The reliability of the Glasgow Coma Scale in detecting traumatic brain injury: The continuous effect of age.

Background: Recent studies noted the limited applicability of Glasgow Coma Scale (GCS) for elderly patients with Traumatic Brain Injury (TBI). However, the dichotomic distinction between "elderly" and "non-elderly" does not cover the full span of influence of age on GCS presentation.Objective: To analyze the influence of age on GCS scores of patients with isolated TBI.Methods: A retrospective study of 18,534 patients hospitalized due to isolated TBI recorded in the Israeli National Trauma Registry in 1997-2017. The GCS scores were compared between four age-groups: 20-44, 45-64, 65-74 and 75+ years old. Additional factors included patient's sex, Abbreviated Injury Scores (AIS) and injury circumstances.Results: GCS scores increased continuously with age at all AIS levels. The trend was significant even after adjustment for patient's sex and injury circumstances. The angle of the trend was different in various injury circumstances, with GCS scores of victims of Road Traffic Accidents sharply increasing after age of 44 and that of the patients hospitalized after falling from own height surging after age of 64.Conclusions: Screening procedures for patients with TBI should give a greater weight to the actual age of adults, as well as to the circumstances of their injury.

Equipping Public Spaces to Facilitate Rapid Point-of-Injury Hemorrhage Control After Mass Casualty.

In response to increasing violent attacks, the Stop the Bleed campaign recommends that everyone have access to both personal and public bleeding-control kits. There are currently no guidelines about how many bleeding victims public sites should be equipped to treat during a mass casualty incident. We conducted a retrospective review of intentional mass casualty incidents, including shootings, stabbings, vehicle attacks, and bombings, to determine the typical number of people who might benefit from immediate hemorrhage control by a bystander before professional medical help arrives. On the basis of our analysis, we recommend that planners at public venues consider equipping their sites with supplies to treat a minimum of 20 bleeding victims during an intentional mass casualty incident.

New Trends in Terrorism-Related Injury Mechanisms: Is There a Difference in Injury Severity?

STUDY OBJECTIVE: The latest wave of terrorism worldwide has seen significant use by terrorists of mundane, "low-technology" weapons, such as utility knives and civilian vehicles. How do the injuries they produce compare with that of more conventional terrorism mechanisms, such as use of firearms and explosives? We compare injury patterns of the most frequent terrorism-related injury mechanisms in an Israeli data set. METHODS: This was a retrospective study of 1,858 patients hospitalized because of terrorism events, which were recorded in the Israeli National Trauma Registry between January 1997 and December 2016. The events were divided into 4 groups based on weapon used: explosions, shootings, stabbings, and vehicular attacks. The groups were compared in terms of injuries sustained, use of hospital resources, and clinical outcomes. RESULTS: Explosion-related and vehicular terrorism resulted in a higher proportion of multiple injuries, whereas stabbings and shootings mostly led to isolated injuries. Victims of vehicular attacks had a high proportion of severe head injuries, whereas stabbing victims had a high volume of vascular injuries. All mechanisms involved significant damage to extremities; however, among stabbing victims injury was mainly to the upper extremities, whereas among vehicular attack victims it was mostly to the lower extremities. The overall injury severity of the compared groups was similar, leading to comparable levels of intensive care use and inhospital mortality. Certain similarities in victims' characteristics were observed between the shootings and stabbings and between explosions and vehicular attacks. CONCLUSION: Despite differences between various terrorist attack mechanisms, the resulting injury severity and inhospital mortality are very similar, with stabbings and vehicular attacks causing injuries as serious as those caused by conventional weapons.

The Differences in Stabbing-Related Injury Profiles of Men and Women.

BACKGROUND: Although women comprise only a minority of patients hospitalized due to violence-related injury, the circumstances of attacks against women may make their injuries more severe. METHODS: We conducted a retrospective study using data of 9173 patients with stabbing-related injuries from 19 trauma centers participating in the Israeli National Trauma Registry between 1 January 1997 and 31 December 2014. Male and female patients were compared in terms of demographic and circumstantial factors, clinical characteristics, and outcomes. RESULTS: Women were found to have greater injury severity according to the Injury Severity Scale (ISS) - 18% vs. 11% of severe (ISS 16+) injuries - requiring more hospital resources. Injuries that contributed most to injury severity in the female population were head and severe abdominal trauma. Women also sustained injuries to more body sites than men; however, regression analysis showed that the contribution of this factor to the overall difference in injury severity was less important than the injured sites. Regression analysis among severely injured patients pointed at injury to lower extremities as an independent factor related to female mortality. Different from men, among women the stabbing injuries to the upper extremities were not a protective factor in terms of mortality. CONCLUSIONS: There are significant differences in the injury profiles of male and female stabbing victims, which can be explained by the different circumstances of the injury event.

Violence-related Versus Terror-related Stabbings: Significant Differences in Injury Characteristics.

OBJECTIVE: To demonstrate the gap between injury epidemiology of terror-related stabbings (TRS) and non-terror-related intentional stabbings. BACKGROUND: Terror attacks with sharp instruments have multiplied recently, with many victims of these incidents presented to hospitals with penetrating injuries. Because most practical experience of surgeons with intentional stabbing injuries comes from treating victims of interpersonal violence, potential gaps in knowledge may exist if injuries from TRS significantly differ from interpersonal stabbings (IPS). METHODS: A retrospective study of 1615 patients from intentional stabbing events recorded in the Israeli National Trauma Registry during the period of "Knife Intifada" (January 2013-March 2016). All stabbings were divided into TRS and IPS. The 2 categories were compared in terms of sustained injuries, utilization of hospital resources, and clinical outcomes. RESULTS: TRS patients were older, comprised more females and were ethnically homogenous. Most IPS incidents happened on weekdays and at night hours, whereas TRS events peaked midweek during morning and afternoon hours. TRS patients had more injuries of head, face, and neck, and severe head and neck injuries. IPS patients had more abdomen injuries; however, respective injuries in the TRS group were more severe. Greater injury severity of the TRS patients reflected on their higher hospital resources utilization and greater in-hospital mortality. CONCLUSIONS: Victims of terror stabbings are profoundly different in their characteristics, sustain injuries of a different profile and greater severity, require more hospital resources, and have worse off clinical outcomes, emphasizing the need of the healthcare systems to adjust itself appropriately to deal successfully with future terror attacks.

Gadolinium-based contrast agents in children.

Gadolinium-based contrast agents (GBCAs) are widely used in medical imaging, with greater than 300 million doses administered since their introduction. The risk of adverse reactions is very low, and GBCAs were thought to be very safe until the discovery of nephrogenic systemic fibrosis (NSF). Since that time, gadolinium has been found to deposit throughout the body, including the brain, where it is visible on non-contrast T1-weighted MR images in people with normal renal function. The clinical effects of this deposition remain unknown and may not exist. In this review the authors provide a comprehensive update on GBCAs and their potential risks, within a historical context and through the lens of a pediatric radiologist.

Extended diffusion weighted magnetic resonance imaging with two-compartment and anomalous diffusion models for differentiation of low-grade and high-grade brain tumors in pediatric patients.

PURPOSE: The purpose of this study was to examine advanced diffusion-weighted magnetic resonance imaging (DW-MRI) models for differentiation of low- and high-grade tumors in the diagnosis of pediatric brain neoplasms. METHODS: Sixty-two pediatric patients with various types and grades of brain tumors were evaluated in a retrospective study. Tumor type and grade were classified using the World Health Organization classification (WHO I-IV) and confirmed by pathological analysis. Patients underwent DW-MRI before treatment. Diffusion-weighted images with 16 b-values (0-3500 s/mm2) were acquired. Averaged signal intensity decay within solid tumor regions was fitted using two-compartment and anomalous diffusion models. Intracellular and extracellular diffusion coefficients (Dslow and Dfast), fractional volumes (Vslow and Vfast), generalized diffusion coefficient (D), spatial constant (µ), heterogeneity index (ß), and a diffusion index (index_diff = µ × Vslow/ß) were calculated. Multivariate logistic regression models with stepwise model selection algorithm and receiver operating characteristic (ROC) analyses were performed to evaluate the ability of each diffusion parameter to distinguish tumor grade. RESULTS: Among all parameter combinations, D and index_diff jointly provided the best predictor for tumor grades, where lower D (p = 0.03) and higher index_diff (p = 0.009) were significantly associated with higher tumor grades. In ROC analyses of differentiating low-grade (I-II) and high-grade (III-IV) tumors, index_diff provided the highest specificity of 0.97 and D provided the highest sensitivity of 0.96. CONCLUSIONS: Multi-parametric diffusion measurements using two-compartment and anomalous diffusion models were found to be significant discriminants of tumor grading in pediatric brain neoplasms.

Use of gadolinium-based magnetic resonance imaging contrast agents and awareness of brain gadolinium deposition among pediatric providers in North America.

BACKGROUND: Numerous recent articles have reported brain gadolinium deposition when using linear but not macrocyclic gadolinium-based contrast agents (GBCAs). OBJECTIVE: To determine the current landscape of gadolinium use among pediatric institutions and the knowledge base of radiologists and referring providers with regard to GBCAs and brain gadolinium deposition. MATERIALS AND METHODS: We e-mailed voluntary closed surveys to 5,390 physicians in various pediatric professional societies between January 2016 and March 2016. We used chi-square and Fisher exact tests to compare response distributions among specialties. RESULTS: We found that 80% of surveyed pediatric hospitals use macrocyclic contrast agents. In the last year, 58% switched their agent, most commonly to gadoterate meglumine, with the most common reason being brain gadolinium deposition. Furthermore, surveys indicated that 23% of hospitals are considering switching, and, of these, 83% would switch to gadoterate meglumine; the most common reasons were brain gadolinium deposition and safety. Radiologists were more aware of brain gadolinium deposition than non-radiologist physicians (87% vs. 26%; P<0.0001). Radiologists and referring providers expressed similar levels of concern (95% and 89%). Twelve percent of radiologists and 2% of referring providers reported patients asking about brain gadolinium deposition. Radiologists were significantly more comfortable addressing patient inquiries than referring pediatric physicians (48% vs. 6%; P<0.0001). The number of MRIs requested by referring pediatric physicians correlated with their knowledge of brain gadolinium deposition, contrast agent used by their hospital, and comfort discussing brain gadolinium deposition with patients (P<0.0001). CONCLUSION: Since the discovery of brain gadolinium deposition, many pediatric hospitals have switched to or plan to switch to a more stable macrocyclic MR contrast agent, most commonly gadoterate meglumine. Despite this, there is need for substantial further education of radiologists and referring pediatric providers regarding GBCAs and brain gadolinium deposition.

A New Paradigm of Injuries From Terrorist Explosions as a Function of Explosion Setting Type.

OBJECTIVE: Examine the impact of setting on the magnitude and pattern of civilian injuries from terrorist explosions. This may help surgical staffs anticipate the resources required to treat victims of terrorist attacks. METHODS: A retrospective study of 823 patients from 65 explosive events of the Second Intifada (2000-2005) in the National Trauma Registry. After verification all the events were divided into 5 categories: explosions inside buildings (CS), explosions near buildings (SO), explosions inside buses (IB), explosions near buses (AB), and explosions in an open space (OS). The categories were then compared in terms of sustained injuries, utilization of hospital resources and clinical outcomes. RESULTS: CS and IB scenarios were found to cause the most severe injuries, demanded the most hospital resources and had the worst outcomes, but had several important differences in injury profiles. AB setting proved to be a stand-alone scenario with the lowest severity, possibly due to protection provided to the passengers by the bus. The high volume of blast injuries in SO scenario supports the idea that the explosion wave could be reflected onto the people standing outside a building next to its wall. OS patients had the lowest proportion of blast trauma and burns. CONCLUSIONS: The existing taxonomy of terrorist bombings, which distinguishes explosions in open spaces from those occurring in closed environments, does not fully differentiate patterns of injury that follow blasts in intermediate environments. Expanding the framework from 2 categories to 5 appears to provide greater precision and may be clinically useful to health care providers.

MRI Findings After Surgery for Chiari Malformation Type I.

OBJECTIVE: Surgery plays an important role in the management of Chiari I malformation. The purpose of this article is to review expected and unexpected MRI findings after the various types of surgery performed during the treatment of Chiari I malformation and associated abnormalities. CONCLUSION: Familiarity with optimal MRI techniques and findings is important when evaluating postoperative changes after treatment of Chiari I malformation.

ISS groups: are we speaking the same language?

BACKGROUND: Despite ISS being a widely accepted tool for measuring injury severity, many researchers and practitioners use different partition of ISS into severity groups. The lack of uniformity in ISS use inhibits proper comparisons between different studies. Creation of ISS group boundaries based on single AIS value squares and their sums was proposed in 1988 during Major Trauma Study (MTOS) in the USA, but was not validated by analysis of large databases. METHODS: A validation study analysing 316,944 patients in the Israeli National Trauma registry (INTR) and 249,150 patients in the American National Trauma Data Bases (NTDB). A binary algorithm (Classification and Regression Trees (CART)) was used to detect the most significantly different ISS groups and was also applied to original MTOS data. RESULTS: The division of ISS into groups by the CART algorithm was identical in both Trauma Registries and very similar to original division in the MTOS. For most samples, the recommended groups are 1-8, 9-14, 16-24 and 25-75, while in very large samples or in studies specifically targeting critical patients there is a possibility to divide the last group into 25-48 and 50-75 groups, with an option for further division into 50-66 and 75 groups. CONCLUSIONS: Using a statistical analysis of two very large databases of trauma patients, we have found that partitioning of ISS into groups based on their association with patient mortality enables us to establish clear cut-off points for these groups. We propose that the suggested partition of ISS into severity groups would be adopted as a standard in order to have a common language when discussing injury severity.

Base excess as a predictor for injury severity in pediatric trauma patients.

BACKGROUND: Base excess is considered a predictor of mortality and severity of injury in trauma patients. Base excess had been widely examined in different settings. Only few studies have examined the role of base excess in pediatric trauma patients. OBJECTIVE: To evaluate the value of admission base excess in pediatric trauma patients with respect to intensive care unit (ICU) admission rate and length of hospital stay. METHODS: A retrospective study of pediatric trauma patients was conducted at a Level II trauma center. All patients aged 0-16 years for which a trauma team was activated over the years 2006-2009 were included. Study database included admission base excess, mechanism of injury, location and nature of injury, injury severity score, length of hospital stay, and ICU admission. RESULTS: The study group consisted of 359 patients. There was a weak linear correlation between admission base excess, length of stay in the hospital, and ICU admission. Base excess seemed to show a stronger correlation for the youngest age group (0-6 years) and no correlation for the middle age group. There was a positive but weak correlation (R Spearman = 0.26) between admission base excess and Injury Severity Score (ISS). However, 40% of the children with an ISS score >25 had normal admission base excess values. The area under the curve of the receiver operating characteristic curves of base excess for predicting ICU admission was 0.66. CONCLUSIONS: The admission base excess in pediatric trauma patients seems to be a weak prognostic factor in our facility.

Nationwide trends in abdominal aortic aneurysm repair and use of endovascular repair in the emergency setting.

PURPOSE: To analyze nationwide trends in abdominal aortic aneurysm (AAA) repair and the use of endovascular abdominal aortic aneurysm repair (EVAR) in the emergency setting. MATERIALS AND METHODS: Data were obtained from the Nationwide Inpatient Sample (NIS) using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes for open and endovascular repairs from 2001-2009. Trends in outcome parameters and hospital charges were compared. RESULTS: The number of emergency EVAR procedures increased from 382 in 2001 to 1,247 in 2009 (P < .001). During the study period, length of hospital stay associated with total number of EVAR procedures decreased from 3.8 days to 3.4 days (P < .05), and the in-hospital mortality decreased from 2.4% to 2% (P = .32). From 2001-2009, mean hospital charges associated with EVAR increased from $50,630 to $91,401 (74% increase), whereas charges associated with open repairs increased from $54,578 to $128,925 (136% increase). The proportion of patients needing rehabilitation or nursing home placement after EVAR increased from 5.8% to 7.7% (P < .01), and need for home health increased from 6.9% to 10.5% (P < .01). CONCLUSIONS: There was a significant increase in the number of emergency EVAR procedures during the study period; however, the overall in-hospital mortality associated with EVAR remained unchanged, and the length of hospital stay showed a decreasing trend. The total hospital charges for EVAR were lower than the charges for open abdominal aneurysm repair throughout the study period; the difference in charges between the procedures showed a significant increasing trend with time.

Injuries From Explosions: More Differences Than Similarities Between Various Types.

OBJECTIVE: To compare injury patterns of different types of explosions. METHODS: A retrospective study of 4508 patients hospitalized due to explosions recorded in the Israel National Trauma Registry between January 1997 and December 2018. The events were divided into 4 groups: terror-related, war-related, civilian intentional explosions, and civilian unintentional explosions. The groups were compared in terms of injuries sustained, utilization of hospital resources, and clinical outcomes. RESULTS: Civilian intentional and terror-related explosions were found to be similar in most aspects except for factors directly influencing mortality and a larger volume of severely injured body regions among terror-victims. Comparisons between other groups produced some parallels, albeit less consistent. Civilian intentional explosions and civilian unintentional explosions were different from each other in most aspects. The latter group also differed from others by its high volume of life-threatening burns and a higher proportion of children casualties. CONCLUSIONS: While consistent similarities between explosion casualties exist, especially between victims of intentional civilian and terror-related explosions, the general rule is that clinical experience with a type of explosion cannot be directly transferred to other types.

COVID-19 Changed the Injury Patterns of Hospitalized Patients.

INTRODUCTION: Injury patterns are closely related to changes in behavior. Pandemics and measures undertaken against them may cause changes in behavior; therefore, changes in injury patterns during the coronavirus disease 2019 (COVID-19) outbreak can be expected when compared to the parallel period in previous years. STUDY OBJECTIVE: The aim of this study was to compare injury-related hospitalization patterns during the overall national lockdown period with parallel periods of previous years. METHODS: A retrospective study was completed of all patients hospitalized from March 15 through April 30, for years 2016-2020. Data were obtained from 21 hospitals included in the national trauma registry during the study years. Clinical, demographic, and circumstantial parameters were compared amongst the years of the study. RESULTS: The overall volume of injured patients significantly decreased during the lockdown period of the COVID-19 outbreak, with the greatest decrease registered for road traffic collisions (RTCs). Patients' sex and ethnic compositions did not change, but a smaller proportion of children were hospitalized during the outbreak. Many more injuries were sustained at home during the outbreak, with proportions of injuries in all other localities significantly decreased. Injuries sustained during the COVID-19 outbreak were more severe, specifically due to an increase in severe injuries in RTCs and falls. The proportion of intensive care unit (ICU) hospitalizations did not change, however more surgeries were performed; patients stayed less days in hospital. CONCLUSIONS: The lockdown period of the COVID-19 outbreak led to a significant decrease in number of patients hospitalized due to trauma as compared to parallel periods of previous years. Nevertheless, trauma remains a major health care concern even during periods of high-impact disease outbreaks, in particular due to increased proportion of severe injuries and surgeries.

National study: Most elderly patients benefit from earlier hip fracture surgery despite co-morbidity.

OBJECTIVE: To estimate the potential influence of pre-operative patient condition on the benefit of earlier hip fracture surgery for elderly patients. BACKGROUND: Many studies emphasize the benefit of earlier hip fracture surgery for patient survival. However less is known regarding how this relationship is influenced by clinical factors which could serve as potential contra-indicators for earlier surgery. Rushed surgery of patients with contra-indications may even compromise their survival. METHODS: A retrospective study of patients aged 65 and above with an isolated hip fracture following trauma, based on data from 19 hospitals of the national trauma registry available for the years 2015-2016. Registry data was crossed with data on co-morbidities and medication intake from the biggest health insurance agency in the country, serving more than 50% of the country's population. Mediation analysis was performed on a wide list of co-morbidities, medications and clinical test results in order to establish the mediation of their relationship with inhospital mortality by earlier hip fracture surgery. Factors found significant in the mediation analysis were utilized to adjust a logistic regression for predicting inhospital mortality by function of waiting time to surgery and patient's sex and age. RESULTS: Anti-coagulant and anti-platelet intake; test results pointing to decreased kidney function and being diagnosed with diabetes or Ischemic Heart Disease were found to be significantly mediated in their influence on inhospital mortality by hip fracture surgery. Despite anti-platelet intake and kidney function having a significant impact on mortality in the multi-variate analysis, the positive effect of earlier hip surgery on survival remained unchanged after adjustment. CONCLUSIONS: Earlier hip fracture surgery was found to be beneficial for elderly patients even when their co-morbidities and medication intake are taken into account.

Poorer outcomes for mass casualty events victims: is it evidence based?

BACKGROUND: The sudden influx of patients during mass casualty events (MCEs) may compromise the quality of care provided and possibly impact on the medical outcomes of these patients. To test this assumption, a comparison must be made between injuries sustained in MCE and non-MCE events caused by the same mechanism. The mechanism of injury selected for this study was gunshot wounds, which occur in both types of event. METHODS: A retrospective study was carried out using the Israel's National Trauma Registry data on patients hospitalized between November 1, 2000, and December 31, 2005, as a result of high-energy gunshot trauma. Descriptive statistics and bivariate analysis were used to characterize injury patterns, and multivariate analysis was used to determine factors influencing inpatient mortality. RESULTS: Of 462 patients with gunshot wounds, 120 cases (26.38%) were defined as MCE and 342 (73.62%) as non-MCE. Both populations had ∼30% of severely injured patients (Injury Severity Score 16+). MCE patients had undergone significantly fewer operational procedures. No differences between MCE and non-MCE were found in intensive care units utilization. The likelihood of death as a result of MCE was 2.75 (CI 1.09-7.02) times higher than non-MCE. Factors influencing this difference are the number of injured regions and injuries to the brain, chest, and abdomen. CONCLUSIONS: MCE patients have a significantly higher mortality than non-MCE patients, not manifesting substantial differences in the severity of injuries. The absence of difference in intensive care units utilization may be related to the effectiveness of existing protocols for dealing with MCEs.

Violence-related injury of children in Israel: age-dependent pattern.

OBJECTIVE: To characterize the population of children hospitalized as a result of violence. METHODS: This retrospective study used data from the Israeli National Trauma Registry on patients aged 0-17 years hospitalized for trauma during 1998-2006. Of 65,430 patients, 2060 (3.1%) had violence-related injuries. Descriptive statistics and bivariate analysis were used to characterize injury patterns and multivariate analysis was used to identify factors associated with severe injury. FINDINGS: Half the victims of violence < 18 years of age were 15-17 years old. Most were boys. Violence-related trauma occurred more often than other trauma in the street, at school or in a public place or leisure facility, but less often at home. Unarmed brawling and stabbing were the most common types of violence. Brawling affected Jewish children more, while non-Jewish children were more often injured by firearms. The boundaries of age groups with different injury rates corresponded to the 'institutional' childhood stages of the Israeli educational system: the violence-related injury rate dropped after the first year of life, stayed low during kindergarten, rose slightly during elementary school and rose steeply during secondary and high school. The percentage of males increased with each age group. The street became more dangerous with age, while school and home became safer. Adolescents aged 15-17 years, newborn infants and those injured by firearms had the highest risk of severe injury. CONCLUSION: Age and type of violence were the most important predictors of violence frequency and severity. Ethnicity lost importance when adjusted by these factors. Further research on their influence on violence-related injury is needed.

The danger of non-exhaustive quality measures: requiring hip fracture repair surgery within 48 hours - a case study.

Quality measures are widely used globally in order to measure clinical performance and organizational efficiency of the healthcare systems. However, in a race to achieve certain numerically defined goal, the more important purpose of any organizational step being aimed at improving clinical outcomes could be overshadowed.The introduction of the requirement to perform most hip fracture surgeries in the first 48 h of hospitalization by the Israeli Ministry of Health (IMOH) provides an interesting example of the complexity of this phenomenon. In 2004, the IMOH decided that hospitals would receive the full DRG payment for hip fractures operations only in cases in which the operation is performed within 48 h of hospitalization. In 2013, the IMOH proceeded to designate the proportion of less than 48 h surgeries as an official quality parameter for comparing hospital performance.Despite the widely acknowledged and proven clinical benefit of earlier surgery for hip fracture patients, the desired proportion of such surgeries in a given population is not easily defined for a given population, as a significant number of patients may be unsuited for immediate surgery due to medical instability, having a serious co-morbidity or receiving anticoagulant treatment. Rushing these patients to surgery can be therefore expected to have a negative effect on their outcomes, and the subsequent increase in hip fracture mortality recorded in Israel after 2013 may be a result of that.This example suggests that designating an organizational quality measure without adjusting it for the patient's medical condition may make it too inaccurate to guide healthcare policy.