and 21 (1.3%) of the 1606 subjects had a closed ENT and neck wound as the leading and concomitant injury, respectively. According to the materials collected in MMM, ENT contusion was the main injury in 111 (25%) of the 410 servicemen who had received contused wounds in the armed conflict of 1999-2002.

Pulmonary contusions in patients with rib fractures: The need to better classify a common injury.

BACKGROUND: Pulmonary contusions are common injuries. Computed tomography reveals vast contused lung volume spectrum, yet pulmonary contusions are defined dichotomously (unilateral vs bilateral). We assessed whether there is stepwise increased risk of pulmonary complications among patients without, with unilateral, and with bilateral pulmonary contusion. METHODS: We identified adults admitted with rib fractures using the largest US inpatient database. After propensity-score-matching patients without vs with unilateral vs bilateral pulmonary contusions and adjusting for residual confounders, we compared risk for pneumonia, ventilator-associated pneumonia (VAP), respiratory failure, intubation, and mortality. RESULTS: Among 148,140 encounters of adults with multiple rib fractures, 19% had concomitant pulmonary contusions. Matched patients with pulmonary contusions had increased risk of pneumonia 19% [95%CI:16-33%], respiratory failure 40% [95%CI: 31-50%], and intubation 46% [95%CI: 33-61%]. Delineation showed bilateral contusions, not unilateral contusions, attributed to increased risk of complications. CONCLUSIONS: There is likely a correlation between contused lung volume and risk of pulmonary complications; dichotomously classifying pulmonary contusions is insufficient. Better understanding this correlation requires establishing the clinically significant contusion volume and a correspondingly refined classification system.

[Animal model of grading skeletal muscle contusion due to blunt impact in rats].

OBJECTIVE: To establish a new animal model of grading skeletal muscle contusions that could be controllable and repetitive. METHODS: The rats' gastrocnemius was injured by a new weight-dropping device designed. The force acting on gastrocnemius with a comparatively constant duration and inducing elastic deformation of the gastrocnemius was expressed with velocity (v) and deformation (DF). Instant velocity was changed to create gastrocnemius contusions. Pathological changes of gastrocnemius were graded by the gross and histological examinations of 39 rats. RESULTS: At low level of impact (v: 2 m/s, DF: 5.5 mm), mild injuries were detected in epimysium and superficial layer of gastrocnemius. At moderate level of impact (v: 2.5 m/s, DF: 6.5 mm), the injuries were observed in epimysium and whole gastrocnemius. At high level of impact (v: 3 m/s, DF: 7.5 mm), severe injuries were seen deeper to soleus with more extensive skeletal muscle damage. CONCLUSION: Grading of skeletal muscle blunt force contusion is created by parameter of velocity and muscle deformation. The model could be used for further research on skeletal muscle contusions.

Ultrasonography and return to play of the different clinical grading of quadriceps contusions: a case series.

Prognostication of quadriceps contusion is based on the patient's active knee flexion after the injury. Unlike ultrasonography, clinical grading does not define the extent of soft tissue injury and may provide inaccurate time for return to play. The purposes of this report are to describe the ultrasound findings of the different clinical grading of quadriceps contusion and document the return to play of each case. Seven patients were evaluated in this series. Results showed discrepancies in the disability time between clinical grading and ultrasound findings. Clinical grading did not consistently estimate the return to play as described in previously published literature. Contusions with hyperechoic lesions had earlier return to play compared to patients with hypoechoic findings. Contusions with hypoechoic lesions might require aggressive monitoring and therapy to decrease disability time and avoid complications such as myositis ossificans.

Classification of myocardial contusion and blunt cardiac trauma.

Myocardial injury caused by blunt chest trauma has been recognized with increased frequency over the past 2 decades. Increased awareness by physicians and the increased use of various clinical and laboratory diagnostic modalities have contributed to this recognition. Injuries range from inconsequential to catastrophic and can affect any or all areas of the heart: pericardium, myocardium, coronary arteries and veins, chordae, papillary muscles, valves, and great vessels. In addition to the medical importance of the diagnosis, substantial forensic implications have been known to arise. It is important to assess and classify properly the extent of the trauma and its prognostication as to the possibility of residual sequelae. A proposed classification is presented that has both medical and legal application. The uses of stages 0 (suspect), I (mild), II (moderate), III (severe), and IV (catastrophic) are illustrated in detail.

Overlooked but critical: traumatic brain injury as a consequence of interpersonal violence.

Despite evidence that more than 80% of female victims of intimate partner violence, seen for medical treatment of violence-related injuries, have sustained facial injuries, traumatic brain injury is often overlooked as a consequence of those injuries. This article reviews the scant literature available and examines research on equivalent injuries sustained by athletes. Practical domains of symptoms are described, as is a review of literature pertinent to culturally relevant rehabilitation for victims sustaining traumatic brain injuries.

Injury toll following the 1997 Maccabiah Games bridge collapse: implications of major disasters for sports medicine teams.

A major disaster was encountered at the 1997 Maccabiah Games in Israel. As the Australian team was about to enter the main stadium for the opening ceremony, a pedestrian bridge they were crossing collapsed, killing 4 athletes and injuring many others. The aim of this paper is to establish the rates, types and anatomical locations of musculoskeletal injuries incurred by members of the Australian Maccabiah Games team, with particular reference to the impact of the bridge collapse. In total, the 410 members of the team (360 athletes and coaches and 50 team officials) reported 166 injuries from their participation in sport and 30 musculoskeletal injuries associated with the collapse of the bridge. The most common sports-related injuries were sprains and strains to the hip/thigh, lumbar spine and ankle/foot regions, while the bridge collapse resulted in, most commonly, sprains and contusions to the hip/thigh, knee, lower leg and ankle/foot regions. In addition, team members incurred many medical and psychological conditions. This paper makes several recommendations for sports medicine staff based on the experience of this significant sport disaster.

Urogenital trauma: imaging upper GU trauma.

OBJECTIVES: This article will define the current controversies and concepts in the classification, clinical presentation, imaging approaches and management of upper urinary tract trauma. MATERIALS AND METHODS, RESULTS: This review will include the experience of the authors in the field of renal trauma over a 32-year period. Current thinking accepts the view that significant renal trauma is generally present when there is gross hematuria, signs of shock, or other clinical signs of severe injury. In most patients, suspected renal injury will be evaluated as a part of the overall assessment of the patient for suspected intraperitoneal injury. The authors will stress some exceptions to the rule. CONCLUSIONS: Most trauma experts now advocate conservative management, unless the patient is unstable or a renal vascular thrombosis or avulsion is suspected. Similarly, penetrating trauma to the kidney in and of itself no longer requires mandatory surgery. In the United States, computed tomography (CT), especially spiral CT, is considered the best diagnostic study, if available. Intravenous pyelography (IVP) is adequate if this is the only imaging modality available and if no concomitant injuries to the abdominal structure are suspected. Ultrasound, although strongly advocated in some countries, can lead to some significant false negatives. The diagnosis and management of unusual problems such as the traumatic AV fistula, the patient with an absent kidney or injury to the congenitally abnormal kidney, the serendipitous renal tumor in a patient with trauma, or serious bleeding after an apparent minor injury (i.e., spontaneous hemorrhage) are also reviewed in this article.

Mechanisms of foot and ankle injuries in soccer.

BACKGROUND: Although player-to-player contact is a risk factor in the majority of soccer injuries, the mechanisms leading to these injuries have not been analyzed. PURPOSE: To assess the relationships between foot/ankle injuries and foul play and tackle type, and to identify the position of the foot and ankle at the time of injury. STUDY DESIGN: Prospective cohort study. METHODS: Team physicians prospectively recorded each injury in four world soccer competitions, and the videotaped incident leading to the injury was retrospectively analyzed. RESULTS: Of 76 foot and ankle injuries (52 contusions, 20 sprains, 4 fractures), direct contact occurred between players in 72. Significantly more injuries involved a tackle from the side and a lateral or medial tackle force. The injured limb was weightbearing in 41 and nonweightbearing in 35 of the incidents. Significantly more injuries resulted in time lost from soccer when the limb was weightbearing. The most common foot and ankle positions at the time of injury were pronated/neutral in the sagittal plane for weightbearing limbs, and plantar flexed/neutral in the coronal plane for nonweightbearing limbs. The most common foot and ankle rotations at the time of injury were external (23) and eversion (28). CONCLUSIONS: The majority of injuries were caused by tackles involving lateral or medial forces that created a corresponding eversion or inversion rotation of the foot or ankle. The weightbearing status of the injured limb was a significant risk factor.

"Bone bruises" of the knee: a review.

Magnetic resonance (MR) imaging is often used to assess the location and degree of ligamentous or cartilage damage in the knee following acute traumatic injury. Occasionally, these studies will also document abnormal signal within the adjacent subchondral bone. These "bone bruises" are considered incidental findings by some, while others suggest possible clinical significance. The purpose of this paper is to review the literature and consolidate current thinking on the radiographic characteristics, classification, histopathology and natural history of bone bruises.

[Kidney injuries in children. Apropos of 65 cases]. / Le traumatisme du rein chez l'enfant. A propos de 65 cas.

The authors report a retrospective series of 65 cases of renal contusion in children affecting 45 boys and 20 girls between the ages of 10 months and 15 years (mean age: 10 years). The causes of renal trauma were dominated by household accidents (53.8%) and road accidents (33.8%). Associated extrarenal lesions were observed in 21.5% of cases. 55.4% of the 65 contusions were considered to be benign, 27.7% of moderate severity and 16.9% were serious. The blunt trauma affected a pathological kidney in 19 cases. Exclusively medical treatment was recommended in 31 patients, while surgery was indicated in the other 34 patients. Apart from one death in a context of multiple trauma, few complications were observed in the group of operated patients and consisted of 4 cases of urinary fistula and 4 cases of infection, all of which resolved.

[Laser fixation of the crystalline lens in its contused subluxation]. / Lazernaia fiksatsiia khrustalika pri ego kontuzionnom podvyvikhe.

The authors report a nontraditional effective method of treating patients with contusion semiluxation of the lens. It consists in fixation of the lens at the expense of formation of posterior synechiae because of an inflammatory process induced by laser exposure of pigmented epithelium of the iris and ciliary body. Complex clinical evaluation of the organ of vision in 132 patients, including the remote period (after 3-10 years), showed good stabilization of visual functions and of the geometrical position of the incompletely dislocated lens after its laser fixation.

The use of photographs to record variation in bruising response in humans.

There is considerable value in developing tools capable of accurately and reliably determining when bruises were inflicted in humans. Previous work has focused on the visual changes observed in a bruise as the injury develops and heals. However, due to variables such as how and where on the body the bruise was inflicted, differing tissue compositions at the injured skin site between individuals and inter- and intra-observer variation; a technique sufficiently robust for use in a clinical or medicolegal setting has not yet been identified. In this study we present a series of photographs taken under controlled conditions illustrating standardised bruises induced on participants using a weight dropping mechanism. We show that variation in the appearance of bruises over time across individuals is large and, although photography may be a suitable technique for the recording of injuries, it is not sufficiently reliable for determining the age of a bruise.

Characteristics of bruises in carcasses of cows sourced from farms or from livestock markets.

Bruises in cattle develop after the application of force, and they provide evidence for sub-optimal animal welfare. The aim of this study was to describe the gross characteristics of bruises in cows arriving at the slaughterhouse directly from farms or through the livestock market. The number of bruises and their distribution on the carcass as well as their severity, shape, size and colour were assessed post mortem in a slaughterhouse in Chile. A total of 258 cow carcasses were evaluated, and a total of 846 bruises were found on 243 of the carcasses. Cows that had passed through a livestock market (M-carcasses) had in total 563 bruises (mean 3.8 bruises/carcass, s.d. 2.0), whereas cows transported directly from farms (F-carcasses) had in total 283 bruises (mean 2.5 bruises/carcass, s.d. 1.8). The backs of F-carcasses had twice as many bruises as M-carcasses (32.9% and 16.2%, respectively), whereas bruises in the rib area were more frequently observed in M-carcasses (13.1%) than in F-carcasses (8.1%). Superficial bruises (grade 1) were the most frequently observed (66.2% of all bruises). Regarding the size of the bruises, 64 (7.6%) were classified as large, 271 (32.0%) as medium and 511 (60.4%) as small. Irregularly shaped bruises were the most frequent (91.1%, n = 771), followed by linear (3.8%, n = 32), circular (3.1%, n = 26) and tramline-shaped bruises (1.9%, n = 16). The latter were noticed only in M-carcasses, which may indicate that these animals were beaten more frequently with sticks or other rod-shaped objects. Fresh, bright red-coloured bruises were found more frequently on all the animals (69.5% from farms and 70.5% from market) compared with bluish (29.7% and 29.3%, respectively) and yellow bruises (0.4% and 0.2%, respectively). The method of selling was significantly associated with the number of bruises on the carcass (P < 0.001) and the anatomical site (P < 0.05), but not with the severity, shape and colour of the bruises. Increased fat coverage reduced the severity of bruises (P < 0.001). This study shows that, in Chile, market animals have more bruises than those sourced directly from farms, and their distribution is different. More information about the causes of infliction may help reduce bruises and it may also improve their welfare. Further studies are required to elucidate whether the causes of the high bruising in the case of animals passing through markets are related only to extra handling (repeated loading, unloading, transportation, eventual mixing) or to the way of handling by personnel and inadequate design.

Selective validation of the WHO Bleeding Scale in patients with chronic immune thrombocytopenia.

OBJECTIVE: To evaluate the World Health Organization's (WHO) Bleeding Scale in two studies of eltrombopag in adults with chronic immune thrombocytopenia (ITP). RESEARCH DESIGN AND METHODS: Validated scales assessing bleeding in adults with ITP are lacking. Data from two long-term, phase 3 clinical trials (RAISE: NCT00370331; EXTEND: NCT00351468) that assessed eltrombopag in adults with chronic ITP were analyzed to evaluate the performance of the WHO Bleeding Scale. RESULTS: In RAISE, effect size (0.71), standardized response (0.75), and responsiveness statistics (0.57) were moderate for bleeding and bruising assessments. In EXTEND, effect size (0.62) and responsiveness statistics (0.59) were moderate; the standardized response statistic was 0.487. Intraclass correlation for test-retest reliability was 0.75 in RAISE and 0.71 in EXTEND. A positive correlation was observed between the WHO Bleeding Scale and the ITP Bleeding Scale. Bleeding scores and quality-of-life measures were inversely correlated (p < 0.05 for all). Minimal important differences for the WHO Bleeding Scale were 0.33-0.40 at baseline and last on-treatment assessment in both studies. LIMITATIONS: The majority of bleeding in these studies was mild to moderate, so this analysis cannot provide strong evidence of the validity of the WHO Bleeding Scale in patients with more severe bleeding. Potential limitations to the WHO Bleeding Scale itself include dependence on clinician interpretation of patient recall, inability to distinguish among bleeding events occurring at different anatomical sites, and an inherent assumption of linear increases in severity of bleeding across the response categories. CONCLUSIONS: These findings suggest potential usefulness of the WHO Bleeding Scale in adult patients with chronic ITP for standardizing grading of bleeding across research studies and in clinical practice.