Exercise training induces thrombogenic benefits in recent but not late postmenopausal females.

Although regular physical activity is known to improve cardiovascular health in men, evidence for its beneficial effects in postmenopausal females is less convincing and it remains unclear whether initiation of exercise training soon after, rather than many years after menopause impacts the magnitude of training-induced adaptations. We evaluated exercise-induced changes in markers of thrombotic risk and conduit artery function in recent≤5yr compared with late≥10yr postmenopausal females. Fourteen recent≤5yr and 13 late≥10yr healthy postmenopausal females completed 8 wk of regular intensive exercise training, consisting of floorball and cycling. Markers of thrombotic risk and vascular health were assessed before and after the intervention, and data were analyzed using a linear mixed model. Exercise training reduced markers of thrombotic risk, including an 11% reduction (P = 0.007) in agonist-induced platelet reactivity and a reduction (P = 0.027) in incipient clot microstructure (∼40% reduction in clot mass) in the recent≤5yr but not the late≥10yr (P = 0.380; P = 0.739, respectively) postmenopausal females. There was no change in conduit artery function, as measured by brachial (recent≤5yr, P = 0.804; late≥10yr, P = 0.311) and popliteal artery (recent≤5yr, P = 0.130; late≥10yr, P = 0.434) flow-mediated dilation. Only the late≥10yr postmenopausal females exhibited an increase (by 9.6%, P = 0.022) in intracellular adhesion molecule-1 levels after training, which may have impacted the thrombogenic adaptation in this group. These findings suggest that 8 wk of high-intensity exercise training reduces thrombotic risk in recent≤5yr, but not late≥10yr postmenopausal females. Thus, regular physical activity initiated soon after, rather than many years after menopause and at a higher age, may be more efficient for reducing thrombogenic risk.NEW & NOTEWORTHY Eight weeks of high-intensity exercise training reduces platelet reactivity as well as blood clot density and strength in females ≤5 yr past menopause but not in females ≥10 yr past menopause. The divergent response in the late postmenopausal females may be explained by training-induced low-grade systemic inflammation. These findings suggest that regular physical activity initiated soon after menopause, compared with many years after menopause, may be more efficient for reducing the risk of blood clots.

The efficacy of low molecular weight heparin is reduced in COVID-19.

BACKGROUND: A significant degree of mortality and morbidity in COVID-19 is through thromboembolic complications, only partially mitigated by anticoagulant therapy. Reliable markers of infection severity are not fully established. OBJECTIVES: This study investigated whether visco-elastic biomarkers predict disease severity on presentation to the Emergency Department (ED) and how they measure response to anticoagulationMETHODS:Patients testing positive for COVID-19 at a large University Teaching Hospital ED were recruited at presentation. Multiple blood samples were taken throughout hospital admission to monitor disease progression with end outcome recorded. Visco-elastic markers, fractal dimension (df) and Time to Gel Point (TGP) which measure the properties of the incipient clot were compared in patients with and without anticoagulation by Low Molecular Weight Heparin (LMWH). RESULTS: TGP and df did not predict severity of infection with COVID-19. Although LMWH prolonged TGP, there was no change in df indicating LMWH did not change clot microstructure. CONCLUSIONS: Therapeutic efficacy of LMWH appears blunted in COVID-19 infection. This may be due to the inflammatory state creating a resistance to LMWH activity, which may explain why LMWH appears less effective in COVID-19 compared to other disease states. COVID-19 was not predicted by visco-elastic testing at the time of ED presentation.

Impaired fibrinolysis in severe Covid-19 infection is detectable in early stages of the disease.

BACKGROUND: A significant degree of mortality and morbidity in Covid-19 is due to thromboembolic disease. Coagulopathy has been well described in critically unwell patients on ICU. There is less clear evidence regarding these changes at the time of presentation to the Emergency Department and the progression of disease over time. OBJECTIVE: We sought to investigate whether coagulation markers can predict severity and how they change over the disease course. METHODS: Patients presenting to a single University Teaching Hospital were recruited and followed up if PCR was positive. Alongside routine blood testing, Rotational Thromboelastometry (ROTEM) was performed. Outcome data was recorded for all patients, and ROTEM values were compared across outcome groups. RESULTS: Extem and Intem Maximum Lysis were significantly reduced in those who died or required an ICU admission, indicating a reduced ability to break down clot mass in the most critically unwell patients. CONCLUSION: Comparisons between groups demonstrated that one distinguishing feature between those who require ICU admission or die of Covid-19 compared with those who survive a hospital stay to discharge was the extent to which fibrinolysis could occur. Mortality and morbidity in Covid-19 infection appears in part driven by an inability to break down clot mass.

Does Exercise Influence the Susceptibility to Arterial Thrombosis? An Integrative Perspective.

Arterial thrombosis is the primary cause of death worldwide, with the most important risk factors being smoking, unhealthy diet, and physical inactivity. However, although there are clear indications in the literature of beneficial effects of physical activity in lowering the risk of cardiovascular events, exercise can be considered a double-edged sword in that physical exertion can induce an immediate pro-thrombotic environment. Epidemiological studies show an increased risk of cardiovascular events after acute exercise, a risk, which appear to be particularly apparent in individuals with lifestyle-related disease. Factors that cause the increased susceptibility to arterial thrombosis with exercise are both chemical and mechanical in nature and include circulating catecholamines and vascular shear stress. Exercise intensity plays a marked role on such parameters, and evidence in the literature accordingly points at a greater susceptibility to thrombus formation at high compared to light and moderate intensity exercise. Of importance is, however, that the susceptibility to arterial thrombosis appears to be lower in exercise-conditioned individuals compared to sedentary individuals. There is currently limited data on the role of acute and chronic exercise on the susceptibility to arterial thrombosis, and many studies include incomplete assessments of thrombogenic clotting profile. Thus, further studies on the role of exercise, involving valid biomarkers, are clearly warranted.

The effect of diabetic ketoacidosis (DKA) and its treatment on clot microstructure: Are they thrombogenic?

BACKGROUND: Diabetic ketoacidosis (DKA) is a medical emergency with a high mortality rate and is associated with severe metabolic acidosis and dehydration. DKA patients have an increased risk of arterial and venous thromboembolism, however little is known about this metabolic derangement in the first 24 hours of admission and to assess its effect on coagulation. We therefore utilised a novel functional marker of clot microstructure (fractal dimension - df) to assess these changes within the first 24 hours. METHODS: Prospective single centre observational study to demonstrate whether the tendency of blood clot formation differs in DKA patients. RESULTS: 15 DKA patients and 15 healthy matched controls were recruited. Mean df in the healthy control group was 1.74±0.03. An elevated df of 1.78±0.07 was observed in patients with DKA on admission. The mean pH on admission was 7.14±0.13 and the lactate was 3.6±2.0. df changed significantly in response to standard treatment and was significantly reduced to 1.68±0.09 (2-6& h) and to 1.66±0.08 at 24& h (p < 0.01 One-way ANOVA). df also correlated significantly with lactate and pH (Pearson correlation coefficient 0.479 and -0.675 respectively, p < 0.05). CONCLUSIONS: DKA patients at presentation have a densely organising less permeable thrombogenic clot microstructure as evidenced by high df. These structural changes are due to a combination of dehydration and a profound metabolic acidosis, which was reversed with treatment. These changes were not mirrored in standard clinical markers of thromboge-nicity.

Comparison of the use of lung ultrasound and chest radiography in the diagnosis of rib fractures: a systematic review.

INTRODUCTION: It is well-recognised that the detection of rib fractures is unreliable using chest radiograph. The aim of this systematic review was to investigate whether the use of lung ultrasound is superior in accuracy to chest radiography, in the diagnosis of rib fractures following blunt chest wall trauma. METHODS: The search filter was used for international online electronic databases including MEDLINE, EMBASE, Cochrane and ScienceDirect, with no imposed time or language limitations. Grey literature was searched. Two review authors completed study selection, data extraction and data synthesis/analysis process. Quality assessment using the Quality Assessment of Diagnostic Accuracy Studies Tool (QUADAS-2) was completed. RESULTS: 13 studies were included. Overall, study results demonstrated that the use of lung ultrasound in the diagnosis of rib fractures in blunt chest wall trauma patients appears superior compared with chest radiograph. All studies were small, single centre and considered to be at risk of bias on quality assessment. Meta-analysis was not possible due to high levels of heterogeneity, lack of appropriate reference standard and poor study quality. DISCUSSION: The results demonstrate that lung ultrasound may be superior to chest radiography, but the low quality of the studies means that no definitive statement can be made.

The effect of sepsis and septic shock on the viscoelastic properties of clot quality and mass using rotational thromboelastometry: A prospective observational study.

PURPOSE: The study purpose was to define changes in coagulation across the sepsis spectrum using rotational thromboelastometry (ROTEM). METHODS: Sepsis patients were recruited on admission to the Emergency Department and Intensive Care Units of a large teaching hospital in Wales. ROTEM markers of clot development and fibrinolysis were determined, as well as standard coagulation markers. A healthy control group matched for age and gender was also recruited (n=44). RESULTS: 100 patients were recruited (50 sepsis, 20 severe sepsis and 30 septic shock). Maximum clot firmness was significantly higher in the sepsis (p<0.001) and severe sepsis (p=0.012) groups than the healthy control (71.6±4.5 and 70.4±4.1 vs 64.4 respectively). In septic shock there was prolonged clot development; however, maximum clot firmness remained normal. Fibrinolytic function was significantly impaired in septic shock, which was also significantly associated with 28-day mortality (p<0.001). CONCLUSIONS: ROTEM indicated significantly enhanced clot structural development in sepsis and severe sepsis, which could be indicative of a hypercoagulable phase. In septic shock, despite there being a prolongation of clotting pathways and impaired fibrinolysis, clot mass was comparably normal, suggestive of the development of a clot with healthy characteristics.

Characterisation of clot microstructure properties in stable coronary artery disease.

BACKGROUND: Coronary artery disease (CAD) is associated with an increased prothrombotic tendency and is also linked to unfavourably altered clot microstructure. We have previously described a biomarker of clot microstructure (df) that is unfavourably altered in acute myocardial infarction. The df biomarker assesses whether the blood will form denser or looser microstructures when it clots. In this study we assessed in patients with stable chest pain whether df can differentiate between obstructed and unobstructed CAD. METHODS: A blood sample prior to angiography was obtained from 251 consecutive patients undergoing diagnostic coronary angiography. Patients were categorised based on angiographic findings as presence or absence of obstructive CAD (stenosis ≥50%). The blood sample was assessed using the df biomarker, standard laboratory markers and platelet aggregometry (Multiplate). RESULTS: A significant difference (p=0.028) in df was observed between obstructive CAD (1.748±0.057, n=83) and unobstructive CAD (1.732±0.052, n=168), where patients with significant CAD produce denser, more tightly packed clots. df was also raised in men with obstructive CAD compared with women (1.745±0.055 vs 1.723±0.052, p=0.007). Additionally df significantly correlated with the platelets response to arachidonic acid as measured by the ASPItest area under the curve readings from platelet aggregometry (correlation coefficient=0.166, p=0.008), a low value of the ASPItest indicating effective aspirin use was associated with looser, less dense clots. CONCLUSIONS: For the first time, we characterise clot microstructure, as measured by df, in patients with stable CAD. df can potentially be used to risk-stratify patients with stable CAD and assess the efficacy of therapeutic interventions by measuring changes in clot microstructure.

The effect of sepsis and its inflammatory response on mechanical clot characteristics: a prospective observational study.

PURPOSE: Sepsis and its progression are known to have a major influence on the coagulation system. Current coagulation tests are of limited use when assessing coagulation in sepsis patients. This study aims to assess the potential for a new functional biomarker of clot microstructure, fractal dimension, to identify changes in the mechanical properties of clot microstructure across the sepsis spectrum (sepsis, severe sepsis and septic shock). METHODS: A total of 100 patients that presented acutely to a large teaching hospital were included in this prospective observational study (50 sepsis, 20 severe sepsis and 30 septic shock) against a matched control of 44 healthy volunteers. Fractal analysis was performed, as well as standard markers of coagulation, and six plasma markers of inflammation. RESULTS: Fractal dimension was significantly higher in the sepsis and severe sepsis groups than the healthy control (1.78 ± 0.07 and 1.80 ± 0.05, respectively vs 1.74 ± 0.03) (p < 0.001), indicating a significant increase in mechanical clot strength and elasticity consistent with a hypercoagulable state. Conversely, fractal dimension was significantly lower in septic shock (1.66 ± 0.10, p < 0.001), indicating a significant reduction in mechanical clot strength and functionality consistent with a hypocoagulable state. This corresponded with a significant increase in the inflammatory response. CONCLUSIONS: This study confirms that clot microstructure is significantly altered through the various stages of sepsis. Of particular importance was the marked change in clot development between severe sepsis and septic shock, which has not been previously reported.

An Investigation Into the Effects of In Vitro Dilution With Different Colloid Resuscitation Fluids on Clot Microstructure Formation.

BACKGROUND: Balancing the beneficial effects of resuscitation fluids against their detrimental effect on hemostasis is an important clinical issue. We aim to compare the in vitro effects of 3 different colloid resuscitation fluids (4.5% albumin, hydroxyethyl starch [Voluven 6%], and gelatin [Geloplasma]) on clot microstructure formation using a novel viscoelastic technique, the gel point. This novel hemorheologic technique measures the biophysical properties of the clot and provides an assessment of clot microstructure from its viscoelastic properties. Importantly, in contrast to many assays in routine clinical use, the measurement is performed using unadulterated whole blood in a near-patient setting and provides rapid assessment of coagulation. We hypothesized that different colloids will have a lesser or greater detrimental effect on clot microstructure formation when compared against each other. METHODS: Healthy volunteers were recruited into the study (n = 104), and a 20-mL sample of whole blood was obtained. Each volunteer was assigned to 1 of the 3 fluids, and the sample was diluted to 1 of 5 different dilutions (baseline, 10%, 20%, 40%, and 60%). The blood was tested using the gel point technique, which measures clot mechanical strength and quantifies clot microstructure (df) at the incipient stages of fibrin formation. RESULTS: df and clot mechanical strength decrease with progressive dilution for all 3 fluids. A significant reduction in df from baseline was recorded at dilutions of 20% for albumin (P < .0001), 40% for starch (P < .0001), and 60% for gelatin (P < .0001). We also observed significant differences, in terms of df, when comparing the different types of colloid (P < .0001). We found that albumin dilution produced the largest changes in clot microstructure, providing the lowest values of df (= 1.41 ± 0.061 at 60% dilution) compared with starch (1.52 ± 0.081) and gelatin (1.58 ± 0.063). CONCLUSIONS: We show that dilution with all 3 fluids has a significant effect on coagulation at even relatively low dilution volumes (20% and 40%). Furthermore, we quantify, using a novel viscoelastic technique, how the physiochemical properties of the 3 colloids exert individual changes on clot microstructure.

Cognitive Outcomes following Thrombolysis in Acute Ischemic Stroke: A Systematic Review.

BACKGROUND: Patients treated with thrombolytic therapy within 4.5 hours after stroke onset appear to have improved survival and functional outcomes. Poststroke cognitive impairment is associated with reduced quality of life and survival and needs to be reviewed in consideration of the administration of thrombolysis. This review aims to systematically evaluate literature exploring the effect of thrombolysis for ischemic stroke on cognition. METHODS: An electronic search was conducted to identify articles and gray literature applying broad Medical Subject Heading terms. Literature was reviewed with a 2-step process against predetermined inclusion criteria. All relevant studies were included if they investigated global or individual cognitive domains. RESULTS: Three studies satisfied the inclusion criteria but were diverse in outcome measures and duration, their heterogeneity limiting any possible pooled analysis. One study examined long-term treatment effects on global cognition and did not find a positive effect at 6 months. A positive treatment effect was reported in the acute phase in 1 study examining domains of visuoconstructive and perceptive abilities. One study retrospectively analyzed treatment effects on language and found improvement in the acute phase but not in the long term. CONCLUSIONS: The limited existing evidence on the effects of thrombolytic therapy on long- and short-term cognition is varied in both outcome measures and diagnostic classifications, making it difficult to extrapolate results to a global stroke population. This review should be used to inform future research in stroke treatment outcomes and highlights the immediate need for larger, more robust studies in this area.

Epidemiology of burns and scalds in children presenting to the emergency department of a regional burns unit: a 7-year retrospective study.

BACKGROUND: Variation in the incidence and mechanism of thermal injury has been reported in different age groups in children. The aim of this study was to report the incidence, mechanisms, and environmental factors of all burns presentations to the emergency department (ED) of a regional burns centre over a 7-year period. METHODS: A retrospective, chart review study of all burns presentations to the ED of a regional burns centre in South Wales was conducted. All children recorded as having sustained a burn or scald, aged less than 16 years were included in the analysis. Subjects' demographics were analysed using descriptive statistics, and comparisons were made between patients aged less than 5 and patients aged 5-16 using chi-square test and Mann-Whitney U test. RESULTS: A total of 1387 cases were included in the final analysis. Scalds were the most common thermal injury with 569 (41.0 %) reported, followed by contact burns in 563 (40.6 %) patients. The patients requiring hospitalisation were significantly younger (2 vs 3 years; p < 0.001) and had a higher rate of non-accidental injury (10 vs 4; p < 0.001). The most commonly injured site in both age groups was a hand or digit. CONCLUSIONS: Scalds and contact burns were the most commonly reported thermal injury in children aged less than 16. Common mechanisms were hot beverages, hobs and hair straighteners, highlighting further burn prevention strategies are needed and good-quality prospective studies that investigate the effectiveness of such strategies.

The Effects of Temperature on Clot Microstructure and Strength in Healthy Volunteers.

BACKGROUND: Anesthesia, critical illness, and trauma are known to alter thermoregulation, which can potentially affect coagulation and clinical outcome. This in vitro preclinical study explores the relationship between temperature change and hemostasis using a recently validated viscoelastic technique. We hypothesize that temperature change will cause significant alterations in the microstructural properties of clot. METHODS: We used a novel viscoelastic technique to identify the gel point of the blood. The gel point identifies the transition of the blood from a viscoelastic liquid to a viscoelastic solid state. Furthermore, identification of the gel point provides 3 related biomarkers: the elastic modulus at the gel point, which is a measure of clot elasticity; the time to the gel point (TGP), which is a measure of the time required to form the clot; and the fractal dimension of the clot at the gel point, df, which quantifies the microstructure of the clot. The gel point measurements were performed in vitro on whole blood samples from 136 healthy volunteers over a temperature range of 27°C to 43°C. RESULTS: There was a significant negative correlation between increases in temperature, from 27°C to 43°C, and TGP (r = -0.641, P < 0.0005). Conversely, significant positive correlations were observed for both the elastic modulus at the gel point (r = 0.513, P = 0.0008) and df (r = 0.777, P < 0.0005) across the range of 27°C to 43°C. When temperature was reduced below 37°C, significant reductions in df and TGP occurred at ≤32°C (Bonferroni-corrected P = 0.0093) and ≤29°C (Bonferroni-corrected P = 0.0317), respectively. No significant changes were observed when temperature was increased to >37°C. CONCLUSIONS: This study demonstrates that the gel point technique can identify alterations in clot microstructure because of changes in temperature. This was demonstrated in slower-forming clots with less structural complexity as temperature is decreased. We also found that significant changes in clot microstructure occurred when the temperature was ≤32°C.

Fractal dimension (df) as a new structural biomarker of clot microstructure in different stages of lung cancer.

Venous thromboembolism (VTE) is common in cancer patients, and is the second commonest cause of death associated with the disease. Patients with chronic inflammation, such as cancer, have been shown to have pathological clot structures with modulated mechanical properties. Fractal dimension (df) is a new technique which has been shown to act as a marker of the microstructure and mechanical properties of blood clots, and can be performed more readily than current methods such as scanning electron microscopy (SEM). We measured df in 87 consecutive patients with newly diagnosed lung cancer prior to treatment and 47 matched-controls. Mean group values were compared for all patients with lung cancer vs controls and for limited disease vs extensive disease. Results were compared with conventional markers of coagulation, fibrinolysis and SEM images. Significantly higher values of df were observed in lung cancer patients compared with controls and patients with extensive disease had higher values than those with limited disease (p< 0.05), whilst conventional markers failed to distinguish between these groups. The relationship between df of the incipient clot and mature clot microstructure was confirmed by SEM and computational modelling: higher df was associated with highly dense clots formed of smaller fibrin fibres in lung cancer patients compared to controls. This study demonstrates that df is a sensitive technique which quantifies the structure and mechanical properties of blood clots in patients with lung cancer. Our data suggests that df has the potential to identify patients with an abnormal clot microstructure and greatest VTE risk.

The role of whole blood impedance aggregometry and its utilisation in the diagnosis and prognosis of patients with systemic inflammatory response syndrome and sepsis in acute critical illness.

OBJECTIVE: To assess the prognostic and diagnostic value of whole blood impedance aggregometry in patients with sepsis and SIRS and to compare with whole blood parameters (platelet count, haemoglobin, haematocrit and white cell count). METHODS: We performed an observational, prospective study in the acute setting. Platelet function was determined using whole blood impedance aggregometry (multiplate) on admission to the Emergency Department or Intensive Care Unit and at 6 and 24 hours post admission. Platelet count, haemoglobin, haematocrit and white cell count were also determined. RESULTS: 106 adult patients that met SIRS and sepsis criteria were included. Platelet aggregation was significantly reduced in patients with severe sepsis/septic shock when compared to SIRS/uncomplicated sepsis (ADP: 90.7±37.6 vs 61.4±40.6; p<0.001, Arachadonic Acid 99.9±48.3 vs 66.3±50.2; p = 0.001, Collagen 102.6±33.0 vs 79.1±38.8; p = 0.001; SD ± mean)). Furthermore platelet aggregation was significantly reduced in the 28 day mortality group when compared with the survival group (Arachadonic Acid 58.8±47.7 vs 91.1±50.9; p<0.05, Collagen 36.6±36.6 vs 98.0±35.1; p = 0.001; SD ± mean)). However haemoglobin, haematocrit and platelet count were more effective at distinguishing between subgroups and were equally effective indicators of prognosis. Significant positive correlations were observed between whole blood impedance aggregometry and platelet count (ADP 0.588 p<0.0001, Arachadonic Acid 0.611 p<0.0001, Collagen 0.599 p<0.0001 (Pearson correlation)). CONCLUSIONS: Reduced platelet aggregometry responses were not only significantly associated with morbidity and mortality in sepsis and SIRS patients, but also correlated with the different pathological groups. Whole blood aggregometry significantly correlated with platelet count, however, when we adjust for the different groups we investigated, the effect of platelet count appears to be non-significant.

Expert opinion of the risk factors for morbidity and mortality in blunt chest wall trauma: results of a national postal questionnaire survey of Emergency Departments in the United Kingdom.

OBJECTIVE: Blunt chest wall trauma is a common injury treated in the Emergency Departments and has a high reported morbidity and mortality. No national guidelines exist for the management of this patient group unless the patient has severe immediate life-threatening injuries. The aim of this study was to investigate current management of blunt chest wall trauma patients in the UK and to gather expert opinion of the risk factors for morbidity and mortality. METHODOLOGY: A sample of 100 physicians working in Emergency Departments in the UK were purposively selected and sent a postal questionnaire to complete. Non-responder analysis was undertaken in order to assess bias. The completed questionnaires were analysed with descriptive statistics. RESULTS: A response rate of 90% was achieved. The different type of hospital providing emergency care was well represented in the results. The general surgical team was the most frequently used ward-based team when the patient required admission to hospital (51%). Inconsistencies exist regarding the use of guidelines for the management of the blunt chest wall patient. The risk factors for morbidity and mortality suggested by the sample concurred with current literature including patient age, pre-existing conditions and number of ribs fractured and areas for further research were highlighted. CONCLUSION: Variation exists in the management of blunt chest wall trauma patients in the UK. This study provides the expert opinion of a sample of 90 physicians working in Emergency Departments in the UK regarding the risk factors for morbidity and mortality in blunt chest wall trauma patients.

The risk factors for the development of complications during the recovery phase following blunt chest wall trauma: a retrospective study.

STUDY OBJECTIVE: The difficulties in the management of the blunt chest wall trauma patient in the Emergency Department (ED) due to the development of late complications are well recognised in the literature. The aim of this study was to investigate the risk factors for the development of complications in the recovery phase following blunt chest wall trauma. METHODS: A retrospective study was completed in which the medical notes were analysed of all blunt chest wall trauma patients presenting to a large trauma centre in South Wales in 2009 and 2010. Using univariate and multivariable logistic regression analysis, the risk factors for development of complications during the recovery phase following blunt chest wall trauma were investigated. RESULTS: Risk factors for development of complications in the recovery phase following blunt chest wall trauma in the univariate analysis were a patient age of 65 years or more, three or more rib fractures, presence of chronic lung disease or cardiovascular disease, pre-injury anticoagulant use and blood oxygen saturation levels of less than 90%. On multivariable analysis, the risk factors were three or more rib fractures, chronic lung disease, pre-injury anticoagulant use and oxygen saturations of less than 90%. CONCLUSION: A number of risk factors have been presented in this study which should be considered in the management of the blunt chest wall trauma patient. This is the first study in which a number of the risk factors have been investigated and this may provide the basis for further prospective studies.

The UK burden of injury study - a protocol. [National Research Register number: M0044160889].

BACKGROUND: Globally and nationally large numbers of people are injured each year, yet there is little information on the impact of these injuries on people's lives, on society and on health and social care services. Measurement of the burden of injuries is needed at a global, national and regional level to be able to inform injured people of the likely duration of impairment; to guide policy makers in investing in preventative measures; to facilitate the evaluation and cost effectiveness of interventions and to contribute to international efforts to more accurately assess the global burden of injuries. METHODS/DESIGN: A prospective, longitudinal multi-centre study of 1333 injured individuals, atttending Emergency Departments or admitted to hospital in four UK areas: Swansea, Surrey, Bristol and Nottingham. Specified quotas of patients with defined injuries covering the whole spectrum will be recruited. Participants (or a proxy) will complete a baseline questionnaire regarding their injury and pre-injury quality of life. Follow up occurs at 1, 4, and 12 months post injury or until return to normal function within 12 months, with measures of health service utilisation, impairment, disability, and health related quality of life. National estimates of the burden of injuries will be calculated by extrapolation from the sample population to national and regional computerised hospital in-patient, emergency department and mortality data. DISCUSSION: This study will provide more detailed data on the national burden of injuries than has previously been available in any country and will contribute to international collaborative efforts to more accurately assess the global burden of injuries. The results will be used to advise policy makers on prioritisation of preventive measures, support the evaluation of interventions, and provide guidance on the likely impact and degree of impairment and disability following specific injuries.