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.

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.).

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.

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.

[Cross-sectional study of satisfaction with studies and lifestyle among medical students in Austria, Germany and Switzerland]. / Studienzufriedenheit und Lebensstil von Medizinstudenten im deutschsprachigen Raum.

BACKGROUND: The aim was to examine potential differences in various aspects of life as well as study satisfaction amongst medical students of three German speaking countries. METHOD: Data was collected between February and June 2010 using an online survey with the open source survey tool Limesurvey (Version 1.85 RC3). RESULTS: 1179 medical students in year 4-6 completed the online questionnaire (798 in Germany (Ger), 265 in Austria (A) and 116 in Switzerland (CH)). Mean age was similar (25.0-25.3) for the countries (p = 0.14). Respondents from Austria were significantly more often (17.4 %) smoking than Swiss (12.1 %) or German (10 %) medical students (p = 0.002). The average number of hours spent studying per week and desired weekly work hours varied significantly between countries. The average desired working week post-graduation was 42 hours. The perceived ability to work as junior doctor post-graduation was below 5 on a visual analogue scale of 1-10. CONCLUSION: Results of consumption, work life balance and activity were similar to statistics of the population of each country. With regard to the desired work time after graduation this is in clear contrast to the reality as a doctor. Improvement of medical courses can be achieved with better preparation for the internship.

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.

Incidence and clinical relevance of heterotopic ossification after internal fixation of acetabular fractures: retrospective cohort and case control study.

OBJECTIVE: The aim of the study was to evaluate predictors and clinical relevance of heterotopic ossification (HO) in patients treated for acetabular fractures in a tertiary referral centre. PATIENTS AND METHODS: The study is a retrospective cohort study with a nested case-control study. All patients treated with internal fixation of acetabular fractures from January 2004 to October 2013. Ninety patients had postoperative imaging available at 6 and 12 months postoperatively and received no prophylaxis. Plain radiographs were used to grade HO. The Hip disability and Osteoarthritis Outcome Score (HOOS) was used to compare outcomes between patients suffering from HO with patients who did not. RESULTS: Sixteen patients (17.7%) suffered from HO. According to the Brooker classification, 5 had class I, 4 class II, 3 class III and 4 class IV HO. Traumatic brain injury (TBI) was the only significant risk factor for developing HO (odds ratio (OR) 8.6, 95% confidence interval (CI) (1.693-43.753), p = 0.014). The HO rate in patients with an anterior (ilioinguinal) or posterior (Kocher-Langenbeck) surgical approach was 20% and 21% respectively, and the HO rate in patients with a combined approach was much lower at 11%. Neither fracture type nor gender nor age increased the risk of HO significantly. The outcome measured by HOOS was not significantly different between patients with HO and patients in the control group. Patients with HO Brooker class II-IV had slightly lower (effect estimate +4.25, 95% CI (-10.2 to +12.10), p = 0.220) HOOS compared to the majority of the control group. CONCLUSION: A very low rate of HO was found compared to the HO rates described in other studies with similar patient cohorts who received prophylaxis. Based on our findings and the current literature, we do not recommend giving prophylaxis against HO to patients after internal fixation of acetabular fractures.

Acromioclavicular joint dislocation with associated brachial plexus injury.

We present the case of a 32-year-old female who sustained a left acromioclavicular (AC) joint type V injury and brachial plexus injury. The patient's AC joint injury was identified 6 days after she was involved in a motorbike accident where she sustained multiple other injuries. She required operative fixation of the AC joint using a locking compression medial proximal tibial plate. At 3 months post operatively, the patient was found to have a subluxed left shoulder as a result of an axonal injury to the upper trunk of the brachial plexus. In addition, the tibial plate had cut out. The plate was subsequently removed. At 8 months the glenohumeral articulation had been restored and the patient had clinically regained significant shoulder function. After 15 months the patient was pain free and could complete all her activities of daily living without impediment. She returned to playing competitive pool after 24 months.

A holistic perspective of patients' lives post-Ilizarov external fixation.

BACKGROUND: The Ilizarov external fixator (IEF) is used in the treatment of complicated fractures with severe soft tissue damage. Despite advantages of being minimally invasive and allowing early weight-bearing, the IEF has limitations, including size, treatment duration and crucial pin-site care. Many patients showed enormous resilience despite the devastating effects of their injuries. Our aim was to assess the value of IEF treatment for trauma patients with a focus on their quality of life. METHODS: A postal survey was administered to 89 patients treated with an IEF at a level 1 trauma centre between January 2000 and June 2009. An SF-12 health survey was incorporated to measure quality of life. SPSS 18.0 was used for statistical analysis of the data. RESULTS: The response rate was 73%. The majority of patients (77%) were treated with IEF for primary fractures. The median duration in IEF was 174 days (56-614 days). The SF-12 mean mental component score was 51 (16-66) and the mean physical component score was 38 (16-57) at the time of survey. The mental component score was similar to that of a normal population but the physical component score was markedly below. A total of 96.8% respondents were satisfied with the IEF treatment and 91.7% reported that under the same circumstances they would have the same treatment again. CONCLUSIONS: Patient's quality of life scores correlated directly with their injury severity and pre-existing conditions. They were not negatively affected by IEF treatment itself. High quality of life scores (non-physical) were achieved with IEF treatment.

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.

Adrenal pseudoaneurysm due to blunt trauma.

Blunt trauma to adrenal glands causing pseudoaneurysm is relatively uncommon. We report a case of an adrenal pseudoaneurysm in a young man who had a blunt abdominal trauma. The pseudoaneurysm was embolized. Pseudoaneurysm formation is a significant, albeit rare complication and can lead to adrenal hemorrhage. Currently, best treatment option is embolization. There is little known about natural course of a pseudoaneurysm, and there are no controlled trails in regard to follow up computed tomography (CT) scans in blunt solid organ injury.

Factors influencing motorcycle crash victim outcomes: a prospective study.

BACKGROUND: Motorcyclists have the highest morbidity and mortality rates of all road users. Little evidence is available to demonstrate how rider, crash and speed influence short- and long-term patient outcomes. METHODS: A prospective study of 208 consecutive crash presentations was undertaken at the Royal Perth Hospital, Western Australia. All motorcycle, scooter, trike and quad bike accident victims over a 4-month period ending 31 March 2009 were included. RESULTS: One hundred and forty-three admissions and 1344 days of hospitalization were recorded, with 6.56 days mean length of stay and 9.27 mean Injury Severity Scores. Loosing control due to intoxication, being hit by another vehicle and travelling above the speed limit yielded the worst patient outcomes. Hitting a stationary object and travelling below the speed limit were the most common accident features. Travelling in excess of 50 kph increased risk of intracranial injury, with an odds ratio of 4.8. CONCLUSION: Crash factors including intoxication, speed and accident cause significantly influence both short- and long-term patient outcomes.

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.

Optional inferior vena cava filter use in surgical patients: a Western Australian experience.

BACKGROUND: The optional filter is gaining ground, supplementing anticoagulation in the management of venous thromboembolism (VTE) in high-risk surgical patients, this despite knowledge gaps relating to its efficacy. We studied the literature and audited our experience with inferior vena cava filters to educate ourselves on this mode of VTE prophylaxis, particularly its practical implications, if any, for the surgeon. METHODS: A retrospective clinical study on inferior vena cava filter (IVCF)-related events in a Western Australian tertiary centre in 2008 was performed. Literature on IVCFs was reviewed. RESULTS: The 118 IVCF-related events at our centre in 2008, involved either Recovery-G2 75(88%) or Cook-Celect nine (11%). Of these, 78 were insertions and 36 were retrievals with four failed retrievals (10% of the attempts). Major indications for insertion included multi-trauma 32 (38%), prothrombotic state 29 (34%), head injury/intracranial bleeding 16 (19%) and others eight (9%). The mean dwelling time was 100 days (12­349 days). The mean age was 43 and the retrieval rate was 58%. CONCLUSION: Optional filters have presented both versatility and challenge to the management of VTE in high-risk patients. An underlying concern about the quintessential efficacy of IVCFs lingers on, while the impact of lost follow-ups in young patients is still at large. Class 1 studies on optional filters would add certainty to the use of this generation of filters, be a step forward in relevance from the seminal work of Decousus and garner the willingness needed to engage teamwork and institutional proactiveness against loopholes such as lost follow-ups that can undermine the portrayed benefits of a potentially lifesaving device.

Cemented Thompson versus cemented bipolar prostheses for femoral neck fractures.

PURPOSE: To compare early functional outcomes, complications, and mortality in elderly patients treated with the less costly, cemented Thompson prosthesis or the cemented bipolar prosthesis in order to identify factors affecting outcomes. METHODS: Records of 303 patients with femoral neck fractures treated with the cemented Thompson monoblock prosthesis (n=206) or the cemented bipolar prosthesis (n=97) were reviewed. The choice of prosthesis was solely determined by surgeon's preference. Data relating to patient demographics, clinical and residential status, mobility, mental function, mortality, and complications during hospitalisation and rehabilitation were collected. RESULTS: After adjusting for confounding variables, independent postoperative indoor mobility was associated with preoperative indoor mobility (p=0.002) and mental function (p=0.001), whereas postoperative outdoor mobility was associated with preoperative outdoor mobility (p=0.003), daily living activity (p=0.02), and mental function (p=0.02). Mortality within 6 months was only associated with poor mental function (p=0.009). At 6-month follow-up, there was no significant difference between the 2 types of prosthesis in terms of functional outcomes, mortality and complication rates. CONCLUSION: In elderly patients with limited mobility, treatment with the bipolar prosthesis was not associated with better short-term outcomes than those receiving the Thompson prosthesis.