Impact of mild traumatic brain injury on physical, mental and cognitive functioning of abused women admitted to emergency units.

Limited studies exist on women's mild traumatic brain injury received from episode of intimate partner violence. This study aims to identify the occurrence of intimate partner violence-related mild traumatic brain injury in Chinese women admitted to emergency units; and examine the physical, mental, and cognitive functioning of abused women with mild traumatic brain injury related to violent episodes. Eighty-six Chinese abused women presenting at emergency units in four major local hospitals in Hong Kong between January 2014 and December 2016 were recruited. They were admitted for the treatment of intimate partner violence-related physical injuries and were screened for traumatic brain injury by the emergency unit nurses at triage. Participants were assessed for traumatic brain injury based on the definition from US Center for Disease Control and Prevention, post-concussion physical symptoms, anxiety and depression, health-related quality of life, and cognitive functioning. Structured multiphase regression was used to examine the impact of intimate partner violence-related mild traumatic brain injury on physical, mental, and cognitive functioning of participants. We found that 24.4% of participants had intimate partner violence-related mild traumatic brain injury. There were significantly more severe post-concussion physical symptoms in abused women with intimate partner violence-related mild traumatic brain injury than those without mild traumatic brain injury (estimate = 18.7, 95% CI = 10.9 to 26.6, p < 0.001). The Mental Component Summary was also significantly associated with intimate partner violence-related mild traumatic brain injury (estimate = -7.9, 95% CI = -13.8 to -2.1, p = 0.009). Regarding cognitive functioning, the mean total test scores indicated that both groups were cognitively abnormal and there was no significant impact from mild traumatic brain injury. This study provides evidence on the impact of mild traumatic brain injury and implications in screening for mild traumatic brain injury and early intervention for improving quality of life in abused women.

Quantification of injury burden using multiple data sources: a longitudinal study.

Quantification of injury burden is vital for injury prevention, as it provides a guide for setting policies and priorities. This study generated a set of Hong Kong specific disability weights (DWs) derived from patient experiences and hospital records. Patients were recruited from the Accident and Emergency Department (AED) of three major trauma centers in Hong Kong between September 2014 and December 2015 and subsequently interviewed with a focus on health-related quality of life at most three times over a 12-month period. These patient-reported data were then used for estimation of DWs. The burden of injury was determined using the mortality and inpatient data from 2001 to 2012 and then compared with those reported in the UK Burden of Injury (UKBOI) and global burden of diseases (GBD) studies. There were 22,856 mortality cases and 817,953 morbidity cases caused by injuries, in total contributing to 1,027,641 disability-adjusted life years (DALYs) in the 12-year study timeframe. Estimates for DALYs per 100,000 in Hong Kong amounted to 1192, compared with 2924 in UKBOI and 3459 in GBD. Our findings support the use of multiple data sources including patient-reported data and hospital records for estimation of injury burden.

Clinical Features of Heterosexual Intimate Partner Violence Victims With Escalating Injury Severity.

Intimate partner violence (IPV) is largely recognized to have a cyclical pattern and violence escalation in terms of frequency and intensity over time. However, there is a lack of systematic investigation of the profiles of victims and quantification of the patterns of injury of the victims associated with the first time versus repeated violence episodes. This study aimed to fill this knowledge gap by medical chart review of 878 victims in a 5-year period from 2010 to 2014 in Accident and Emergency Department (AED) of two public general hospitals in Hong Kong. The differences in injury patterns between the first IPV episode (FE) and recurrent IPV episodes (REs) experienced by male and female victims in heterosexual relationship were evaluated. The results indicated the violence escalation occurred in recurrent IPV in both genders. In female victims, there was significant increase in the number of injury locations (mean [M] = 2.0 vs. 2.2, p < .05), number of causes of injury (M = 1.7 vs. 2.2, p < .001) and police escort (15.2% vs. 22.1%, p < .05) in RE compared to FE. In male victims, however, only the increase in the number of causes of injury was significant (M = 1.6 vs. 2.1, p < .05) in RE compared to FE. In summary, our results highlight the escalation in the severity of harm of IPV victims in heterosexual relationship, and the gender differences in severity aggression and injury and help-seeking behavior change in recurrent IPV. Preventive measures are indicated to intervene the IPV occurrence and recurrence with rising morbidity and a potential of mortality.

Three-in-one protocol reduces mortality of patients with haemodynamically unstable pelvic fractures-a five year multi-centred review in Hong Kong.

PURPOSE: The mortality rate in patients with haemodynamically unstable pelvic fractures is as high as 40-60%. Despite the new advances in trauma care which are in phase in trauma centres in Hong Kong, the management of haemodynamically unstable pelvic fracture is still heterogeneous. The aim of this study is to review the results of management of haemodynamically unstable pelvic fracture patients in Hong Kong over a five year period. METHODS: This is a retrospective multi-centred cohort study of patients with haemodynamic and mechanically unstable pelvic fractures from 1 January 2010 to 31 December 2014. The primary outcome investigated is mortality of patients (including overall, 30-day, 7-day and 24-hour mortalities). RESULTS: Implementation of three-in-one pelvic damage control protocol was identified to be a significant independent predictive factor for overall, 30-day, seven-day and 24-hour mortalities. The overall in-hospital and 30-day mortality rates for patients managed with three-in-one protocol was 12.5%, while it was 11% for seven day mortality and 6% for 24 hour mortality. There were no significant differences in demographic characteristics, physiological measurements, types of pelvic fracture, severity and mechanism of injury between patients managed with or without three-in-one protocol. CONCLUSIONS: Implementation of the multidisciplinary three-in-one pelvic damage control protocol reduces mortality and therefore should be highly recommended. The results are convincing as it has eliminated the limitations of our previous single-centred trial.

Predictive model integrating dynamic parameters for massive blood transfusion in major trauma patients: The Dynamic MBT score.

BACKGROUND: Currently existing predictive models for massive blood transfusion in major trauma patients had limitations for sequential evaluation of patients and lack of dynamic parameters. OBJECTIVE: To establish a predictive model for predicting the need of massive blood transfusion major trauma patients, integrating dynamic parameters. DESIGN: Multi-center retrospective cohort study. SETTING: Four designated trauma centers in Hong Kong. METHODS: Trauma patients aged >12years were recruited from the trauma registries from 2005 to 2012. MBT was defined as delivery of ≥10units of packed red cells within 24h. Split sampling method was adopted for model building and validation. Multivariate logistic regression was adopted for model building, with weight assigned based on logarithmic of adjusted odds ratios. The performance of the dynamic MBT score (DMBT) was compared with the PWH score and the Trauma Associated Severe Hemorrhage (TASH) score in the validation data set. RESULTS: 4991 patients were included in the study. The DMBT was established with 8 parameters: systolic blood pressure, heart rate, hemoglobin, hemoglobin drop within the first 2h, INR, base deficit, unstable pelvic fracture and hemoperitoneum in radiological imaging. At cut-off score of 6 the DMBT achieved sensitivity of 78.2% and specificity of 89.2%. In the validation set, the AUCs of the DMBT, PWH score, and TASH score were 0.907, 0.844, and 0.867 respectively. CONCLUSIONS: The DMBT score allows both snapshot and sequential activation along the trauma care pathway and has better performance than the PWH score and TASH score.

Intravenous fluid selection rationales in acute clinical management.

BACKGROUND: Intravenous fluid (IVF) is commonly used in acute clinical management. This study aimed to review the choice and primary considerations in IVF prescriptions and to evaluate the adequacy of guidelines and trainings on it in the New Territories West Cluster (NTWC) of Hong Kong. METHODS: This is a descriptive study based on data collected from an online survey. Data were processed by SPSS for statistical analysis. This study focused on a general description and doctor-nurse between group comparison. Participants were asked the choice of IVF for nine acute clinical scenarios and provide reason. A 1-10 scale was used to assess the sufficiency of guideline, training and information, and time for revision on IVF prescription. RESULTS: 0.9% sodium chloride was the most familiar IVF (36%), followed by 5% Dextrose solution (26%). In the nine scenarios, the most chosen IVF was 0.9% sodium chloride (37%-61%). There was significant difference in the choice of IVF between doctors and nurses in 7 cases. The second most chosen IVF for doctors was Plasma-Lyte A while that for nurses was Gelofusine. Departmental practice was the most chosen reason to account for the prescription. The adequacy of guideline, information and training, and time for revision was rated 5. Doctors had significantly more time at work than nurses to update knowledge in IVF prescription (5.41 versus 4.57). CONCLUSION: 0.9% sodium chloride was mostly chosen. The choice of IVF was mainly based on departmental practice. Adequacy of guideline, information and training, and time for revision on IVF prescription were average, indicating significant training deficit.

Intimate partner violence victims' acceptance and refusal of on-site counseling in emergency departments: Predictors of help-seeking behavior explored through a 5-year medical chart review.

Healthcare services constitute the first formal support that many intimate partner violence (IPV) victims receive and a link to formal welfare and psychological support. The help-seeking behavior for psychosocial support, e.g., Accident and Emergency Departments (AED) onsite counseling, is key to developing effective support for IPV victims. This study aimed to strengthen the health-welfare support link to aid IPV prevention in AEDs by investigating the acceptance and refusal of on-site counseling by IPV victims. A retrospective cohort study retrieved and reviewed all records of IPV victims presenting at the AEDs of two Hong Kong hospitals between 2010 and 2014. A total of 157 male and 823 female IPV victims were identified, 295 of whom refused on-site counseling. Bivariate and multivariate analyses were performed to examine the association between help-seeking and demographic and violent injury-related factors. The odds of help-seeking via on-site counseling were significantly lower for victims with mental illness (aOR=0.49; 95% CI=0.27, 0.88). After controlling for all demographic characteristics, mental illness, and drug abuse information, sex remained an independent predictor of help-seeking (aOR=2.62; 95% CI=1.45, 4.74); victims who had experienced >2 abuse incidents were more likely to seek help than those who had experienced ≤2 abuse incidents (aOR=1.90; 95% CI=1.11, 3.26). The factors associated with help-seeking from on-site services by IPV victims reflect the need for multidisciplinary collaborative work aimed at IPV prevention. Healthcare professionals require training on how to promote help-seeking behavior targeted specifically for male and female IPV victims according to their needs and preferences.

Idarucizumab for Dabigatran Reversal - Full Cohort Analysis.

BACKGROUND: Idarucizumab, a monoclonal antibody fragment, was developed to reverse the anticoagulant effect of dabigatran. METHODS: We performed a multicenter, prospective, open-label study to determine whether 5 g of intravenous idarucizumab would be able to reverse the anticoagulant effect of dabigatran in patients who had uncontrolled bleeding (group A) or were about to undergo an urgent procedure (group B). The primary end point was the maximum percentage reversal of the anticoagulant effect of dabigatran within 4 hours after the administration of idarucizumab, on the basis of the diluted thrombin time or ecarin clotting time. Secondary end points included the restoration of hemostasis and safety measures. RESULTS: A total of 503 patients were enrolled: 301 in group A, and 202 in group B. The median maximum percentage reversal of dabigatran was 100% (95% confidence interval, 100 to 100), on the basis of either the diluted thrombin time or the ecarin clotting time. In group A, 137 patients (45.5%) presented with gastrointestinal bleeding and 98 (32.6%) presented with intracranial hemorrhage; among the patients who could be assessed, the median time to the cessation of bleeding was 2.5 hours. In group B, the median time to the initiation of the intended procedure was 1.6 hours; periprocedural hemostasis was assessed as normal in 93.4% of the patients, mildly abnormal in 5.1%, and moderately abnormal in 1.5%. At 90 days, thrombotic events had occurred in 6.3% of the patients in group A and in 7.4% in group B, and the mortality rate was 18.8% and 18.9%, respectively. There were no serious adverse safety signals. CONCLUSIONS: In emergency situations, idarucizumab rapidly, durably, and safely reversed the anticoagulant effect of dabigatran. (Funded by Boehringer Ingelheim; RE-VERSE AD ClinicalTrials.gov number, NCT02104947 .).

Healthcare resource utilization in patients receiving idarucizumab for reversal of dabigatran anticoagulation due to major bleeding, urgent surgery, or procedural interventions: interim results from the RE-VERSE AD™ study.

AIMS: Patients treated with anticoagulants may experience serious bleeding or require urgent surgery or intervention, and may benefit from rapid anticoagulant reversal. This exploratory analysis assessed healthcare resource utilization (HCRU) in patients treated with idarucizumab, a specific reversal agent for dabigatran etexilate. MATERIALS AND METHODS: RE-VERSE AD™ (NCT02104947), a prospective, multi-center open-label study, is evaluating idarucizumab for dabigatran reversal in patients with serious bleeding (Group A) or undergoing emergency surgery/procedures (Group B). HCRU outcome measures evaluated in the first 90 patients enrolled were use of blood products and pro-hemostatic agents, length of stay (LOS) in hospital, and LOS in intensive care unit (ICU). RESULTS: Blood products or pro-hemostatic agents were given to 63% (32/51) of patients in Group A and 23% (9/39) of patients in Group B on the day of/day after surgery. An overnight hospital stay was reported for 82% (42/51) of patients in Group A with median LOS = 7 (range = 1-71) bed-days. For Group B, 92% (36/39) had an overnight hospital stay with a median LOS = 9 (range = 1-92) bed-days. In Group A, 17 patients were admitted to the ICU for at least 1 day with median LOS = 4 (range = 1-44) days; in Group B the number was 15 with median LOS = 2 (range = 1-92) days. LIMITATIONS: The lack of a control group and the small patient numbers limit the strength of the conclusions. CONCLUSIONS: The use of idarucizumab may simplify emergency management of dabigatran-treated patients with life-threatening bleeds and reduce perioperative complications in patients undergoing emergency surgery.

A comparison of intimate partner violence and associated physical injuries between cohabitating and married women: a 5-year medical chart review.

BACKGROUND: Cohabitation, referring to a co-residential romantic relationship between two intimate partners without a marriage license, has become widely accepted in contemporary societies. It has been found that cohabitating women have a higher risk of experiencing intimate partner violence (IPV) than married women. However, as yet, no studies have investigated the level and pattern of IPV-associated physical injuries and its mental health impact on cohabitating women. Therefore, we aim to compare IPV-associated physical injuries between cohabitating and married women by conducting a review of 5-year medical records from the emergency departments of two major public hospitals in Hong Kong. METHODS: This is a retrospective cohort study. Using two computerized systems, we identified the medical charts of 1011 women who had experienced IPV and presented at emergency departments between 2010 and 2014, of which, 132 were cohabitating and 833 were married. RESULTS: Cohabitating women were significantly younger (p-value < .0001) and had obtained a higher educational level (p-value = .008) than married women. After adjusting for those two variables, the logistic regression models showed that cohabitating women were approximately 2.1 times more likely than married women to present with head, neck, or facial injuries (OR = 2.1, 95% CI = 1.30-3.40, p = .002), and the risk of having multiple injuries in different locations (head, neck, face, torso, limbs) was almost twice that for cohabitating women compared with married women (OR = 1.82, 95% CI = 1.25-2.65, p = .001). Furthermore, cohabitating women were almost two times as likely as married women to experience more than one method of physical violence (OR = 1.72, 95% CI = 1.18-2.51, p = .005). There were no significant differences regarding mental health, police reporting, and discharge plans. CONCLUSIONS: Owing to recent social changes to the family structure, including the growing acceptance of cohabitation, it is essential that a screening program for IPV is established for cohabitating women, as well as the inclusion of IPV content in medical and nursing curriculums and in-service training.

Characterization of available automated external defibrillators in the market based on the product manuals in 2014.

BACKGROUND: To popularize the wide-spread use of automated external defibrillator (AED) to save life in sudden cardiac arrest, we compared the strength and weakness of different types of AEDs to enable a sound selection based on regional requirement. METHODS: This was a retrospective descriptive study. Different types of AEDs were compared according to the information of AEDs from manuals and brochures provided by the manufacturers. Fifteen types of AEDs were divided into 3 groups, basic, intermediate and advanced. RESULTS: Lifeline™ AUTO AED had the best performance in price, portability and user-friendly among AEDs of basic level. It required less time for shock charging. Samaritan PAD defibrillator was superior in price, portability, durability and characteristic among AEDs of intermediate level. It had the longest warranty and highest protection against water and dust. Lifeline™ PRO AED had the best performance in most of the criteria among AEDs of advanced level and offered CPR video and manual mode for laypersons and clinicians respectively. CONCLUSION: Lifeline™ AUTO AED, Samaritan PAD defibrillator, Lifeline™ PRO AED are superior in AEDs of basic, intermediate and advanced levels, respectively. A feasible AED may be chosen by users according to the regional requirement and the current information about the best available products.

Role of copeptin in dual-cardiac marker strategy for patients with chest pain presented to ED.

OBJECTIVE: The objective of the study is to evaluate the role of copeptin in the diagnosis of acute coronary syndrome (ACS) and its role in dual-cardiac marker diagnostic strategy with troponin. DESIGN: A prospective cohort study was carried out from May 2012 to October 2012. SETTING: The study was conducted at the emergency department (ED) of a public hospital in a cluster of Hong Kong. METHODS: Patients aged at least 18 years presented with chest pain to ED who have intermediate or high likelihood of ACS were included. All patients had blood taken in the ED for copeptin and troponin I. The adjudicated diagnoses of ACS were made by 2 independent physicians based on the universal definition. Diagnostic characteristics were calculated. Receiver operating characteristic curves were created. Areas under the curves were compared for copeptin, troponin I, and dual-marker strategy with copeptin and troponin I. RESULTS: A total of 637 patients were recruited. Seventy-eight had been diagnosed to be ACS. The negative predictive value of copeptin for ACS was 0.881 (0.849-0.907) compared with troponin I, 0.937 (0.913-0.956). The areas under the receiver operating characteristic curves of copeptin, troponin I, and dual-marker strategy were 0.68, 0.859, and 0.880, respectively. CONCLUSIONS: Addition of copeptin to troponin does not have significant improvement of the diagnostic accuracy of ACS in patients presented with chest pain.

Idarucizumab for Dabigatran Reversal.

BACKGROUND: Specific reversal agents for non-vitamin K antagonist oral anticoagulants are lacking. Idarucizumab, an antibody fragment, was developed to reverse the anticoagulant effects of dabigatran. METHODS: We undertook this prospective cohort study to determine the safety of 5 g of intravenous idarucizumab and its capacity to reverse the anticoagulant effects of dabigatran in patients who had serious bleeding (group A) or required an urgent procedure (group B). The primary end point was the maximum percentage reversal of the anticoagulant effect of dabigatran within 4 hours after the administration of idarucizumab, on the basis of the determination at a central laboratory of the dilute thrombin time or ecarin clotting time. A key secondary end point was the restoration of hemostasis. RESULTS: This interim analysis included 90 patients who received idarucizumab (51 patients in group A and 39 in group B). Among 68 patients with an elevated dilute thrombin time and 81 with an elevated ecarin clotting time at baseline, the median maximum percentage reversal was 100% (95% confidence interval, 100 to 100). Idarucizumab normalized the test results in 88 to 98% of the patients, an effect that was evident within minutes. Concentrations of unbound dabigatran remained below 20 ng per milliliter at 24 hours in 79% of the patients. Among 35 patients in group A who could be assessed, hemostasis, as determined by local investigators, was restored at a median of 11.4 hours. Among 36 patients in group B who underwent a procedure, normal intraoperative hemostasis was reported in 33, and mildly or moderately abnormal hemostasis was reported in 2 patients and 1 patient, respectively. One thrombotic event occurred within 72 hours after idarucizumab administration in a patient in whom anticoagulants had not been reinitiated. CONCLUSIONS: Idarucizumab completely reversed the anticoagulant effect of dabigatran within minutes. (Funded by Boehringer Ingelheim; RE-VERSE AD ClinicalTrials.gov number, NCT02104947.).

Injury Patterns and Help-seeking Behavior in Hong Kong Male Intimate Partner Violence Victims.

BACKGROUND: Few studies have focused on the characteristics of male victims of intimate partner violence (IPV). Providers of care lack knowledge on the pathognomonic features to identify male IPV victims, who tend to be hidden. OBJECTIVES: This study investigated the injury patterns of male IPV victims and their help-seeking characteristics. METHODS: A retrospective cohort study was carried out in two regional hospitals in Hong Kong. Data were collected from the hospital computer databases (i.e., the Accident & Emergency Information System and the Clinical Data Analysis and Reporting System) and the medical charts completed by physicians. RESULTS: Medical records were retrieved from August 1, 2009 to December 31, 2011 for all IPV victims presenting at the accident and emergency departments. There were 372 cases in total, including 54 male and 318 female cases. Male victims were more likely to have abrasions/scrapes (66.7%), human bites (20.4%), and laceration/cutting (18.5%) than female victims (31.4%, 1.3%, 6.9%; p < 0.001, p < 0.01, p < 0.001, respectively). More male victims received dressing (38.9%) and injection (13.0%) than female victims (14.5%, 3.5%; p < 0.001, p < 0.01, respectively). Fewer male victims attended consultation by the medical social worker (MSW; 5.6%) than female victims (21.7%). CONCLUSION: Abrasion wounds are the most common in male victims of IPV. Male victims have lower rates of seeking help from MSWs, and most are aged 40 years or above. This study has identified important characteristics of male victims to aid the development of a comprehensive program for early IPV detection and management.

Design and rationale for RE-VERSE AD: A phase 3 study of idarucizumab, a specific reversal agent for dabigatran.

Idarucizumab, a Fab fragment directed against dabigatran, produced rapid and complete reversal of the anticoagulation effect of dabigatran in animals and in healthy volunteers. The Study of the REVERSal Effects of Idarucizumab in Patients on Active Dabigatran (RE-VERSE AD™) is a global phase 3 prospective cohort study aimed at investigating idarucizumab in dabigatran-treated patients who present with uncontrollable or life-threatening bleeding, and in those requiring urgent surgery or intervention. We describe the rationale for, and design of the trial (clinicaltrials.gov NCT02104947).

How to secure the connection between thoracostomy tube and drainage system?

BACKGROUND: Thoracostomy tube insertion is one of the common bedside procedures in emergency medicine and many acute specialties. Dislodgement of thoracostomy tube from the connection tube of chest drainage system is an important problem with potential complications such as contamination, infection and pneumothorax. Besides, mere loosening can also lead to malfunction. It is a common practice to tape the connection of the system. This study aimed to evaluate the materials and methods of connection of chest drain system to minimize drainage dislodgement. METHODS: We conducted an experimental study to assess the tightness of the connection with various taping materials and methods. We selected three commonly used adhesive materials (3M™ Transpore™ Medical tape, 3M™ Micropore™ Medical tape, 3M™ Soft Cloth Tape on Liner) and three different methods (cross method, straight method, nylon band) to secure the junction between the thoracostomy tube and the bi-conical adaptor in the drainage system. The measured outcome was the weight causing visible loosening of the junction between thoracotomy tube and the adaptor. RESULTS: For each taping material and taping method, 10 trials were performed. The median weight required to disconnect the junction is 26.22 lb for Transpore™, 31.29 lb for Micropore™ and 32.44 lb for Soft Cloth Tape on Liner. A smaller force was required to disconnect if Transpore™ is used (P<0.001). There was no statistical significant difference between Micropore™ and Soft Cloth Tape on Liner (P=0.98). The median disconnecting force is 32.44 lb for straight taping method, 40.55 lb for cross taping method and 21.15 lb for plastic band. The cross-taping method was the more secure method (P<0.0001 when compared with plastic band) (P=0.033 when compared with straight method). CONCLUSION: Cross-taping is the most secure method among the tested varieties in connecting the thoracostomy tube to the chest drainage system. Transpore™ is not a recommended material for thoracostomy tube taping.

Patterns, aetiology and risk factors of intimate partner violence-related injuries to head, neck and face in Chinese women.

BACKGROUND: Intimate partner violence (IPV) related injuries have been recognized among health care professionals. However, few studies have provided detailed information on injuries to the head, neck and face regions in Chinese women. As abused Chinese women are generally unwilling to disclose IPV and there are differences in socio-demographic characteristics, societal norms and behaviours, the women may exhibit different patterns, aetiology and risk factors of IPV-related HNF injuries. This study aims to examine the patterns of head, neck and face injuries presenting to Accident and Emergency departments, including the anatomical regions, types, severity, aetiology and demographic and non-demographic risk factors of injuries inflicted by intimate partners in Chinese context. METHODS: Medical charts of 223 women presented to the Accident and Emergency departments of two regional hospitals in Hong Kong between January 2010 and December 2011 were reviewed independently by two reviewers. RESULTS: Head, neck and face injuries remained the most common injuries found in abused Chinese women (77.6%), and punching with a fist was the most common aetiology (60.2%). In particular, punching with a fist was significantly associated on the upper third of the maxillofacial region (p = .01) and the back part of the head (p = .03). Moreover, cohabiting and separated women were more likely to have multiple injuries than those who were married (OR = 3.3, 95% CI = 1.4, 7.8; OR = 2.1, 95% CI = .4, 11.9). CONCLUSIONS: The findings enhance the understanding of head, neck and face injuries and inform clinicians about the linkage among injuries and risks in abused Chinese women.

Evolving Frontiers in Severe Polytrauma Management – Refining the Essential Principles

This editorial aims to refine the severe polytrauma management principles. While keeping ABCDE priorities, the termination of futile resuscitation and the early use of tourniquet to stop exsanguinating limb bleeding are crucial. Difficult-airway-management (DAM) is by a structured 5-level approach. The computerised tomography (CT) scanner is the tunnel to death for hemodynamically unstable patients. Focused Abdominal Sonography for Trauma–Ultrasonography (FAST USG) has replaced diagnostic peritoneal lavage (DPL) and is expanding to USG life support. Direct whole-body multidetector-row computed tomography (MDCT) expedites diagnosis & treatment. Non-operative management is a viable option in rapid responders in shock. Damage control resuscitation comprising of permissive hypotension, hemostatic resuscitation & damage control surgery (DCS) help prevent the lethal triad of trauma. Massive transfusion protocol reduces mortality and decreases the blood requirement. DCS attains rapid correction of the deranged physiology. Mortality reduction in major pelvic disruption requires a multi-disciplinary protocol, the novel pre-peritoneal pelvic packing and the angio-embolization. When operation is the definitive treatment for injury, prevention is best therapy.

A cross-sectional survey of snake oral bacterial flora from Hong Kong, SAR, China.

OBJECTIVE: To determine the pattern of oral bacterial flora and their sensitivity to antibiotics in freshly captured native snakes in Hong Kong SAR, People's Republic of China. METHODS: Healthy native snakes were captured and kept in a designated centre. Snake species were identified by experienced herpetologists. Mouth swabs were taken by the veterinarian using strict aseptic techniques. The snakes were released back to the wild immediately after the above procedure. Swabs were sent for microbiological studies of bacterial culture and antibiotic sensitivity. RESULTS: 47 venomous snakes of the families Colubridae, Elapidae and Viperidae and 53 non-medically important snakes were captured. 406 bacterial isolates of 72 different species were cultured: these included gram negative and positive bacterial species and also anaerobic bacterial species. With the exception of the white-lipped pit viper (Cryptelytrops albolabris), venomous snakes harboured more pathogenic bacteria and total bacteria species compared to the non-medically important species. Of the venomous snakes, the Chinese cobra (Naja atra) harboured the largest number of bacterial species. In the present study, all gram negative bacteria associated with wound infection were sensitive to levofloxacin, netilmicin and piperacillin/tazobactam. Many gram negative bacteria in the study were not sensitive to cefuroxime axetil. Amoxicillin/clavulanic acid was an appropriate choice to cover Enterococcus faecalis and anaerobes. CONCLUSION: In the presence of wound infection from snakebite injury in Hong Kong, first line empirical antibiotics include amoxicillin/clavulanic acid plus levofloxacin. Prophylactic antibiotics may be considered in selected cases of Chinese cobra (N. atra) bite, otherwise prophylactic antibiotics are not recommended in snakebite unless tissue necrosis is present.