Quantitative assessment of intraneural vascular alterations in peripheral nerve trauma using high-resolution neurosonography: technical note.

High-resolution neurosonography (HRNS) has become a major imaging modality in assessment of peripheral nerve trauma in the recent years. However, the vascular changes of traumatic lesions have not been quantitatively assessed in HRNS. Here, we describe the vascular-ratio, a novel HRNS-based quantitative parameter for the assessment of intraneural vascular alterations in patients with nerve lesions. N = 9 patients suffering from peripheral nerve trauma were examined clinically, electrophysiologically and with HRNS (SonoSite Exporte, Fuji). Image analyses using Fiji included determination of the established fascicular ratio (FR), the cross-section ratio (CSR), and as an extension, the calculation of a vascular ratio (VR) of the healthy versus damaged nerve and a muscle perfusion ratio (MPR) in comparison to a healthy control group. The mean VR in the healthy part of the affected nerve (14.14%) differed significantly (p < 0.0001) from the damaged part (VR of 43.26%). This coincides with significant differences in the FR and CSR calculated for the damaged part versus the healthy part and the controls. In comparison, there was no difference between VRs determined for the healthy part of the affected nerve and the healthy controls (14.14% / 17.72%). However, the MPR of denervated muscles was significantly decreased compared to the non-affected contralateral controls. VR and MPR serve as additional tools in assessing peripheral nerve trauma. Image analysis and calculation are feasible. Combined with the more morphologic FR and CSR, the VR and MPR provide a more detailed insight into alterations accompanying nerve trauma.

Long-term medical and productivity costs of severe trauma: Results from a prospective cohort study.

BACKGROUND: Through improvements in trauma care there has been a decline in injury mortality, as more people survive severe trauma. Patients who survive severe trauma are at risk of long-term disabilities which may place a high economic burden on society. The purpose of this study was to estimate the health care and productivity costs of severe trauma patients up to 24 months after sustaining the injury. Furthermore, we investigated the impact of injury severity level on health care utilization and costs and determined predictors for health care and productivity costs. METHODS: This prospective cohort study included adult trauma patients with severe injury (ISS≥16). Data on in-hospital health care use, 24-month post-hospital health care use and productivity loss were obtained from hospital registry data and collected with the iMTA Medical Consumption and Productivity Cost Questionnaire. The questionnaires were completed 1 week and 1, 3, 6, 12 and 24 months after injury. Log-linked gamma generalized linear models were used to investigate the drivers of health care and productivity costs. RESULTS: In total, 174 severe injury patients were included in this study. The median age of participants was 55 years and the majority were male (66.1%). The mean hospital stay was 14.2 (SD = 13.5) days. Patients with paid employment returned to work 21 weeks after injury. In total, the mean costs per patient were €24,760 with in-hospital costs of €11,930, post-hospital costs of €7,770 and productivity costs of €8,800. Having an ISS ≥25 and lower health status were predictors of high health care costs and male sex was associated with higher productivity costs. CONCLUSIONS: Both health care and productivity costs increased with injury severity, although large differences were observed between patients. It is important for decision-makers to consider not only in-hospital health care utilization but also the long-term consequences and associated costs related to rehabilitation and productivity loss.

Wound Size Imaging: Ready for Smart Assessment and Monitoring.

Significance: We introduce and evaluate emerging devices and modalities for wound size imaging and also promising image processing tools for smart wound assessment and monitoring. Recent Advances: Some commercial devices are available for optical wound assessment but with limited possibilities compared to the power of multimodal imaging. With new low-cost devices and machine learning, wound assessment has become more robust and accurate. Wound size imaging not only provides area and volume but also the proportion of each tissue on the wound bed. Near-infrared and thermal spectral bands also enhance the classical visual assessment. Critical Issues: The ability to embed advanced imaging technology in portable devices such as smartphones and tablets with tissue analysis software tools will significantly improve wound care. As wound care and measurement are performed by nurses, the equipment needs to remain user-friendly, enable quick measurements, provide advanced monitoring, and be connected to the patient data management system. Future Directions: Combining several image modalities and machine learning, optical wound assessment will be smart enough to enable real wound monitoring, to provide clinicians with relevant indications to adapt the treatments and to improve healing rates and speed. Sharing the wound care histories of a number of patients on databases and through telemedicine practice could induce a better knowledge of the healing process and thus a better efficiency when the recorded clinical experience has been converted into knowledge through deep learning.

Development of prehospital assessment findings associated with massive transfusion.

BACKGROUND: Massive transfusion is frequently a component of the resuscitation of combat casualties. Because blood supplies may be limited, activation of a walking blood bank and mobilization of necessary resources must occur in a timely fashion. The development of a risk prediction model to guide clinicians for early transfusion in the prehospital setting was sought. STUDY DESIGN AND METHODS: This is a secondary analysis of a previously described data set from the Department of Defense Trauma Registry from January 2007 to August 2016 focusing on casualties undergoing massive transfusion. Serious injury was defined based on an Abbreviated Injury Scale score of 3 or greater by body region. The authors constructed multiple imputations of the model for risk prediction development. Efforts were made to internally validate the model. RESULTS: Within the data set, there were 15540 patients, of which 1238 (7.9%) underwent massive transfusion. In the body region injury scale model, explosive injuries (odds ratio [OR], 3.78), serious extremity injuries (OR, 6.59), and tachycardia >120/min (OR, 5.61) were most strongly associated with receiving a massive transfusion. In the simplified model, major amputations (OR, 17.02), tourniquet application (OR, 6.66), and tachycardia >120 beats/min (OR, 8.72) were associated with massive transfusion. Both models had area under the curve receiver operating characteristic values of greater than 0.9 for the model and bootstrap forest analysis. CONCLUSION: In the body region injury scale model, explosive mechanisms, serious extremity injuries, and tachycardia were most strongly associated with massive transfusion. In the simplified model, major amputations, tourniquet application, and tachycardia were most strongly associated.

Prognostic factors for medical and productivity costs, and return to work after trauma.

AIM: The aim of this study was to determine prognostic factors for medical and productivity costs, and return to work (RTW) during the first two years after trauma in a clinical trauma population. METHODS: This prospective multicentre observational study followed all adult trauma patients (≥18 years) admitted to a hospital in Noord-Brabant, the Netherlands from August 2015 through November 2016. Health care consumption, productivity loss and return to work were measured in questionnaires at 1 week, 1, 3, 6, 12 and 24 months after injury. Data was linked with hospital registries. Prognostic factors for medical costs and productivity costs were analysed with log-linked gamma generalized linear models. Prognostic factors for RTW were assessed with Cox proportional hazards model. The predictive ability of the models was assessed with McFadden R2 (explained variance) and c-statistics (discrimination). RESULTS: A total of 3785 trauma patients (39% of total study population) responded to at least one follow-up questionnaire. Mean medical costs per patient (€9,710) and mean productivity costs per patient (€9,000) varied widely. Prognostic factors for high medical costs were higher age, female gender, spine injury, lower extremity injury, severe head injury, high injury severity, comorbidities, and pre-injury health status. Productivity costs were highest in males, and in patients with spinal cord injury, high injury severity, longer length of stay at the hospital and patients admitted to the ICU. Prognostic factors for RTW were high educational level, male gender, low injury severity, shorter length of stay at the hospital and absence of comorbidity. CONCLUSIONS: Productivity costs and RTW should be considered when assessing the economic impact of injury in addition to medical costs. Prognostic factors may assist in identifying high cost groups with potentially modifiable factors for targeted preventive interventions, hence reducing costs and increasing RTW rates.

In Vitro, In Vivo, and In Silico Methods for Assessment of Muscle Size and Muscle Growth Regulation.

Trauma, burn injury, sepsis, and ischemia lead to acute and chronic loss of skeletal muscle mass and function. Healthy muscle is essential for eating, posture, respiration, reproduction, and mobility, as well as for appropriate function of the senses including taste, vision, and hearing. Beyond providing support and contraction, skeletal muscle also exerts essential roles in temperature regulation, metabolism, and overall health. As the primary reservoir for amino acids, skeletal muscle regulates whole-body protein and glucose metabolism by providing substrate for protein synthesis and supporting hepatic gluconeogenesis during illness and starvation. Overall, greater muscle mass is linked to greater insulin sensitivity and glucose disposal, strength, power, and longevity. In contrast, low muscle mass correlates with dysmetabolism, dysmobility, and poor survival. Muscle mass is highly plastic, appropriate to its role as reservoir, and subject to striking genetic control. Defining mechanisms of muscle growth regulation holds significant promise to find interventions that promote health and diminish morbidity and mortality after trauma, sepsis, inflammation, and other systemic insults. In this invited review, we summarize techniques and methods to assess and manipulate muscle size and muscle mass in experimental systems, including cell culture and rodent models. These approaches have utility for studies of myopenia, sarcopenia, cachexia, and acute muscle growth or atrophy in the setting of health or injury.

Disease-specific out-of-pocket healthcare expenditure in urban Bangladesh: A Bayesian analysis.

BACKGROUND: Because of the rapid increase of non-communicable diseases (NCDs) and high burden of healthcare-related financial issues in Bangladesh, there is a concern that out-of-pocket (OOP) payments related to illnesses may become a major burden on household. It is crucial to understand what are the major illnesses responsible for high OPP at the household level to help policymakers prioritize key areas of actions to protect the household from 100% financial hardship for seeking health care as part of universal health coverage. OBJECTIVES: We first estimated the costs of illnesses among a population in urban Bangladesh, and then assessed the household financial burden associated with these illnesses. METHOD: A cross-sectional survey of 1593 randomly selected households was carried out in Bangladesh (urban area of Rajshahi city), in 2011. Catastrophic expenditure was estimated at 40% threshold of household capacity to pay. We employed the Bayesian two-stage hurdle model and Bayesian logistic regression model to estimate age-adjusted average cost and the incidence of household financial catastrophe for each illness, respectively. RESULTS: Overall, approximately 45% of the population of Bangladesh had at least one episode of illness. The age-sex-adjusted average medical expenses and catastrophic health care expenditure among the households were TK 621 and 8%, respectively. Households spent the highest amount of money 7676.9 on paralysis followed by liver disease (TK 2695.4), injury (TK 2440.0), mental disease (TK 2258.0), and tumor (TK 2231.2). These diseases were also responsible for higher incidence of financial catastrophe. Our study showed that 24% of individuals who suffered typhoid incurred catastrophic expenditure followed by liver disease (12.3%), tumor (12.1%), heart disease (8.4%), injury (7.9%), mental disease (7.9%), cataract (7.1%), and paralysis (6.5%). CONCLUSION: The study findings suggest that chronic illnesses were responsible for high costs and high catastrophic expenditures in Bangladesh. Effective risk pooling mechanism might reduce household financial burden related to illnesses. Chronic illness related to NCDs is the major cause of OOP. It is also important to consider prioritizing vulnerable population by subsidizing the high health care cost for some of the chronic illnesses.

ASSESSMENT OF RESIDUAL VASCULARIZATION OF THE LIMB AS A PROGNOSTIC FACTOR TO AVOID SEA TURTLE FLIPPER AMPUTATION.

Entanglement occurs when a marine turtle becomes trapped within anthropogenic materials such as debris or fishery gear, inducing strangulation of anatomical parts such as flippers or the neck, causing deep lacerations, maiming, amputation, or choking. Often, severely entangled flippers in captured or stranded turtles are removed surgically. Turtles with flipper impairment have difficulty in swimming, diving, and feeding. Our aim was to use color Doppler ultrasound and multi-detector computer tomography to evaluate residual vascularization or neovascularization in severely entangled flippers of loggerhead sea turtles (Caretta caretta) to assess viability of flippers, even in the absence of limb sensation. We studied 12 turtles with either unilateral (n=8) or bilateral (n=4) involvement. A total of 14 flippers were severely entangled and two flippers were spontaneously amputated. Only two of the 14 entangled flippers had to be removed surgically. For 12 entangled flippers, after surgical curettage, the treatment protocol was based on the use of a plant-derived commercial dressing. The animals were monitored and treated for 1-3 mo, until the soft tissue defects were completely healed by secondary intention. Interestingly, in the treated animals the healing flippers steadily recovered motility and sensation, restoring the complete functionality of the flipper. Vascularization of the limb was found to be critical to prevent amputation of entangled flippers, preserving the flipper and its functionality with conservative therapy and avoiding amputation as much as possible. Our study showed that in cases of entanglement, amputation does not need to be performed immediately but can wait for nonviability to declare itself following conservative therapy and should be reserved as a last-resort treatment.

Determining the Effectiveness of Noncontact Three-Dimensional Surface Scanning for the Assessment of Open Injuries.

Noncontact three-dimensional (3D) surface scanning methods are used within forensic medicine to record traumas and other related findings. A structured light scanning technique is one of these methods and the most suitable for the forensic field. An assessment of the efficiency of different structured light scanners with forensic injuries is essential to validate this technique for wound documentation. The purpose of this study was to evaluate the capability of the HP structured light scanner Pro S3 for digitizing open injuries having complicated areas and depths. Fifteen simulated injuries on mannequins were scanned and assessed. Comparisons between 3D and direct wound measurements were made. The results showed that the technique was able to create detailed 3D results of the extensive injuries. Statistical significance tests revealed no difference between the two measurement methods. Because the scanner is applicable for routine work, it should be considered to confirm the same results on real cadavers and actual wounds.

Characterizing differences in the collagen fiber organization of skin wounds using quantitative polarized light imaging.

Collagen fiber organization requires characterization in many biomedical applications, but it is difficult to objectively quantify in standard histology tissue sections. Quantitative polarized light imaging is a low-cost technique that allows for rapid measurement of collagen fiber orientation and thickness. In this study, we utilize a quantitative polarized light imaging system to characterize fiber orientation and thickness from wound sections. Full thickness skin wound sections that were previously stained with hematoxylin and eosin were used to assess collagen fiber content and organization at different points during the wound healing process. Overall, wounds exhibited a measurable increase in collagen fiber thickness and a nonlinear change in fiber reorganization within the wound. Our study demonstrates that quantitative polarized light imaging is an inexpensive alternative or supplement to standard histology protocols, requiring no additional stains or dyes, and yields repeatable quantitative assessments of collagen organization.

Incidence-Based versus Prevalence-Based Approaches on Measuring Disability-Adjusted Life Years for Injury.

BACKGROUND: Injury represents an important aspect of disease that affects everyone at some point in their lives. To better understand and prevent these injuries, various analytical methods have been developed to assess both the magnitude and features of injury burden. In this study, we attempted to estimate the injury burden of Korea in 2014 by comparing the prevalence-based approach used by the Global Burden of Diseases (GBD) team and the World Health Organization against an alternative incidence-based approach, and to assess the different implications of these measurements. METHODS: The 10th Korean National Hospital Discharge survey data and causes of death statistics in 2014 were used as data sources. Years of life lost (YLL), years lived with disability (YLD) and disability-adjusted life years (DALYs) were calculated using both the incidence- and prevalence-based approaches. The Korean Classification of Diseases (KCD) version 5 diagnostic codes were used to classify the mechanism of injury. RESULTS: The prevalence-based injury burden tended to be higher (1,670,229 DALYs) than the incidence-based injury burden (1,544,467 DALYs). The elderly population exhibited a higher prevalence-based YLD and DALY relative to incidence-based outcomes. In order of significance, the three most common causes of injury as calculated using an incidence-based approach were road injury, fall, and self-harm, compared with a prevalence-based method, which identified self-harm, road injury, and falls as the most common injuries. CONCLUSION: An appropriate prevention program is needed for injuries with potential to cause long-lasting morbidity. Accordingly, a tailored injury-prevention strategy should be developed for each high-risk group.

Negative pressure dressings are no better than standard dressings for open fractures.

The studyEffect of negative pressure wound therapy vs standard wound management on 12-month disability among adults with severe open fracture of the lower limb: the WOLLF randomised clinical trial.Costa ML, Achten J, Bruce J, et al; UK WOLLF CollaborationPublished on 9 October 2018 JAMA 2018;319:2280-8.This project was funded by the National Institute for Health Research Health Technology Assessment Programme (project number 10/57/20).To read the full NIHR Signal, go to: https://discover.dc.nihr.ac.uk/content/signal-000655/negative-pressure-dressings-are-no-better-than-standard-dressings-for-open-fractures.

Retrospective Payor Claims Analysis of Patients Receiving Outpatient Negative Pressure Wound Therapy With Remote Therapy Monitoring.

INTRODUCTION: Patient nonadherence to home care treatment poses an obstacle to wound healing that can lead to additional costs and prolong care. OBJECTIVE: This retrospective pilot study examines the potential time and cost savings associated with a remote therapy monitoring (RTM) program designed to improve negative pressure wound therapy (NPWT) adherence in the home care setting. MATERIALS AND METHODS: Payor claims data of patients receiving NPWT with (n = 199) or without (n = 232) RTM between January 1 and June 30, 2017 were analyzed. RESULTS: The RTM patients were significantly older (P = .0401), had a higher percentage of Medicare Advantage plans (P = .0015), and had a higher mean Charleston Comorbidity Index score (P = .0115) than non-RTM patients. For both groups, chronic wounds had higher 90-day wound-related costs than acute wounds. The median length of treatment for RTM patients was shorter than non-RTM patients (P = .0394). Mean 90-day wound-related costs for RTM and non-RTM patients were $10 515 and $12 158, respectively. CONCLUSIONS: These results build upon previous studies of RTM-assisted outpatient NPWT and suggest an opportunity for wound care cost savings.

Use of mechanically powered disposable negative pressure wound therapy: recommendations and reimbursement update.

Use of ultra-portable, mechanically powered disposable negative pressure wound therapy (dNPWT) has grown as an adjunctive modality to manage wounds in outpatient care and to expedite transition of inpatients to an outpatient setting. This technology has demonstrated similar efficacy and usability for mobile outpatients when compared with electrically powered negative pressure wound therapy devices. It was designed for patients with smaller, low to moderately exudating wounds and does not require batteries or a power source. However, very few studies address best practices for using dNPWT in a variety of wound types. There is a need for comprehensive clinical recommendations to better direct clinicians and patients in using this therapy. In addition, it is critical that providers are knowledgeable about processes for obtaining reimbursement for placement of dNPWT since codes and procedures differ drastically from standard NPWT. A panel meeting of experts with a high level of experience with dNPWT in varied wound types was convened to develop clinical recommendations and summarize current US reimbursement coding guidelines for the use of dNPWT. This publication summarizes the recommendations from panel members, in addition to supporting evidence, to help guide appropriate use of dNPWT. Panel recommendations regarding optimal patient and wound selection, wound preparation, proper patient training, and use of dNPWT in various wound types are included as well as clinical techniques for dressing application, bridging under offloading devices and compression, maintaining a seal, and protecting intact skin. Processes and codes for obtaining reimbursement for dNPWT are reviewed by care setting. Clinical recommendations and reimbursement guidelines summarized in this publication are meant to provide direction to clinicians in using dNPWT that potentially could translate into improved clinical and economic value.

Child injuries in Ethiopia: A review of the current situation with projections.

BACKGROUND: Heavy burden of child injuries and lack of policy response in Ethiopia call for an improved understanding of the situation and development of action plans from multiple governmental agencies and stakeholders. METHODS: A consortium of international and Ethiopian researchers and stakeholders used extensive literature review and mixed analytical methods to estimate and project the burden of fatal and non-fatal child unintentional injuries in Ethiopia from 2015 to 2030. Estimates were derived for children aged 0-14 years. Data sources include a longitudinal study conducted by the Central Statistics Agency of Ethiopia and the World Bank as well as model-based estimates from World Health Organization 2017 and Global Burden of Disease 2016 project. RESULTS: Injuries caused about 25 thousand deaths among 0-14-year olds in Ethiopia in 2015. The leading cause of fatal child unintentional injuries in Ethiopia was road-traffic injuries, followed by fire, heat and hot substances and drowning. The death rate due to injuries among 0-14 years olds was about 50 percent higher in males than females. Rural children were exposed to a greater risk of injury than their urban peers. The longitudinal survey suggests that the incidence rate of child injuries increased during the period 2011-2014. The annual mortality caused by injuries is projected to increase from 10,697 in 2015 to 11,279 in 2020 and 11,989 in 2030 among children under 5 years, an increase of 12 percentage points in 15 years. The number of deaths among 0-14-year olds will be 26,463, 27,807, and 30,364 respectively in 2015, 2020, and 2030. CONCLUSIONS: As the first multisectoral collaboration on child injuries in Ethiopia, this study identified gaps in understanding of the burden of child injuries in Ethiopia. In consultation with Ethiopian government and other stakeholders, we propose starting an injury surveillance system at health clinics and hospitals and building an intervention package based on existing platforms.

Optical coherence tomography for assessment of epithelialization in a human ex vivo wound model.

The ex vivo human skin wound model is a widely accepted model to study wound epithelialization. Due to a lack of animal models that fully replicate human conditions, the ex vivo model is a valuable tool to study mechanisms of wound reepithelialization, as well as for preclinical testing of novel therapeutics. The current standard for assessment of wound healing in this model is histomorphometric analysis, which is labor intensive, time consuming, and requires multiple biological and technical replicates in addition to assessment of different time points. Optical coherence tomography (OCT) is an emerging noninvasive imaging technology originally developed for noninvasive retinal scans that avoids the deleterious effects of tissue processing. This study investigated OCT as a novel method for assessing reepithelialization in the human ex vivo wound model. Excisional ex vivo wounds were created, maintained at air-liquid interface, and healing progression was assessed at days 4 and 7 with OCT and histology. OCT provided adequate resolution to identify the epidermis, the papillary and reticular dermis, and importantly, migrating epithelium in the wound bed. We have deployed OCT as a noninvasive tool to produce, longitudinal "optical biopsies" of ex vivo human wound healing process, and we established an optimal quantification method of re-epithelialization based on en face OCT images of the total wound area. Pairwise statistical analysis of OCT and histology based quantifications for the rate of epithelialization have shown the feasibility and superiority of OCT technology for noninvasive monitoring of human wound epithelialization. Furthermore, we have utilized OCT to evaluate therapeutic potential of allogeneic adipose stem cells revealing their ability to promote reepithelialization in human ex vivo wounds. OCT technology is promising for its applications in wound healing and evaluation of novel therapeutics in both the laboratory and the clinical settings.

Traumatic injury and perceived injustice: Fault attributions matter in a "no-fault" compensation state.

BACKGROUND: Traumatic injury can lead to loss, suffering and feelings of injustice. Previous research has shown that perceived injustice is associated with poorer physical and mental wellbeing in persons with chronic pain. This study aimed to identify the relative association between injury, compensation and pain-related characteristics and perceived injustice 12-months after traumatic injury. METHODS: 433 participants were recruited from the Victorian Orthopedic Trauma Outcomes Registry and Victorian State Trauma Registry, and completed questionnaires at 12-14 months after injury as part of an observational cohort study. Using hierarchical linear regression we examined the relationships between baseline demographics (sex, age, education, comorbidities), injury (injury severity, hospital length of stay), compensation (compensation status, fault, lawyer involvement), and health outcomes (SF-12) and perceived injustice. We then examined how much additional variance in perceived injustice was related to worse pain severity, interference, self-efficacy, catastrophizing, kinesiophobia or disability. RESULTS: Only a small portion of variance in perceived injustice was related to baseline demographics (especially education level), and injury severity. Attribution of fault to another, consulting a lawyer, health-related quality of life, disability and the severity of pain-related cognitions explained the majority of variance in perceived injustice. While univariate analyses showed that compensable injury led to higher perceptions of injustice, this did not remain significant when adjusting for all other factors, including fault attribution and consulting a lawyer. CONCLUSIONS: In addition to the "justice" aspects of traumatic injury, the health impacts of injury, emotional distress related to pain (catastrophizing), and the perceived impact of pain on activity (pain self-efficacy), had stronger associations with perceptions of injustice than either injury or pain severity. To attenuate the likelihood of poor recovery from injury, clinical interventions that support restoration of health-related quality of life, and adjustment to the impacts of trauma are needed.