Association Between Admission Ionized Calcium Level and Neurological Outcome of Patients with Isolated Severe Traumatic Brain Injury: A Retrospective Cohort Study.

BACKGROUND: Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Pathophysiological processes following initial insult are complex and not fully understood. Ionized calcium (Ca++) is an essential cofactor in the coagulation cascade and platelet aggregation, and hypocalcemia may contribute to the progression of intracranial bleeding. On the other hand, Ca++ is an important mediator of cell damage after TBI and cellular hypocalcemia may have a neuroprotective effect after brain injury. We hypothesized that early hypocalcemia might have an adverse effect on the neurological outcome of patients suffering from isolated severe TBI. In this study, we aimed to evaluate the relationship between admission Ca++ level and the neurological outcome of these patients. METHODS: This was a retrospective, single-center, cohort study of all patients admitted between January 2014 and December 2020 due to isolated severe TBI, which was defined as head abbreviated injury score ≥ 4 and an absence of severe (abbreviated injury score > 2) extracranial injuries. The primary outcome was a favorable neurological status at discharge, defined by a modified Rankin Scale of 0-2. Multivariable logistic regression was performed to determine whether admission hypocalcemia (Ca++ < 1.16 mmol L-1) is an independent predictor of neurological status at discharge. RESULTS: The final analysis included 201 patients. Hypocalcemia was common among patients with isolated severe TBI (73.1%). Most of the patients had mild hypocalcemia (1 < Ca++ < 1.16 mmol L-1), and only 13 (6.5%) patients had Ca++ ≤ 1.00 mmol L-1. In the entire cohort, hypocalcemia was independently associated with higher rates of good neurological status at discharge (adjusted odds ratio of 3.03, 95% confidence interval 1.11-8.33, p = 0.03). In the subgroup of 81 patients with an admission Glasgow Coma Scale > 8, 52 (64.2%) had hypocalcemia. Good neurological status at discharge was recorded in 28 (53.8%) of hypocalcemic patients compared with 14 (17.2%) of those with normal Ca++ (p = 0.002). In multivariate analyses, hypocalcemia was independently associated with good neurological status at discharge (adjusted odds ratio of 6.67, 95% confidence interval 1.39-33.33, p = 0.02). CONCLUSIONS: Our study demonstrates that among patients with isolated severe TBI, mild admission hypocalcemia is associated with better neurological status at hospital discharge. The prognostic value of Ca++ may be greater among patients with admission Glasgow Coma Scale > 8. Trials are needed to investigate the role of hypocalcemia in brain injury.

Indications for prehospital intubation among severely injured children and the prevalence of significant traumatic brain injury among those intubated due to impaired level of consciousness.

BACKGROUND: Prehospital endotracheal intubation (PEI) of head injured children with impaired level of consciousness (LOC) aims to minimize secondary brain injury. However, PEI is controversial in otherwise stable children. We aimed to investigate the indications for PEI among pediatric trauma patients and the prevalence of clinically significant traumatic brain injury (csTBI) among those intubated solely due to impaired consciousness. METHODS: This is a multicenter retrospective cohort study of children who underwent PEI in northern Israel between January 2014 and December 2020 by six EMS agencies and were transported to two trauma centers in the area. We extracted data from EMS records and trauma registries. RESULTS: PEI was attempted in 179/986 (18.2%) patients and was successful in 92.2% of cases. Common indications for PEI were hypoxemia not corrected by supplemental oxygen (n = 30), traumatic cardiac arrest (n = 16), and facial injury compromising the airway (n = 13). 112 patients (62.6%) were intubated solely due to impaired or deteriorating LOC. Among these patients, 68 (62.4%) suffered csTBI. The prevalence of csTBI among those with field Glasgow Coma Scale (GCS) of 3, 4-8, and > 8 was 81.4%, 55.8%, and 28.6%, respectively (p < 0.001). Among children ≤ 10 years old intubated due to impaired LOC, 50% had csTBI. CONCLUSION: Impaired LOC is a major indication for PEI. However, a significant proportion of these patients do not suffer csTBI. Older age and lower pre-intubation GCS are associated with more accurate field classification. Our data indicate that further investigation and better characterization of patients who may benefit from PEI is necessary.

Gunshot casualties in Israel: A decade of violence.

OBJECTIVE: The purpose of this study was to identify and characterize casualties hospitalized with assault (non-terror) related gunshot wounds (GSW) in Israel as a basis for determining the incidence, trends and at-risk population groups. METHODS: This retrospective cohort study is based on data from the Israel National Trauma Registry. The data includes GSW casualties hospitalized between January 1, 2011 and December 31, 2020. Attempted suicide, unintentional injury, legal intervention, children (ages 0-9) and terror (Israeli-Arab conflict) related GSW were excluded. The remaining population was classified with an ICD-9-CM diagnosis code of 965.0-965.4. RESULTS: The study population included 2,763 GSW admissions. A noticeable increase in GSW casualties was reported, from 206 hospitalization in 2011 to 456 in 2020. The proportion of Arab casualties increased from 73.3% of all GSW casualties in 2011 to 90.8% in 2020, far more than their proportion in the population (∼20%). The majority of the GSW casualties were males (95.8%) and between the ages of 20 and 29 (42.2%). Among severe/critical casualties, 19% of Arabs and 9.9% of Jews arrived by private car. Severe thoracic and abdominal injuries were the prominent injuries among fatal casualties (47.6 and 40.8, respectively). While the all-severity mortality rate was 5.6% (n = 147), 24.4% (n = 135) of severe/critical (ISS16+) casualties died, with no significant differences between Jews and Arabs. Forty percent of deaths occurred in the emergency department. CONCLUSIONS: This study establishes that during the past decade in Israel, not only has there been a continuous increase in hospitalizations due to GSW, but also Arabs are at great risk of such related hospitalizations. Preventive strategies targeting at-risk groups are crucial for minimizing morbidity and mortality related to GSW in Israel.

Admission hypocalcemia in pediatric major trauma patients-An uncommon phenomenon associated with an increased need for urgent blood transfusion.

BACKGROUND: Hemorrhage is a leading cause of death among children. Recent data from adult trauma suggests that early, transfusion-unrelated, hypocalcemia is common and that it is associated with an increased need for blood transfusion, mortality, and coagulopathy. The objectives of this study are to evaluate the prevalence of admission hypocalcemia in severely injured children and its correlation with urgent blood transfusion. STUDY DESIGN AND METHODS: This is a retrospective cohort study of all severely injured (Injury Severity Score [ISS] > 15) pediatric (<18 years) trauma patients admitted to Rambam Health Care Campus, Israel between 2012 and 2020. We excluded patients transferred from other facilities and those who received blood before determining calcium levels. Severe hypocalcemia was defined as ionized calcium (Ca++ ) < 1.0 mmol/L and mild hypocalcemia as 1.0 mmol/L ≤ Ca++  < 1.1 mmol/L. The primary outcome was urgent blood transfusion (transfusion in the emergency department [ED]). RESULTS: Six hundred seventy-three severely injured children were admitted from the field. Ca++ levels were determined before blood transfusion in 457 patients. Severe hypocalcemia was found in three patients (0.7%) and mild hypocalcemia in additional 21 patients (4.6%). Hypocalcemic patients required more urgent blood transfusion (29.2% vs. 6.5%, p < .001) and had higher ISS (29 [interquartile range, IQR: 22-35] vs. 25 [IQR: 19-34], p = .05). Multivariable logistic regression analysis identified Ca++  < 1.1 mmol/L as an independent predictor of the need for blood transfusion, odds ratio 5.44 (95% confidence interval 1.44-20.58), p = .01. DISCUSSION: Contrary to adults, admission hypocalcemia is uncommon in severely injured children. However, it may be associated with an increased risk of blood transfusion in the ED.

The Feedback Form and Its Role in Improving the Quality of Trauma Care.

Background: One of the tasks of a level I trauma center is quality improvement of level II and level III regional hospitals and emergency medical services by means of continuous education and learning processes. One of the tools for this, which provides constant monitoring of the quality of treatment, is feedback. The purpose of the study was to evaluate the effect of feedback on the quality of trauma care. Methods: Retrospective cohort study comprising two periods of time, 2012-2013 and 2017-2018. The study group included physicians and pre-hospital staff who treated patients prior to referral to the level I center. Upon arrival when the trauma teams identified issues requiring improvement, they were asked to fill in feedback forms. Data on patients treated in the trauma shock room for whom feedback forms were filled out were also extracted. Results: A total of 662 feedback forms were completed, showing a significant improvement (p ˂ 0.0001). The majority of the medical personnel who received the most negative feedback were the pre-hospital staff. A significant increase was revealed in the number of feedbacks with reference to mismanagement of backboard spinal fixation, of the pre-hospital staff, in 2012-2013 compared to 2017-2018 (p < 0.001). Improvement in reducing the time of treatment in the field was also revealed, from 15.2 ± 8.3 min in 2012-2013 to 13.4 ± 7.9 min in 2017-2018. Conclusion: The findings show that feedback improves the treatment of injured patients. Furthermore, constantly monitoring the quality of treatment provided by the trauma team is vital for improvement.

Preparedness for Mass Casualty Incidents: The Effectiveness of Current Training Model.

The importance of MCI organization and training was highlighted by the events of September 11, 2001. Training focuses on the management of physical injuries caused by a single traumatic event over a well-defined, relatively short timeframe. MCI management is integrated into surgical and trauma training, with disaster management training involving the emergency services, law enforcement, and state infrastructure agencies. The COVID-19 pandemic revealed gaps in the preparedness of nation states and global partners in disaster management. The questions that arose include 'has training really prepared us for an actual emergency,' 'what changes need to be made to training to make it more effective,' and 'who else should training be extended to?' This article focuses on the importance of involving multiple sectors in mass casualty training and asks whether greater involvement of non-medical agencies and the public, in operational drills might improve preparedness for global events such as the COVID-19 pandemic.

Injuries from civilian under-vehicle improvised explosive devices: an analysis of the Israeli National Trauma Registry during the years 2006-2020.

PURPOSE: Under-vehicle explosions caused by improvised explosive devices (IED) came to the public's attention during armed conflicts. However, IEDs are also used by criminals in the civilian setting. This study aimed to determine the pattern of injury, medical management, and outcomes of civilians injured during under-vehicle explosions caused by IEDs. METHODS: This is a retrospective cohort study based on the Israeli National Trauma Registry of patients injured from under vehicle explosions caused by IEDs during 2006-2020. Injuries resulting from terror attacks and war were excluded. Descriptive statistics were used for data analysis. RESULTS: During the study period, 58 incidents were recorded, resulting in 74 patients who arrived alive to the hospitals and 17 who died on scene. Seventy-one (95.9%) were male with a median age of 32 years (IQR 24-42). 42% were severely injured (ISS ≥ 16). There was an average of 2.4 injured regions per patient, with extremity injuries being the most common (70.3%). Face (34%), abdomen (28%), and chest (22%) injuries were frequent. 45% were immediately transferred to the operating theatre, and 72% underwent at least one operation. Orthopedic surgeries were the most common interventions. 27 amputations were performed. CONCLUSIONS: Injuries caused by under-vehicle IEDs in civilian settings differ from those caused by IEDs used during military conflicts or acts of terrorism: they are associated with fewer victims per incident, more severe injuries, more truncal injuries, and more lower extremity injuries requiring amputations. This can be attributed to the lack of personal and vehicle protection, and the different explosive types.

Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness.

OBJECTIVE: Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason. METHODS: Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma. RESULTS: In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively. CONCLUSION: Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.

Traumatic J-Pouch Perforation following a Blunt Abdominal Injury.

A 46-year-old male was admitted to the trauma department after a motor vehicle accident. He presented with severe abdominal pain and a distended abdomen with peritonitis. His past surgical history included total proctocolectomy with ileal J-pouch anal anastomosis for ulcerative colitis 20 years previously. Computed tomography showed free peritoneal air and fluid in the abdomen mandating an exploratory laparotomy. A perforation at the ileal J-pouch blind end was found. Primary closure with diverting loop ileostomy was performed. The patient had an uneventful recovery and underwent closure of the ileostomy two months later. The case and management are discussed after reviewing the literature.

Head- and neck-related symptoms post-motor vehicle collision (MVC): Separate entities or two-sides of the same coin?

BACKGROUND AND AIM: Although post-motor vehicle collision (MVC) pain and symptoms are largely convergent among those with mild traumatic brain injury (mTBI) and whiplash associated disorder (WAD), and patients oftentimes report initial neck and head complaints, the clinical picture of mTBI and WAD has been primarily studied as separate conditions which may result in an incomplete clinical picture. As such, this study was conducted to explore the role of pain and post-traumatic psychological features in explaining both head and neck-related symptom variability in a cohort of post-collision patients. This is with the goal of disentangling if contributory factors are uniquely related to each diagnosis, or are shared between the two. METHODS: Patients recruited in the very early acute phase (<72 h) returned for clinical and psychological assessment at 6 months post-accident. In order to determine which factors were unique and which ones were overlapping the same potential contributors: mean head pain, mean neck pain, female gender, number of post-collision painful body areas, PTSD, and depression were included in the regression models for both neck disability index (NDI) and Rivermead post-concussion symptoms questionnaire (RPQ). RESULTS: Of 223 recruited participants, 70 returned for a follow-up visit (age range 18-64, mean(SD) 37.6 (11.9), 29F). This cohort primarily met the criteria for mTBI, but also fulfilled the criteria for whiplash, reinforcing the duality of injury presentation. Correlations existed between the NDI and RPQ scores (Spearman's ρ=0.66, p<0.001), however overlap was only partial. Regression analysis showed that after the removal of area-of-injury pain neck related disability (r = 0.80, p <0.001) was explained solely by number of painful body areas (ß=0.52, p <0.001). In contrast, post-concussion syndrome symptoms (r = 0.86, p<0.001) are influenced by clinical pain, painful body areas (ß=0.31, p = 0.0026), female gender (ß=0.19, p = 0.0053), and psychological factors of depression (ß=0.31, p = 0.0028) and PTSD symptoms (ß=0.36, p = 0.0013). CONCLUSIONS: It seems that while mechanisms of neck- and head-related symptoms in post-collision patients do share a common explanatory feature, of residual body pain, they are not entirely overlapping. In that psychological factors influence post-concussion syndrome symptoms, but not post-whiplash neck disability.

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.

Craniofacial Injuries Seen Among Electric-Motorized Bicycle Riders.

The popularity of electric-motorized bicycles (E-bikes) has increased dramatically over the past few years. As a result, E-bike--associated injuries are quickly becoming a substantial issue. The aim of the present study was to evaluate the epidemiology and general nature of these injuries, with special attention to craniofacial trauma. This was a retrospective study of 84 E-bike riders who suffered from trauma and treated at our level 1 trauma center between the years 2014 and 2018. The information consisted of demographics, characteristics of injury, Injury Severity Score, and number of hospitalization days.Regarding craniofacial trauma, the mean age was 22.7 years. Data about helmet usage was missing. The most common cause of injuries in maxillofacial region, was falling (80%). The most prevalent injury in the maxillofacial region was fractures of the zygomatic complex with the orbit (33%) and soft tissue lacerations.There is little data regarding craniofacial trauma attributed to electric-motorized bicycle accidents. In Israel there are a lot of young adults and teenagers that use E-bikes as an economical solution for mobility. Education regarding road behavior and the proper use of protective measures such as wearing a helmet can reduce significantly overall injuries and cranio-facial trauma in particular.

Explaining very early acute mild traumatic brain injury after motor vehicle collision pain variability: additive value of pain sensitivity questionnaire.

INTRODUCTION AND OBJECTIVES: Chronic pain is a common postcollision consequence. Wherein, a clearer understanding of acute pain can help stem the acute-to-chronic pain transition. However, the variability of acute pain is only partially explained by psychophysical pain characteristics as measured by quantitative sensory testing. The Pain Sensitivity Questionnaire (PSQ) may reflect inherent psychocognitive representations of patient's sensitivity and thus may reveal less-explored pain dimensions. In the vein of the biopsychosocial approach, this study aimed to explore whether PSQ holds additive value in explaining head and neck pain reports in very early acute-stage mild traumatic brain injury (mTBI) after collision, above the use of psychophysical assessment. METHODS: Study cohort (n = 130) consisted of mTBI patients (age range 19-66, 57 F) after accident with area-of-injury pain of at least 20 on the day of testing (mean pain 58.4 ± 21.6, range 20-100 Numerical Pain Scale) who underwent clinical, psychophysical, and pain-related psychological assessment within 72-hour after injury. RESULTS: Pain Sensitivity Questionnaire scores were significantly correlated with acute clinical, psychophysical, and pain-related psychological measures. Regression model (R 2 = 0.241, P < 0.001) showed that, together, age, sex, high PSQ, enhanced temporal summation, and less-efficient conditioned pain modulation explained head and neck pain variance. This model demonstrated that the strongest contribution to degree of postinjury pain was independently explained by PSQ (ß = 0.32) and then pressure pain threshold-conditioned pain modulation (ß = -0.25). CONCLUSION: Appraisal of cognitive daily-pain representations, by way of memory and imagination, provides an additional important dispositional facet to explain the variability in the acute mTBI postcollision clinical pain experience, above assessing nociceptive responsiveness to experimentally induced pain.

The Face of War: Maxillofacial Patients in the Syrian Civil War.

The type of the armed conflict on the Syrian battle field acquired several types of injuries; including injuries that were caused by explosive, shrapnel and blast injuries.In the current study, the authors conducted an overview of maxillofacial patients, who mainly suffered from ballistic injuries in term of injuries, reconstruction, and management.Overall, 53 maxillofacial Syrian patients were treated. The most prominent injury was soft tissue lacerations (21/97) and in terms of hard tissue injuries, the most prominent site was the mandible (N = 19) while the ramus and the body presented the most common sub-sites of injury. Hard tissue injuries were treated either by close or open reduction to obtain primary stabilization.From the psychological aspect, most of the patients suffered from guilt for leaving the combat area, those patients were mostly males in their 20s or 30s. On the other hand, older patients suffered mainly from depression, stress, and fear of returning to their home land.To conclude, the Syrian civil war has several characteristics that defer from other combats. Thus, the management of Syrian patients has to be tailored accordingly.

Procedural sedation in non-intubated children with severe trauma - A single center study.

BACKGROUND: Non-intubated children frequently undergo emergent procedures in the trauma-bay. This study evaluates whether patients treated with procedural sedation have an increased risk for severe adverse events. METHODS: Retrospective analysis of 1182 children with an injury severity score (ISS) of greater than 15. RESULTS: Of the 565 patients who were spontaneously breathing on arrival, 455 were hemodynamically stable with a Glasgow Coma Score of 15, 201 of whom were treated with sedation; 144 (71.6%) had computerized tomography scan, 35 (17.5%) wound debridement, and 22 (10.9%) fracture reduction. Sedation patients had an ISS of 20 (interquartile range 17-25). There were no death cases, no cases of cardiopulmonary resuscitation, and no cases of neurologic sequelae on hospital discharge. There were 2 (1%) cases of unanticipated endotracheal intubation. CONCLUSIONS: Non-intubated patients who were hemodynamically stable with a Glasgow Coma Score of 15 had a low risk for severe adverse events due to sedation.

Pneumonia Risk in Urgently Intubated Burn Patients.

BACKGROUND: Pneumonia is a major cause of morbidity and mortality in burn patients with inhalation injuries. An increased risk of pneumonia has been demonstrated in trauma and burn patients urgently intubated in the field vs. emergency departments (EDs). OBJECTIVES: To compare intubation setting (field vs. ED) and subsequent development of pneumonia in burn patients and to evaluate the indication for urgent intubation outside the hospital setting. METHODS: A retrospective medical records review was conducted on all intubated patients presenting with thermal (study group, 118 patients) or trauma (control group A, 74 patients) injuries and admitted to the intensive care unit of a level I trauma and burn center at a single institution during a 15 year period. Control group B (50 patients) included non-intubated facial burn patients hospitalized in the plastic surgery department. RESULTS: Field intubation was less frequent (37% field vs. 63% ED), although it was more frequent in larger burns (total body surface area > 50%; 43% field vs. 27% ED). More field intubated patients developed pneumonia during hospitalization (65% field vs. 36% ED [burns]; 81% field vs. 45% ED [multi-trauma]; 2% non-intubated, P < 0.05), with a significantly higher all-cause mortality (49% field vs. 24% ED, P < 0.05) and dramatically lower rates of extubation within 3 days (7% field vs. 27% ED, P < 0.05). CONCLUSIONS: Field intubation is associated with a higher risk of subsequent development of pneumonia in burn and multi-trauma patients and should be applied with caution, only when airway patency is at immediate risk.

Psychophysic-psychological dichotomy in very early acute mTBI pain: A prospective study.

OBJECTIVE: To characterize the pain-related somatosensory and psychological presentation of very early acute patients with a mild traumatic brain injury (mTBI). METHODS: Patients with an mTBI participated in a prospective observational study undergoing clinical, psychophysic, and psychological assessment within 72 hours after the accident. Healthy controls underwent similar protocol. RESULTS: One hundred acute patients with an mTBI (age 36 ± 12.5 [SD] years, range 19-67 years, 42 women) and 80 healthy controls (age 43 ± 14.3 years, range 24-74 years, 40 women) participated. Patients with an mTBI demonstrated a pronociceptive psychophysic response in most tests such as less efficient pressure-pain threshold-conditioned pain modulation (0.19 ±0.19±.09 vs. 0.91±.10 kg, p < 0.001) and lower temperature needed to elicit a Pain50 response (44.72 ± 0.26°C vs 46.41 ± 0.30°C, p < 0.001). Their psychophysic findings correlated with clinical pain measures, e.g., Pain50 temperature and mean head (r = -0.21, p = 0.045) and neck (r = -0.26, p = 0.011) pain. The pain-catastrophizing magnification subscale was the only psychological variable to show a difference from the controls, while no significant correlations were found between any psychological measures and the clinical or psychophysic pain measures. CONCLUSIONS: There appears to be a dichotomy between somatosensory and psychological findings in the very early acute post-mTBI stage; while the first is altered and is associated with the clinical picture, the second is unchanged. In the context of the ongoing debate on the pathophysiologic nature of the post-mTBI syndrome, our findings support its "physical" basis, free of mental influence, at least in the short time window after the injury.

2017 WSES guidelines for the management of iatrogenic colonoscopy perforation.

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45-60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator's level of experience, and surgical device availability. Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers' clinical judgment for individual patients, and they may need to be modified based on the medical team's level of experience and the availability of local resources.

Trend and Demographic Characteristics of Maxillofacial Fractures in Level I Trauma Center.

AIM: The aim of this study was to analyze the pattern and treatment of craniomaxillofacial injuries in the northern part of Israel, within a Jewish majority and large Arab minority population. PATIENTS AND METHODS: A 5-year retrospective study evaluated patients treated for craniomaxillofacial fractures. Fracture cause, type, site, and patient demographics were evaluated. RESULTS: Patient age ranged from 1 to 94 years with an average age of 36.7 years; 52% of the victims were Jews and 48% Arabs. There was male predilection in both sectors (78.3% vs 21.7%). The main site of injury was the zygomatic bone (33.5%) followed by nasal bone, orbital, mandible, frontal sinus, and maxillary fractures. The main etiology of injuries was falls (45.4%) with significantly more falls reported by females (52.1% vs 43.2% in males). Motor vehicle accidents caused injuries more frequent in males. Arabs experienced CMF fractures at a younger age compared to Jews (27.8 and 44.8 average age, respectively). In the elderly, the trend reversed where Jews were more prone to craniomaxillofacial fractures. CONCLUSIONS: Compared to their weight in the population, the Arab sector experiences more craniomaxillofacial injuries. The Jewish elderly population tends to reside in nursing homes where they are more susceptible to accidental falls, whereas young Arab males are more exposed to motor vehicle accidents and interpersonal violence. Falls were the main cause of injuries particularly in women. This may reflect the women's fear of reporting domestic violence. We believe that increased government investments in infrastructures and education will lower the incidence of craniomaxillofacial trauma and balance the gap between both sectors and sexes.