The role of number of affected vessels on radiologic and clinical outcomes of patients with blunt cerebrovascular injury.

OBJECTIVE: There is a lack of data on the role of characteristics of injured vessels on the outcomes of patients with blunt cerebrovascular injuries (BCVIs). The aim of this study was to assess the effect of the number (single vs multiple) of injured vessels on outcomes. METHODS: This is a retrospective study at two American College of Surgeons Level I trauma centers (2017-2021). Adult (>16 years) trauma patients with BCVIs are included. Injuries were graded by the Denver Scale based on the initial computed tomography angiography (CTA). Early repeat CTA was performed 7 to 10 days after diagnosis. Patients were stratified by the number (single vs multiple) of the involved vessels. Outcomes included progression of BCVIs on repeat CTA, stroke, and in-hospital mortality attributable to BCVIs. Multivariable regression analyses were performed to identify the association between the number of injured vessels and outcomes. RESULTS: A total of 491 patients with 591 injured vessels (285 carotid and 306 vertebral arteries) were identified. Sixty percent were male, the mean age was 44 years, and the median Injury Severity Score was 18 (interquartile range, 11-25). Overall, 18% had multiple-vessel injuries, 16% had bilateral vessel injuries, and 3% had multiple injuries on the same side. The overall rates of progression to higher-grade injuries, stroke, and mortality were 23%, 7.7%, and 8.8%, respectively. On uni- and multivariable analyses, multiple BCVIs were associated with progression to higher-grade injuries on repeat imaging, stroke, and mortality compared with single-vessel injuries. CONCLUSIONS: BCVIs with multiple injured vessels are more likely to progress to higher grades on repeat CTA, with multiple injuries independently associated with worse clinical outcomes, compared with those with single injuries. These findings highlight the importance of incorporating the number of injured vessels in clinical decision-making and in defining protocols for repeat imaging.

Abdominal computed tomography scoring systems and experienced radiologists in the radiological diagnosis of small bowel and mesenteric injury.

PURPOSE: Blunt bowel and/or mesenteric injury requiring surgery presents a diagnostic challenge. Although computed tomography (CT) imaging is standard following blunt trauma, findings can be nonspecific. Most studies have focused on the diagnostic value of CT findings in identifying significant bowel and/or mesenteric injury (sBMI). Some studies have described scoring systems to assist with diagnosis. Little attention, has been given to radiologist interpretation of CT scans. This study compared the discriminative ability of scoring systems (BIPS and RAPTOR) with radiologist interpretation in identifying sBMI. METHODS: We conducted a retrospective chart review of trauma patients with suspected sBMI. CT images were reviewed in a blinded fashion to calculate BIPS and RAPTOR scores. Sensitivity and specificity were compared between BIPS, RAPTOR, and the admission CT report with respect to identifying sBMI. RESULTS: One hundred sixty-two patients were identified, 72 (44%) underwent laparotomy and 43 (26.5%) had sBMI. Sensitivity and specificity were: BIPS 49% and 87%, AUC 0.75 (0.67-0.81), P < 0.001; RAPTOR 46% and 82%, AUC 0.72 (0.64-0.79), P < 0.001; radiologist impression 81% and 71%, AUC 0.82(0.75-0.87), P < 0.001. The discriminative ability of the radiologist impression was higher than RAPTOR (P = 0.04) but not BIPS (P = 0.13). There was not a difference between RAPTOR vs. BIPS (P = 0.55). CONCLUSION: Radiologist interpretation of the admission CT scan was discriminative of sBMI. Although surgical vigilance, including evaluation of the CT images and patient, remains fundamental to early diagnosis, the radiologist's impression of the CT scan can be used in clinical practice to simplify the approach to patients with abdominal trauma.

Marijuana may lead to increased platelet activity in trauma patients.

INTRODUCTION: Delta-9-tetraydrocannabinol (THC) usage is associated with venous thromboembolic events (VTE) in trauma patients. We hypothesized that THC â€‹+ â€‹trauma patients would have less platelet inhibition than THC - patients using thromboelastography with platelet mapping (TEG-PM). METHODS: Results from initial TEG- PM assays and patient's UDS were reviewed between 2019 and 2023. Mean levels of arachidonic acid (AA) and adenosine diphosphate (ADP) percent inhibition were compared by THC status. RESULTS: 793 patients had TEG-PM and UDS data. Mean levels of arachidonic acid (AA) percentage inhibition were 32.6 â€‹± â€‹34.2. AA inhibition was lower for THC â€‹+ â€‹vs THC- patients (THC+ 23.9 â€‹± â€‹27.0 vs THC- 34.3 â€‹± â€‹35.3, P â€‹< â€‹0.001). There was no association between THC status and ADP inhibition (THC+ 32.5 â€‹± â€‹27.1 vs THC- 30.8 â€‹± â€‹28.4, P â€‹= â€‹0.536). DISCUSSION: To our knowledge, our data are the first to suggest a clinically measurable increase in platelet reactivity in THC â€‹+ â€‹trauma patients. More work is needed to determine if addition of aspirin to the chemoprophylaxis strategy for THC â€‹+ â€‹patients would mitigate the known association of THC with VTE.

Pentobarbital coma for management of intracranial hypertension following traumatic brain injury: Lack of early response to treatment portends poor outcomes.

INTRODUCTION: Traumatic brain injury (TBI) results in the death of over 50,000 and the permanent disability of 80,000 individuals annually in the United States. Much of the permanent disability is the result of secondary brain injury from intracranial hypertension (ICH). Pentobarbital coma is often instituted following the failure of osmotic interventions and sedation to control intracranial pressure (ICP). The goal of this study was to evaluate the efficacy of pentobarbital coma with respect to ICP management and long-term functional outcome. METHODS: Traumatic brain injury patients who underwent pentobarbital coma at a level 1 trauma center between 2014 and 2021 were identified. Patient demographics, injury characteristics, Glasgow Coma Scale (GCS) scores, intracranial pressures (ICPs), and outcomes were obtained from the trauma registry as well as inpatient and outpatient medical records. The proportion of ICPs below 20 for each hospitalized patient-day was calculated. The primary outcome measured was GCS score at the last follow-up visit. RESULTS: 25 patients were identified, and the majority were male (n â€‹= â€‹23, 92%) with an average age of 30.0 years â€‹± â€‹12.9 and median injury severity score of 30 (21.5-33.5). ICPs were monitored for all patients with a median of 464 (326-1034) measurements. The average hospital stay was 16.9 days â€‹± â€‹11.5 and intensive care stay was 16.9 â€‹± â€‹10.8 days. 9 (36.0%) patients survived to hospital discharge. Mean follow-up time in months was 36.9 â€‹± â€‹28.0 (min-max 3-80). 7 of the 9 surviving patients presented as GCS 15 on follow-up and the remaining were both GCS 9. Patients presenting at last follow-up with GCS 15 had a significantly higher proportion of controlled ICPs throughout their hospitalization compared to patients who expired or with follow-up GCS <15 (GCS 15: 88% â€‹± â€‹10% vs. GCS <15 or dead: 68% â€‹± â€‹22%, P â€‹= â€‹0.006). A comparison of the daily proportion of controlled ICPs by group revealed negligible differences prior to pentobarbital initiation. Groups diverged nearly immediately upon pentobarbital coma initiation with a higher proportion of controlled ICPs for patients with follow-up GCS of 15. CONCLUSION: Patients that do not have an immediate response to pentobarbital coma therapy for ICH universally had poor outcomes. Alternative therapy or earlier palliation should be considered for such patients. In contrast, patients whose ICPs responded quickly to pentobarbital had excellent long-term outcomes.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) prior to interfacility transfer: Who might benefit in a statewide trauma system?

BACKGROUND: Rural trauma patients are often seen at lower-level trauma centers before transfer and have higher mortality than those seen initially at a Level 1 Trauma Center. This study aims to describe the potential for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to bridge this mortality gap. METHODS: We queried the Arizona Trauma Registry between 2014 and 2017 for hypotensive patients who were later transported to a level 1 center. REBOA candidates were identified as those with injuries consistent with major infra-diaphragmatic torso hemorrhage as the likely cause of death. RESULTS: Of 17,868 interfacility transfers during the study period, 333 met inclusion criteria and had sufficient data for evaluation. 26 of the 333 patients were identified as REBOA candidates. CONCLUSIONS: Our study suggests that REBOA may be an effective means to extend survivability to those severely injured trauma patients needing interfacility transfer to a higher level of care.

Missed blunt cerebrovascular injuries using current screening criteria - The time for liberalized screening is now.

Diagnostic Criteria Study BACKGROUND: The morbidity and mortality associated with ischemic stroke attributable to blunt cerebrovascular injury (BCVI) warrant aggressive screening. The Denver Criteria (DC) and Expanded Denver Criteria (eDC) have imprecise elements that can be difficult and subjective in application and can delay or prevent screening. We hypothesize these screening criteria lack adequate ability to consistently identify BCVI and that the use of a liberalized screening approach with CT angiography (CTA) is superior without increasing risk of acute kidney injury (AKI). METHODS: This was a multi-institutional retrospective cohort study of trauma patients who presented between 2015-2020 with radiographically confirmed BCVI diagnosed using each institutions' liberalized screening protocol, defined as automatic CTA of the head and neck for all patients undergoing head and neck CT. Outcomes of interest included AKI, stroke, and death due to BCVI. Outcomes were reported as frequency, percent, and 95% confidence interval as calculated by the Clopper-Pearson method. Incidence of medical follow-up within 1 year of first medical visit was quantified as the median and inter-quartile range of days to follow-up visit. RESULTS: We identified 433 BCVI patients with a mean age of 45.2 (standard deviation 18.9) years, 256 men and 177 women, 1.73 m (0.10) tall, and weighed 80.3 kg (20.3). Forty-one patients had strokes (9.5% [95% confidence interval 6.9, 12.6] and 12 patients (2.8% [1.4, 4.5]) had mortality attributable to BCVI. Of 433 total cases, 132 (30.5% [26.2, 35.1]) would have been missed by DC and 150 (34.6% [30.2, 39.3]) by eDC. Incidence of AKI in our BCVI population was 6 (1.4% [0.01, 3.0]). CONCLUSIONS: BCVI would be missed over 30% of the time using the DC and eDC compared to liberalized use of screening CTA. Risk of AKI due to CTA did not occur at a clinically meaningful level, supporting liberal CTA screening.

Management of Delirium in the Intensive Care Unit.

In the intensive care unit, delirium is a major contributor to morbidity and mortality in adult patients. Patients with delirium have been shown to have increased length of stay, decreased functional outcomes, and increased risk for requiring placement at the time of discharge. In addition, decreased cognitive function and dementia have been shown to be long-term complications from delirium. The mainstay of treatment and prevention include therapy- and behavioral-based interventions, including frequent orientation, cognitive stimulation, mobilization, sleep restoration, and providing hearing and visual aids. Refractory delirium may require pharmacologic intervention with antipsychotics or alpha-2 agonists.

The sustained effect of a temporary measure: Urban firearm mortality following expiration of the Federal Assault Weapons Ban.

BACKGROUND: The Federal Assault Weapons Ban (FAWB) was in effect from 1994 to 2004. We sought to examine its impact on firearm-related homicides. METHODS: All firearm-related homicides occurring in three metropolitan United States cities were analyzed during the decade preceding (PRE), during (BAN), and after (POST) the FAWB. Files were obtained from the Federal Bureau of Investigation. Rates of firearm-related homicides were stratified by year and compared using simple linear regression. RESULTS: 21,327 firearm-related homicides were analyzed. The median number of firearm-related homicides per year decreased from 333 (PRE) to 199 (BAN) (p = 0.008). This effect persisted following expiration of the ban (BAN 199 vs POST 206, p = 0.429). The rate of firearm-related homicides per 1 M population also decreased from 119.4 in 1985 to 49.2 in 2014 (ß = -2.73, p < 0.0001). CONCLUSIONS: During the FAWB, there was a significant decrease in firearm-related homicides in three of the most dangerous cities, underscoring the need for better directed prevention efforts.

Re-Sighting the Gun Debate: Defining Patterns of Firearm-Related Death to Help Focus Prevention Efforts.

BACKGROUND: Gun violence remains a significant public health problem. Although gun violence prevention efforts mostly target homicides, nationally, two-thirds of all firearm deaths are suicides. The purpose of this study was to define patterns of firearm-related deaths and examine the effect of population size. STUDY DESIGN: All firearm-related deaths in the US between 1999 and 2016 were analyzed. Homicides and suicides were obtained from the Federal Bureau of Investigation and the Centers for Disease Control and Prevention, respectively, comprising the database. For each state, the largest metropolitan city by population and a corresponding small urban city were selected. Firearm-related deaths were stratified by type and city size and compared. Rates of firearm-related homicides and suicides per 1 million population were stratified by year and compared over time using simple linear regression. RESULTS: 544,749 firearm-related deaths occurred across the US over the study period (38% homicides, 62% suicides). The median rate of firearm-related suicides was significantly greater than firearm-related homicides regardless of city size and across the US. Linear regression analysis failed to identify a significant change in the rate of firearm-related homicides over the study period. However, the rate of firearm-related suicides increased significantly regardless of city size between 1999 and 2016. CONCLUSION: Although homicides account for the majority of firearm-related deaths in metropolitan areas, suicides constitute a disproportionate number in smaller urban areas. Although the rate of homicides has stabilized, the rate of firearm-related suicides continues to increase significantly, underscoring the need for better direct prevention efforts and public health policy.

Long-term functional outcomes after traumatic spine fractures.

BACKGROUND: Traumatic spine fractures can result in chronic pain, disability, and prolonged rehabilitation. The purpose of this study is to determine the long-term effects of traumatic spine fractures on patients' functional outcomes after nonoperative and operative management. METHODS: Patients with traumatic spine fractures over a 5-year period were identified and stratified by management strategy (nonoperative and operative) and compared. Functional outcomes were measured using the Boston Activity Measure for PostAcute Care to assess basic mobility and daily activity. Multiple linear regression was used to identify predictors of functional outcome after traumatic spine fractures. RESULTS: In total, 488 patients were identified: 271 nonoperative and 217 operative. Follow-up was obtained in 168 (34%) patients: 95 nonoperative and 73 operative. Mean follow-up was 5.7 years (range 3-8 years). Mean Activity Measure for PostAcute Care scores in patients managed nonoperatively for basic mobility (68 vs 64, P = .09) and daily activity (69 vs 66, P = .26) were clinically similar to those managed operatively. Multiple linear regression identified increasing age as a predictor of decreased basic mobility (ß = -0.50, P < .0001, ß = -0.17, P = .022) and daily activity (ß = -0.58, P < .0001, ß = -0.35, P = .003) in nonoperative and operative groups, respectively. In nonoperative patients, thoracic spine fracture was predictive of both decreased basic mobility (ß = -5.88, P = .041) and daily activity (ß = -8.62, P = .043). In operative patients, lower extremity fractures (ß = -8.86, P = .012), discharge location (ß = -6.91, P = .003), and time to operative fixation (ß = -0.77, P = .040) were associated with decreased basic mobility. CONCLUSION: All patients with traumatic spine fractures displayed mild to moderate functional impairment. Age, thoracic fractures, lower extremity fractures, discharge location, and time to operative fixation were associated with poor functional outcomes.

Impact of Endovascular Stenting on Outcomes in Patients with Traumatic Subclavian Artery Injury.

BACKGROUND: Traumatic subclavian artery injury (SAI) remains uncommon but can lead to significant morbidity and mortality. Although open and endovascular repair offer excellent limb salvage rates, their role in blunt and penetrating injuries is not well defined. The goal of this study was to examine the effect of mechanism of injury and type of repair on outcomes in patients with traumatic SAI. STUDY DESIGN: Patients undergoing procedures for traumatic SAI were identified from the Trauma Quality Improvement Program database between 2015 and 2018. Demographics, severity of injury and shock, type of subclavian repair (open vs endovascular), morbidity, and mortality were recorded. Patients with SAI were stratified by mechanism and type of repair and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality. RESULTS: Seven hundred thirty-seven patients undergoing procedures for SAI were identified. Of these, 39% were penetrating. The majority were male (80%) with a median age and Injury Severity Score (ISS) of 37 and 21, respectively. 58% of patients were managed endovascularly. For patients with blunt injury, the type of repair affected neither morbidity (25% vs 19%, p = 0.116) nor mortality (11% vs 10%, p = 0.70). For patients with penetrating injuries, endovascular repair had significantly lower morbidity (12% vs 22%, p = 0.028) and mortality (6% vs 21%, p = 0.001). MLR identified endovascular repair as the only modifiable risk factor associated with reduced mortality (odds ratio, 0.35; 95% confidence interval, 0.14 to 0.87, p = 0.02). CONCLUSIONS: SAI results in significant morbidity and mortality regardless of mechanism. Although the type of repair did not affect mortality in patients with blunt injury, endovascular repair was identified as the only modifiable predictor of reduced mortality in patients with penetrating injuries.

Caught in the crossfire: 37 Years of firearm violence afflicting America's youth.

INTRODUCTION: Publicly available firearm data are difficult to access. Trauma registry data are excellent at documenting patterns of firearm-related injury. Law enforcement data excel at capturing national violence trends to include both circumstances and firearm involvement. The goal of this study was to use publicly available law enforcement data from all 50 states to better define patterns of firearm-related homicides in the young. METHODS: All homicides in individuals 25 years or younger in the United States over a 37-year period ending in 2016 were analyzed: infant, 1 year or younger; child, 1 to 9 years old; adolescent, 10 to 19 years old; and young adult, 20 to 25 years old. Primary data files were obtained from the Federal Bureau of Investigation and comprised the database. Data analyzed included homicide type, situation, circumstance, month, firearm type, and demographics. Rates of all homicides and firearm-related homicides per 1 million population and the proportion of firearm-related homicides (out of all homicides) were stratified by year and compared over time using simple linear regression. RESULTS: A total of 171,113 incidents of firearm-related homicide were analyzed (69% of 246,437 total homicides): 5,313 infants, 2,332 children, 59,777 adolescents, and 103,691 young adults. Most (88%) were male and Black (59%) with a median age of 20 years. Firearm-related homicides peaked during the summer months of June, July, and August (median, 1,156 per year; p = 0.0032). Rates of all homicides (89 to 53 per 1 million population) and firearm-related homicides (56 to 41 per 1 million population) decreased significantly from 1980 to 2016 (ß = -1.12, p < 0.0001 and ß = -0.57, p = 0.0039, respectively). However, linear regression analysis identified a significant increase in the proportion of firearm-related homicides (out of all homicides) from 63% in 1980 to 76% in 2016 (ß = 0.33, p < 0.0001). CONCLUSION: For those 25 years or younger, the proportion of firearm-related homicides has steadily and significantly increased over the past 37 years, with 3 of 4 homicides firearm related in the modern era. Despite focused efforts, reductions in the rate of firearm-related homicides still lag behind those for all other methods of homicide by nearly 50%. That is, while the young are less likely to die from homicide, for those unfortunate victims, it is more likely to be due to a firearm. This increasing role of firearms in youth homicides underscores the desperate need to better direct prevention efforts and firearm policy if we hope to further reduce firearm-related deaths in the young. LEVEL OF EVIDENCE: Epidemiological study, level III.

Use of Thoracic Endovascular Aortic Repair in Patients with Concomitant Blunt Aortic and Traumatic Brain Injury.

BACKGROUND: Blunt aortic injury (BAI) and traumatic brain injury (TBI) represent the 2 leading causes of death after blunt trauma. The goal of this study was to examine the impact of TBI and use of thoracic endovascular aortic repair (TEVAR) on patients with BAI, using a large, national dataset. STUDY DESIGN: Patients with BAI were identified from the Trauma Quality Improvement Program (TQIP) database over 10 years, ending in 2016. Patients with BAI were stratified by the presence of concomitant TBI and compared. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of mortality in BAI patients with and without TBI. Youden's index was used to identify the optimal time to TEVAR in these patients. RESULTS: 17,040 patients with BAI were identified, with 4,748 (28%) having a TBI. Patients with BAI and TBI were predominantly male, with a higher injury burden and greater severity of shock at presentation, underwent fewer TEVAR procedures, and had increased mortality compared with BAI patients without TBI. The optimal time for TEVAR was 9 hours. Mortality was significantly increased in patients undergoing TEVAR before 9 hours (12.9% vs 6.5%, p = 0.003). For BAI patients with and without TBI, MLR identified use of TEVAR as the only modifiable risk factor significantly associated with reduced mortality (odds ratio [OR] 0.41; 95%CI 0.32-0.54, p < 0.0001). CONCLUSIONS: TBI significantly increases mortality in BAI patients. TEVAR and delayed repair both significantly reduced mortality. So, for patients with both BAI and TBI, an endovascular repair performed in a delayed fashion should be the preferred approach.

REBOA as a rescue strategy for catastrophic vascular injury during robotic surgery.

Catastrophic bleeding is a feared complication of robotic abdominal procedures that involve dissection in close proximity to major vessels. In the event of uncontrollable hemorrhage, standard practice involves emergency undocking with conversion to laparotomy. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rapid and life-saving technique gaining acceptance in the trauma setting for the management of catastrophic hemorrhage. The purpose of this study was to evaluate feasibility of REBOA for emergency hemostasis during robotic surgery. The surgical robot was docked to a REBOA mannequin to simulate an upper abdominal surgery. A femoral arterial line was placed in the mannequin. Supplies needed for REBOA insertion were opened and arranged on the surgical back table. The surgeon was seated at the console with an assistant scrubbed. A catastrophic vascular injury was announced. The time it took the surgeon to achieve aortic occlusion by the REBOA was recorded. Four surgeons participated and performed three timed trials each. Each surgeon, irrespective of experience with REBOA or years in surgical practice, was able to obtain aortic occlusion in less than 2 min. The mean time to aortic occlusion for all surgeons was 111 s. No manipulation of the robotic arms was required to perform the procedure. Aortic occlusion was achieved rapidly with REBOA. Ability to achieve prompt aortic control was not associated with surgical experience or prior familiarity with the REBOA device. Prophylactic femoral access and preparation of supplies facilitates prompt placement of the occlusion balloon. REBOA should be considered as a viable alternative to open laparotomy for temporary hemorrhage control during robotic surgery.

An Unusual Presentation and Aggressive Course of Metastatic Myoepithelial Carcinoma.

Myoepithelial carcinomas are rare tumors that make up 1 to 2 percent of all salivary gland neoplasms. We present a case of a 55-year-old man with myoepithelial carcinoma that developed into widespread cutaneous, lung, and brain metastases refractory to treatment, including newer immunotherapies. Newer strategies or treatments are needed for the future benefit of patients with advanced disease.

Community Need Index (CNI): a simple tool to predict emergency department utilization after hospital discharge from the trauma service.

BACKGROUND: Emergency department (ED) visits after hospital discharge may reflect failure of transition of care to the outpatient setting. Reduction of postdischarge ED utilization represents an opportunity for quality improvement and cost reduction. The Community Need Index (CNI) is a Zip code-based score that accounts for a community's unmet needs with respect to healthcare and is publicly accessible via the internet. The purpose of this study was to determine if patient CNI score is associated with postdischarge ED utilization among hospitalized trauma patients. METHODS: Level 1 trauma patient admitted between January 2014 and June 2016 were stratified by 30-day postdischarge ED utilization (yes/no). CNI is a nationwide Zip code-based score (1.0-5.0) and was determined per patient from the CNI website. Higher scores indicate greater barriers to healthcare per aggregate socioeconomic factors. Patients with 30-day postdischarge ED visits were compared with those without, evaluating for differences in CNI score and clinical and demographic characteristics. RESULTS: 309 of 3245 patients (9.5%) used the ED. The ED utilization group was older (38.3±15.7 vs. 36.3±16.4 years, p=0.034), more injured (Injury Severity Score 10.4±8.7 vs. 7.7±8.0, p<0.001), and more likely to have had in-hospital complications (17.5% vs. 5.4%, p<0.001). Adjusted for patient age, injury severity, gender, race/ethnicity, penetrating versus blunt injury, alcohol above the legal limit, illicit drug use, the presence of one or more complications and comorbidities, hospital length of stay, and insurance category, CNI score ≥4 was associated with increased utilization (OR 2.0 [95% CI 1.4 to 2.9, p<0.001]). DISCUSSION: CNI is an easily accessible score that independently predicts postdischarge ED utilization in trauma patients. Patients with CNI score ≥4 are at significantly increased risk. Targeted intervention concerning discharge planning for these patients represents an opportunity to decrease postdischarge ED utilization. LEVEL OF EVIDENCE: III, Prognostic and Epidemiological.