Computed tomography perfusion imaging on traumatic cerebral contusion: a preliminary report

BACKGROUND

Brain ischaemia and infarction are the leading factors in morbidity and mortality of traumatic brain injury. This study aimed to determine the perfusion status of pericontusional hypodense areas in traumatic cerebral contusion

METHODS

Ten patients involved in motor vehicle accidents were enrolled in this study, and contusions were diagnosed from plain computed tomography scans of the brain. Subsequent computed tomography perfusion (CTP) was performed to analyse the perfusion of pericontusional hypodense areas, which were divided into 4 regions of interest (ROI).

RESULTS

Most ischaemic perfusion was found in ROI 6 (affecting 60% of patients), although the mean of the perfusion parameters were normal. A significant positive correlation was found between the perfusion status in the pericontusional area nearest to the skull vault (ROI 3) and its distance/thickness to the skull vault (r = 0.698, P = 0.025). Two adjacent pericontusional hypodense areas (ROI 4 and ROI 5) showed a significant positive correlation with each other (r = 0.667, P = 0.035) in terms of perfusion status. The presence of a hypodense pericontusional area is suggestive of oedema and perfusion disturbances.

CONCLUSION

CTP is a useful, fast, and appropriate method in evaluating perfusion of pericontusional hypodensity area that may help the treating physician to provide an appropriate treatment to the patient.

The use of deep friction massage with olive oil as a means of prevention and treatment of sports injuries in ancient times

The aim of this research was to analyse the use of olive oil as a means of prevention and treatment of sports injuries in the ancient world. The method adopted was based on a thorough study of Greek and world literature. Writings of major ancient philosophers and physicians such as Hippocrates, Aristotle, Philostratus, and Lucian have been analysed in depth. According to the results, the use of massage, together with olive oil rub, helped to reduce muscle fatigue, to remove lactic acid, and to prevent the occurrence of sports injuries through flexibility provided to the skin of athletes. The therapeutic use of oil in the ancient world was fully recognized; and as a result Athenian athlothetes (sponsors of sporting events) provided free oil to all sport facilities where athletes could make free use of it [1].

Coagulation abnormalities in the trauma patient: the role of point-of-care thromboelastography

Current recommendations for resuscitation of the critically injured patient are limited by a lack of point-of-care (POC) assessment of coagulation status. Accordingly, the potential exists for indiscriminant blood component administration. Furthermore, although thromboembolic events have been described shortly after injury, the time sequence of post-injury coagulation changes is unknown. Our current understanding of hemostasis has shifted from a classic view, in which coagulation was considered a chain of catalytic enzyme reactions, to the cell-based model (CBM), representing the interplay between the cellular and plasma components of clot formation. Thromboelastography (TEG), a time-sensitive dynamic assay of the viscoelastic properties of blood, closely parallels the CBM, permitting timely, goal-directed restoration of hemostasis via POC monitoring of coagulation status. TEG-based therapy allows for goal-directed blood product administration in trauma, with potential avoidance of the complications resulting from overzealous component administration, as well as the ability to monitor post-injury coagulation status and thromboprophylaxis. This overview addresses coagulation status and thromboprophylaxis management in the trauma patient and the emerging role of POC TEG.

A murine model for the study of edema induced intestinal contractile dysfunction

BACKGROUND

We have published extensively regarding the effects of edema on intestinal contractile function. However, we have found the need to expand our model to mice to take advantage of the much larger arsenal of research support, especially in terms of transgenic mouse availability and development. To that end, we have developed and validated a hydrostatic intestinal edema model in mice.

METHODS

Male C57 Black 6 mice were subjected to a combination of high volume crystalloid resuscitation and mesenteric venous hypertension in an effort to induce hydrostatic intestinal edema. Wet to dry ratios, myeloperoxidase activity, mucosal injury scoring, STAT-3 nuclear activation, phosphorylated STAT-3 levels, NF-κB nuclear activation, myosin light chain phosphorylation, intestinal contractile activity, and intestinal transit were measured to evaluate the effects of the model.

KEY RESULTS

High volume crystalloid resuscitation and mesenteric venous hypertension resulted in the development of significant intestinal edema without an increase in myeloperoxidase activity or mucosal injury. Edema development was associated with increases in STAT-3 and NF-κB nuclear activation as well as phosphorylated STAT-3. There was a decrease in myosin light chain phosphorylation, basal and maximally stimulated intestinal contractile activity, and intestinal transit.

CONCLUSION & INFERENCES

Hydrostatic edema in mice results in activation of a signal transduction profile that culminates in intestinal contractile dysfunction. This novel model allows for advanced studies into the pathogenesis of hydrostatic edema induced intestinal contractile dysfunction.

Neuroprotective effects of alpha-lipoic acid in experimental spinal cord injury in rats

BACKGROUND

Oxidative stress is a mediator of secondary injury to the spinal cord following trauma.

OBJECTIVE

To investigate the putative neuroprotective effect of alpha-lipoic acid (LA), a powerful antioxidant, in a rat model of spinal cord injury (SCI).

METHODS

Wistar albino rats were divided as control, vehicle-treated SCI, and LA-treated SCI groups. To induce SCI, a standard weight-drop method that induced a moderately severe injury (100 g/cm force) at T10 was used. Injured animals were given either 50 mg/kg LA or saline at 30 minutes postinjury by intraperitoneal injection. At 7 days postinjury, neurologic examination was performed, and rats were decapitated. Spinal cord samples were taken for histologic examination or determination of malondialdehyde (MDA) and glutathione (GSH) levels, myeloperoxidase (MPO) activity, and DNA fragmentation. Formation of reactive oxygen species in spinal cord tissue samples was monitored by using a chemiluminescence (CL) technique.

RESULTS

SCI caused a significant decrease in spinal cord GSH content, which was accompanied with significant increases in luminol CL and MDA levels, MPO activity, and DNA damage. Furthermore, LA treatment reversed all these biochemical parameters as well as SCI-induced histopathologic alterations. Conversely, impairment of the neurologic function caused by SCI remained unchanged.

CONCLUSION

The present study suggests that LA reduces SCI-induced oxidative stress and exerts neuroprotection by inhibiting lipid peroxidation, glutathione depletion, and DNA fragmentation.

Fatal airbag-mediated atlanto-occipital dislocation in a child

An atlanto-occipital dislocation is a rare airbag-induced injury in trauma patients. We report a case of an atlanto-occipital dislocation in a 6-year-old patient who was an unrestrained passenger in the front seat of a vehicle involved in a low-speed motor vehicle accident. This case illustrates the fatal threat of airbag deployment to the child passenger travelling in the vehicle front seat even in a low-speed collision, and supports the recommendation that children under 12 years of age travelling in vehicles with dual airbag systems should be seated in the back.

Psychotherapeutic options for traumatized children

PURPOSE OF REVIEW

This review addresses two issues. First, it updates readers on new treatments for traumatized children. Second, it examines the breadth of target problems that current evidence-based treatments for child posttraumatic stress disorder (PTSD) effectively address in the context of current diagnostic uncertainty. Specifically, changes have been proposed to the Diagnostic and Statistical Manual for Mental Disorders Fourth Edition (DSM-IV) diagnostic criteria for PTSD and a proposal has been submitted to add a new developmental trauma disorder to optimally describe the range of outcomes experienced by traumatized children.

RECENT FINDINGS

Three recently completed treatment studies are described. A review of five established child trauma treatments for PTSD, child-parent psychotherapy, cognitive behavioral interventions for trauma in schools, cognitive behavioral therapy for PTSD, structured psychotherapy for adolescents responding to chronic stress, and trauma-focused cognitive behavioral therapy documents that these treatments effectively resolve problems in multiple domains beyond the current PTSD diagnostic criteria. These domains include affective dysregulation, behavioral dysregulation, cognitive dysregulation, and relational dysregulation.

SUMMARY

New treatments for children are promising for treating PTSD and some other symptoms. Current evidence-based child trauma treatments address a broad array of trauma-related difficulties.

PTSD-8: A Short PTSD Inventory

Traumatic events pose great challenges on mental health services in scarcity of specialist trauma clinicians and services. Simple short screening instruments for detecting adverse psychological responses are needed. Several brief screening instruments have been developed. However, some are limited, especially in relation to reflecting the posttraumatic stress disorder (PTSD) diagnosis. Recently, several studies have challenged pre-existing ideas about PTSD’s latent structure. Factor analytic research currently supports two four factor models. One particular model contains a dysphoria factor which has been associated with depression and anxiety. The symptoms in this factor have been hailed as less specific to PTSD. The scope of this article is therefore to present a short screening instrument, based on this research; Posttraumatic Stress Disorder (PTSD) – 8 items. The PTSD-8 is shown to have good psychometric properties in three independent samples of whiplash patients (n=1710), rape victims (n=305), and disaster victims (n=516). Good test-rest reliability is also shown in a pilot study of young adults from families with alcohol problems (n=56).

[Management of suicide by fall in traumatology]

Introduction

A travers ce travail, l’épidémiologie et la psychopathologie du suicide par précipitation seront rappelées, le rôle du chirurgien traumatologue dans la restauration physique et psychique sera démontré.

Méthodes

Nous rapportons une étude rétrospective de 15 suicidants par précipitation admis pour des traumatismes complexes de l’appareil locomoteur entre 2004 et 2007.

Résultats

Il s’agissait de primosuicidants, comprenant 10 femmes et 5 hommes. L’âge moyen des hommes est de 26,5 ans (24-34 ans) et celui des femmes de 40,7 ans (17-45 ans). Le bilan lésionnel des suicidants a retrouvé 14 fractures des membres inférieurs, 4 traumatisme du rachis avec compression médullaire dans 1 cas, une fracture du bassin; deux traumatismes du membre supérieur. Aucun de ces patients n’a présenté de lésions viscérales ni de traumatismes crâniofacial. 80% ( n = 12) des patients souffraient d’une affection psychiatrique avant leur passage à l’acte suicidaire : 8 pour une pathologie dépressive et 4 pour une schizophrénie. Chaque suicidant a subi au moins un acte chirurgical. Tous les patients avaient poursuivi la prise en charge psychiatrique en ambulatoire. Nos résultats fonctionnels étaient satisfaisants sans complications. Aucun des patients n’a récidivé. La pathologie suicidaire représente un problème de santé publique. Le suicide par précipitation représente 5 % de l’ensemble des modalités suicidaires. Les traumatismes occasionnés par ce mode suicidaire sont complexes et graves. Leur prise en charge nécessite une collaboration multidisciplinaire.

Conclusion

La réparation chirurgicale permet à la fois le rétablissement de la fonction et l’amélioration psychique du sujet prévenant contre une rechute dépressive ou une récidive suicidaire.

Attention to novel and target stimuli in trauma survivors

Trauma and its consequences can have lasting biological and cognitive effects on those who experience them. This study investigated the extent to which trauma, posttraumatic stress disorder (PTSD), and dissociation influenced attention to basic auditory stimuli in a sample of military cadets. After filling out a series of psychometric questionnaires, 27 male military cadets varying in their trauma history participated in the "novelty" oddball task in which participants were asked to count high-pitched tones while ignoring other auditory stimuli. Electroencephalogram (EEG) was continually recorded in order to assess P300 responses, an event-related potential (ERP) associated with attention and memory processes. Trauma history only, and not dissociation or PTSD scores, predicted smaller P300 amplitudes to target tones. To distracting novel sounds, only trauma history and dissociation predicted unique variance in P300 amplitudes. The findings suggest that PTSD may not be central to the attentional disturbances found in traumatized samples, while trauma history and dissociation may play a more important role. Future studies investigating attentional processes post trauma should utilize dissociation scales and a non-trauma sample.

Genetics of post-traumatic stress disorder: review and recommendations for genome-wide association studies

Post-traumatic stress disorder (PTSD) is a prevalent, disabling anxiety disorder that constitutes a major health care burden. Despite evidence supporting a genetic predisposition to PTSD, the precise genetic loci remain unclear. Herein we review the current state and limitations of genetic research on PTSD. Although recent years have seen an exponential increase in the number of studies examining the influence of candidate genes on PTSD diagnosis and symptomatology, most studies have been characterized by relatively low rates of PTSD, with apparent inconsistencies in gene associations linked to marked differences in methodology. We further discuss how current advances in the genetics field can be applied to studies of PTSD, emphasizing the need to adapt a genome-wide approach that facilitates discovery rather than hypothesis testing. Genome-wide association studies offer the best opportunity to identify novel "true" risk variants for the disorder that in turn has the potential to inform our understanding of PTSD etiology.

Multisystemic Therapy for Child Abuse and Neglect: a randomized effectiveness trial

The primary purpose of this study was to conduct a randomized effectiveness trial of Multisystemic Therapy for Child Abuse and Neglect (MST-CAN) for physically abused youth (mean age = 13.88 years, 55.8% female, 68.6% Black) and their families. Eighty-six families being followed by Child Protective Services due to physical abuse were randomly assigned to MST-CAN or Enhanced Outpatient Treatment (EOT), with both interventions delivered by therapists employed at a community mental health center. Across five assessments extending 16 months post baseline, intent-to-treat analyses showed that MST-CAN was significantly more effective than EOT in reducing youth mental health symptoms, parent psychiatric distress, parenting behaviors associated with maltreatment, youth out-of-home placements, and changes in youth placement. Also, MST-CAN was significantly more effective at improving natural social support for parents. Effect sizes were in the medium to large range for most outcomes examined. Although fewer children in the MST-CAN condition experienced an incident of reabuse than did counterparts in the EOT condition, base rates were low and this difference was not statistically significant. The findings of this study demonstrate the potential for broad-based treatments of child physical abuse to be effectively transported and implemented in community treatment settings.

Risk reduction for substance use and trauma-related psychopathology in adolescent sexual assault victims: findings from an open trial

Limited attention has been paid to the development and evaluation of interventions that reduce risk for substance use, while also targeting trauma-related psychopathology among maltreated adolescents. Risk Reduction through Family Therapy (RRFT) is a multicomponent treatment that integrates principles and interventions from existing empirically supported treatments. The purpose of the current study was to evaluate the feasibility of implementation and initial efficacy of RRFT through an open pilot trial involving a small sample (N = 10) of female adolescents (aged 13-17 years) who had experienced at least one memorable sexual assault in their lifetime. Measures of substance use and substance use risk factors (e.g., family functioning), posttraumatic stress disorder (PTSD), and depression symptoms were assessed pre- and posttreatment as well as at 3-month and 6-month posttreatment follow-up assessments. Results demonstrated reductions in multiple areas, including substance use and related risk factors, PTSD, and depression symptoms, which were maintained through follow-up. Clinical implications and future directions with this line of research are discussed.

Psychological resilience and neurocognitive performance in a traumatized community sample

BACKGROUND

Whether psychological resilience correlates with neurocognitive performance is largely unknown. Therefore, we assessed association between neurocognitive performance and resilience in individuals with a history of childhood abuse or trauma exposure.

METHODS

In this cross-sectional study of 226 highly traumatized civilians, we assessed neurocognitive performance, history of childhood abuse and other trauma exposure, and current depressive and PTSD symptoms. Resilience was defined as having > or =1 trauma and no current depressive or PTSD symptoms; non-resilience as having > or =1 trauma and current moderate/severe depressive or PTSD symptoms.

RESULTS

The non-resilient group had a higher percentage of unemployment (P=.006) and previous suicide attempts (P<.0001) than the resilient group. Both groups had comparable education and performance on verbal reasoning, nonverbal reasoning, and verbal memory. However, the resilient group performed better on nonverbal memory (P=.016) with an effect size of .35. Additionally, more severe childhood abuse or other trauma exposure was significantly associated with non-resilience. Better nonverbal memory was significantly associated with resilience even after adjusting for severity of childhood abuse, other trauma exposure, sex, and race using multiple logistic regression (adjusted OR=1.2; P=.017).

CONCLUSIONS

We examined resilience as absence of psychopathology despite trauma exposure in a highly traumatized, low socioeconomic, urban population. Resilience was significantly associated with better nonverbal memory, a measure of ability to code, store, and visually recognize concrete and abstract pictorial stimuli. Nonverbal memory may be a proxy for emotional learning, which is often dysregulated in stress-related psychopathology, and may contribute to our understanding of resilience.

Threatened fertility and gonadal function after a polytraumatic, life-threatening injury

Trauma literature regarding management of genitalia trauma affecting future fertility and gonadal function in the face of coexisting life-threatening injuries is underdeveloped. We present a unique case that necessitated integrative management of a 24-year-old male who became entangled within the blades of a manure spreader and presented with life-threatening trauma in addition to severe genital trauma, including penile degloving, bilateral testicular avulsion and bilateral spermatic cord laceration. During the initial stabilization and surgical management, urology and plastic surgery were consulted to assess the urogenital injuries. Together, the surgical team orchestrated potentially life-saving interventions while successfully performing both a testicular sperm extraction and a testicular revascularization. Viable sperm was collected on the day of surgery and initial follow-up showed preserved sexual function and adequate perfusion to the testicle. This report presents a case and provides a review discussing the management of traumatic genital injuries and the importance of early involvement of surgical specialties in genitalia trauma to optimize future fertility and gonadal function. The literature search was performed in August 2008 using Medline for articles only in English, including any of the following terms: polytrauma, trauma, penis, testicle, degloving, avulsion, spermatic cord, laceration, fertility, reproduction or revascularization.

Comparison of differential biomarkers of osteoarthritis with and without posttraumatic injury in the Hartley guinea pig model

The objective was to compare biomarkers of articular cartilage metabolism in synovial fluid from Hartley guinea pig knees, with and without anterior cruciate ligament transection (ACLT), to establish whether detectable differences in biomarker levels exist between primary and secondary osteoarthritis (OA). Synovial fluid lavages and knees were obtained from 3-month (control group) and 12-month (primary OA group) animals. Another group of animals (posttraumatic OA group) underwent unilateral ACLT at 3 months, and samples were obtained 9 months postsurgery. Synovial fluid concentrations of stromal cell-derived-factor (SDF-1), collagen fragments (C2C), proteoglycan (GAG), lubricin, matrix metalloproteinase-13 (MMP-13), and Interleukin-1 (IL-1beta) were evaluated. Cartilage damage was assessed via histology. The highest concentrations of C2C and SDF-1 in synovial fluid were found in the posttraumatic OA group, moderate concentrations were found in the primary OA group, and low concentrations in the control group. GAG release in synovial fluid was similar to C2C and SDF-1. The lubricin concentrations were significantly lower in ACLT joints than either the control or 12-month primary OA groups, but not between the control and primary OA groups. Higher levels of MMP-13 and IL-1beta were detected in the joints of the posttraumatic OA group as compared to the control or primary OA groups. Histology revealed greatest OA damage in the posttraumatic OA group, followed by moderate and minimal damage in primary OA and control groups, respectively. This study indicates that the biomarkers and progression of OA may differ in the Hartley guinea pig models with and without posttraumatic OA.

Fear potentiation is associated with hypothalamic-pituitary-adrenal axis function in PTSD

A central problem in posttraumatic stress disorder (PTSD) is the inability to suppress fear under safe conditions. We have previously shown that PTSD patients cannot inhibit conditioned fear. Another relevant finding in PTSD is the hypersensitivity of the hypothalamic-pituitary-adrenal (HPA) axis feedback. Given their common neurobiological pathways, alterations in HPA function in PTSD may be associated with impaired fear inhibition. The present study examined the relationship between HPA axis function and fear-potentiated startle and inhibition of conditioned fear in trauma-exposed individuals. We used a conditional discrimination procedure (AX+/BX-), in which one set of shapes (AX+) was paired with aversive airblasts to the throat (danger signal), and the same X shape with a different shape (BX-) were presented without airblasts (safety signal). The paradigm also included a transfer of fear inhibition test (AB). In addition to fear-potentiated startle, blood was drawn for neuroendocrine analysis and the dexamethasone suppression test (DEX) was performed; cortisol and ACTH were assessed at baseline and post-DEX. Ninety highly traumatized individuals recruited from Grady Hospital in Atlanta, GA participated in the study. The sample was divided into those who met DSM-IV criteria for PTSD (n=29) and Non-PTSD controls (n=61) using the PTSD symptom scale (PSS). Both groups showed significant reduction in cortisol and ACTH levels after DEX. Subjects with PTSD had higher fear-potentiated startle to the safety signal, BX- (F(1,88)=4.44, p<0.05) and fear inhibition trials, AB (F(1,88)=5.20, p<0.05), both indicative of less fear inhibition in the presence of B, compared to control subjects. In addition, fear-potentiated startle to AX+, BX-, and AB was positively correlated with baseline and post-DEX ACTH in PTSD subjects. These results suggest that impaired fear inhibition and associated alterations in HPA feedback may reflect amygdala hyperactivity in subjects with PTSD.

The cell biology of suturing tendons

Trauma by suturing tendon form areas devoid of cells termed "acellular zones" in the matrix. This study aimed to characterise the cellular insult of suturing and acellular zone formation in mouse tendon. Acellular zone formation was evaluated using single grasping sutures placed using flexor tendons with time lapse cell viability imaging for a period of 12h. Both tension and injury were required to induce cell death and cell movement in the formation of the acellular zone. DNA fragmentation studies and transmission electron microscopy indicated that cells necrosed. Parallel in vivo studies showed that cell-to-cell contacts were disrupted following grasping by the suture in tensioned tendon. Without tension, cell death was lessened and cell-to-cell contacts remained intact. Quantitative immunohistochemistry and 3D cellular profile mapping of wound healing markers over a one year time course showed that acellular zones arise rapidly and showed no evidence of healing whilst the wound healing response occurred in the surrounding tissues. The acellular zones were also evident in a standard modified "Kessler" clinical repair. In conclusion, the suture repair of injured tendons produces acellular zones, which may potentially cause early tendon failure.

Malunited fracture of the body and condyle of the mandible : A Case Report

Mandibular fractures are the most common facial fractures seen in hospitalized children and their incidence increases with age. Treatment options include soft diet, intermaxillary fixation with eyelet wires, arch bars, circummandibular wiring, or stents. Alternative options include open reduction and internal fixation through either an intraoral or extraoral approach. Many factors complicate the management of pediatric mixed-dentition mandibular fractures: tooth eruption, short roots, developing tooth buds and growth issues. One major factor is the inherent instability of the occlusion in the mixed deciduous-permanent tooth phase. This case report documents a child in mixed dentition period with a complication arising due to direct fixation of the fractured mandible.

Do PTSD symptoms and course predict continued substance use for homeless individuals in contingency management for cocaine dependence?

Homeless individuals (n=187) entering contingency management (CM) for cocaine dependence were assessed for PTSD diagnosis, and a subset of 102 participants reporting traumatic exposure also periodically completed a self-report measure of PTSD symptoms. Patients with PTSD in full remission at 6 months (end of active treatment) and 12 months (end of aftercare) used substances much less frequently during aftercare than those with no PTSD diagnosis. Those whose PTSD diagnosis improved to full remission status during active treatment, and remained in full remission at 12 months, also had superior substance use outcomes. Severity of PTSD symptoms at 6 months, but not baseline or 2 months, was associated with substance use across treatment phases. Substance use during aftercare, however, was better predicted by changes in PTSD symptom severity. Patients whose PTSD symptoms improved more during active treatment fared better during aftercare than those with less improvement. Findings suggest homeless individuals with comorbid PTSD entering CM for cocaine dependence are not necessarily at increased risk for substance use compared to those without the comorbidity. However, course of PTSD does predict substance use, with the potential for CM to be unusually effective for those who respond with substantial, lasting improvements in PTSD.

Ability of the ankaferd blood stopper® to prevent parenchymal bleeding in an experimental hepatic trauma model

Hepatic parenchymal bleeding (HPB) is a major problem following both trauma and elective hepatic procedures. The present study investigated the effect of the Ankaferd Blood Stopper® (ABS) on HPB.

METHOD(S)

A total of 20 rats were used. After creating a laceration model in the left lateral hepatic lobe, the area was compressed for 3 minutes with the ABS in the rats in group 1 (n=10) and with 0.9% NaCl-soaked gauze in the rats in group 2 (n=10).

RESULTS

The mean change in haematocrit levels between baseline and the 24 hour values in group 1 was lower than group 2 (p=0.045). The mean perioperative bleeding in group 1 was lower than group 2 (p=0.003). The histopa-thologic evaluation revealed that there were no differences between the groups with respect to areas of necrosis (p=0.107) or inflammation (p=0.135).

CONCLUSION

Although the ABS does not stop HPB completely, it ensures a statistically significant reduction in HPB.

Developing a neurobehavioral animal model of infant attachment to an abusive caregiver

BACKGROUND

Both abused and well cared for infants show attachment to their caregivers, although the quality of that attachment differs. Moreover, the infant's attachment to the abusive caregiver is associated with compromised mental health, especially under stress. In an attempt to better understand how abuse by the caregiver can compromise mental health, we explore the neural basis of attachment in both typical and abusive environments using infant rats, which form attachments to the mother through learning her odor. Here, we hypothesize that the neural circuitry for infant attachment differs based on the quality of the attachment, which can be uncovered during stressful situations.

METHODS

We used infant rats to compare infant attachment social behaviors and supporting neurobiology using natural maternal odor, as well as two odor-learning attachment paradigms: odor-stroke (mimics typical attachment) and odor-.5 mA shock conditioning (mimics abusive attachment). Next, to uncover differences in behavior and brain, these pups were injected with systemic corticosterone. Finally, pups were reared with an abusive mother to determine ecological relevance.

RESULTS

Our results suggest that the natural and learned attachment odors indistinguishably control social behavior in infancy (approach to the odor and interactions with the mother). However, with corticosterone injection, pups with an abusive attachment show disrupted infant social behavior with the mother and engagement of the amygdala.

CONCLUSIONS

This animal model of attachment accommodates both abusive and typical attachment and suggests that pups' social behavior and underlying neural circuitry may provide clues to understanding attachment in children with various conditions of care.

Accelerated tryptophan degradation predicts poor survival in trauma and sepsis patients

Immune system activation and inflammation accompanies immune dysfunction in trauma and sepsis patients. Immunodeficiency may develop in such patients as one consequence of an activated chronic pro-inflammatory response. According to recent data, degradation of L-tryptophan (TRP) via the kynurenine (KYN) pathway by the cytokine-inducible enzyme indoleamine 2,3-dioxygenase (IDO) could represent an important contributor to the deficient responsiveness of immunocompetent cells. Compared to healthy controls, patients post trauma or with sepsis had increasing KYN concentrations and KYN to TRP ratios (KYN/TRP) whereas TRP concentrations decreased. Likewise, concentrations of cytokines tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) and of immune activation marker neopterin increased in patients (all p < 0.001). Furthermore in patients KYN/TRP, KYN and neopterin concentrations were further increasing (all p < 0.001), whereas the changes of TRP, TNF-α and IL-6 concentrations were not significant. Compared to the survivors, the non-survivors had a higher concentration of KYN, neopterin, TNF-α and IL-6 as well as a higher KYN/TRP ratio. KYN/TRP correlated with neopterin (p < 0.001) and also with TNF-α (p < 0.01) and IL-6 concentrations (p < 0.05) and inversely with the in vitro response of stimulated monocytes. We conclude that increased TRP degradation in patients post trauma is closely associated with immune activation. Cytokines released during the pro-inflammatory response may induce the activity of IDO and thus accelerate TRP degradation. Thus, increased IDO activity most likely represents a result of host response to pro-inflammation in patients. Data support a possible role of inflammation-induced IDO in the diminished immunoresponsiveness in patients.

Emerging technologies for pediatric and adult trauma care

PURPOSE OF REVIEW

Current Emergency Medical Service protocols rely on provider-directed care for evaluation, management and triage of injured patients from the field to a trauma center. New methods to quickly diagnose, support and coordinate the movement of trauma patients from the field to the most appropriate trauma center are in development. These methods will enhance trauma care and promote trauma system development.

RECENT FINDINGS

Recent advances in machine learning, statistical methods, device integration and wireless communication are giving rise to new methods for vital sign data analysis and a new generation of transport monitors. These monitors will collect and synchronize exponentially growing amounts of vital sign data with electronic patient care information. The application of advanced statistical methods to these complex clinical data sets has the potential to reveal many important physiological relationships and treatment effects.

SUMMARY

Several emerging technologies are converging to yield a new generation of smart sensors and tightly integrated transport monitors. These technologies will assist prehospital providers in quickly identifying and triaging the most severely injured children and adults to the most appropriate trauma centers. They will enable the development of real-time clinical support systems of increasing complexity, able to provide timelier, more cost-effective, autonomous care.

Association of trauma-related disorders and dissociation with four idioms of distress among Latino psychiatric outpatients

Past research on idioms of distress among U.S. Latinos has revealed that ataque de nervios and altered perceptions, such as hearing and seeing things when alone, are independent markers of higher morbidity and mental health utilization despite having no one-to-one relationships with any single psychiatric diagnosis. It has been proposed that the idioms exert this effect because they are signs of distressing dissociative capacity associated with traumatic exposure. This study examines the relationships in an ethnically diverse Latino psychiatric outpatient sample (N = 230) among interpersonal trauma, posttraumatic stress disorder (PTSD), major depressive disorder, dissociative capacity and four cultural idioms of distress associated with the popular overall category of nervios. We particularly explore how these relationships change with varied measures of traumatic exposure, including trauma severity and timing or persistence of trauma. A series of adjusted bivariate regressions assessed the matrix of associations between the idioms and the clinical variables. In this highly traumatized population, we identified a strong 'nexus' of associations between dissociation and three of the idioms: currently being ill with nerves, ataque de nervios and altered perceptions. These idioms were largely independent from PTSD and depression and were associated with trauma persistence and severity. A fourth idiom, being nervous since childhood, was not associated with any other variable and may represent a personality trait rather than a diagnosable condition. Our results validate the clinical utility of the construct of nervios as a set of specific idioms associated with dissociation that are useful markers of mental health need among Latinos independently of their association with clinical diagnoses.

Nepali concepts of psychological trauma: the role of idioms of distress, ethnopsychology and ethnophysiology in alleviating suffering and preventing stigma

In the aftermath of a decade-long Maoist civil war in Nepal and the recent relocation of thousands of Bhutanese refugees from Nepal to Western countries, there has been rapid growth of mental health and psychosocial support programs, including posttraumatic stress disorder treatment, for Nepalis and ethnic Nepali Bhutanese. This medical anthropology study describes the process of identifying Nepali idioms of distress and local ethnopsychology and ethnophysiology models that promote effective communication about psychological trauma in a manner that minimizes stigma for service users. Psychological trauma is shown to be a multifaceted concept that has no single linguistic corollary in the Nepali study population. Respondents articulated different categories of psychological trauma idioms in relation to impact on the heart-mind, brain-mind, body, spirit, and social status, with differences in perceived types of traumatic events, symptom sets, emotion clusters and vulnerability. Trauma survivors felt blamed for experiencing negative events, which were seen as karma transmitting past life sins or family member sins into personal loss. Some families were reluctant to seek care for psychological trauma because of the stigma of revealing this bad karma. In addition, idioms related to brain-mind dysfunction contributed to stigma, while heart-mind distress was a socially acceptable reason for seeking treatment. Different categories of trauma idioms support the need for multidisciplinary treatment with multiple points of service entry.

Traumatic experiences, major life stressors, and self-reporting a physician-given fibromyalgia diagnosis

The contribution of stress to the pathophysiology of fibromyalgia has been the subject of considerable debate. The primary purpose of the present study was to evaluate the relationship between traumatic and major life stressors and a fibromyalgia diagnosis in a large group of older women and men. Data were from the federally funded Biopsychosocial Religion and Health Study, and subjects were 10,424 of the 10,988 survey respondents-two-thirds women and one-third men-providing responses to a fibromyalgia question. Average age was 61.0+/-13.5 years. A physician-given fibromyalgia diagnosis in a subject's lifetime was reported by 3.7% of the sample, 4.8% of the women and 1.3% of the men. In two multivariable logistic regression models (all respondents and women only, controlling for age, sex, race/ethnicity, and education), two traumatic experience types (sexual and physical assault/abuse) were associated with a fibromyalgia diagnosis. Two other trauma types (life-threatening and emotional abuse/neglect) and major life stress experiences were not. The highest odds ratios in both models were those for sexual assault/abuse followed by physical assault/abuse. The relationship between age and fibromyalgia was curvilinear in both models (odds ratios rising until approximately age 63 and declining thereafter). In the all-subjects model, being a woman increased the odds of a fibromyalgia diagnosis, and in both models, fibromyalgia was associated with being White (versus non-White) and lower education. We recommend that researchers investigate the relationship between stress and fibromyalgia in concert with genetic and biomarker studies.

Services provided by volunteer psychiatrists after 9/11 at the New York City family assistance center: September 12-November 20, 2001

OBJECTIVE

To characterize the experience of volunteer disaster psychiatrists who provided pro bono psychiatric services to 9/11 survivors in New York City, from September 12, 2001 to November 20, 2001.

METHOD

Disaster Psychiatry Outreach (DPO) is a non-profit organization founded in 1998 to provide volunteer psychiatric care to people affected by disasters and to promote education and research in support of this mission. Data for this study were collected from one-page clinical encounter forms completed by 268 DPO psychiatrists for 2 months after 9/11 concerning 848 patients served by the DPO 9/11 response program at the New York City Family Assistance Center.

RESULTS

In this endeavor, 268 psychiatrist volunteers evaluated 848 individuals and provided appropriate interventions. The most commonly recorded clinical impressions indicated stress-related and adjustment disorders, but other conditions such as bereavement, major depression, and substance abuse/dependence were also observed. Free samples were available for one sedative and one anxiolytic agent; not surprisingly, these were the most commonly prescribed medications. Nearly half of those evaluated received psychotropic medications.

CONCLUSIONS

In the acute aftermath of the attacks of September 11, 2001, volunteer psychiatrists were able to provide services in a disaster response setting, in which they were co-located with other disaster responders. These services included psychiatric assessment, provision of medication, psychological first aid, and referrals for ongoing care. Although systematic diagnoses could not be confirmed, the fact that most patients were perceived to have a psychiatric diagnosis and a substantial proportion received psychotropic medication suggests potential specific roles for psychiatrists that are unique and different from roles of other mental health professionals in the early post-disaster setting. In addition to further characterizing post-disaster mental health needs and patterns of service provision, future research should focus on the short- and long-term effects of psychiatric interventions, such as providing acute psychotropic medication services and assessing the effectiveness of traditional acute post-disaster interventions including crisis counseling and psychological first aid.

Cheerleading-related injuries in the United States: a prospective surveillance study

CONTEXT

Cheerleading injuries are on the rise and are a significant source of injury to females. No published studies have described the epidemiology of cheerleading injuries by type of cheerleading team and event.

OBJECTIVE

To describe the epidemiology of cheerleading injuries and to calculate injury rates by type of cheerleading team and event.

DESIGN

Prospective injury surveillance study.

SETTING

Participant exposure and injury data were collected from US cheerleading teams via the Cheerleading RIO (Reporting Information Online) online surveillance tool.

PATIENTS OR OTHER PARTICIPANTS

Athletes from enrolled cheerleading teams who participated in official, organized cheerleading practices, pep rallies, athletic events, or cheerleading competitions.

MAIN OUTCOME MEASURE(S)

The numbers and rates of cheerleading injuries during a 1-year period (2006-2007) are reported by team type and event type.

RESULTS

A cohort of 9022 cheerleaders on 412 US cheerleading teams participated in the study. During the 1-year period, 567 cheerleading injuries were reported; 83% (467/565) occurred during practice, 52% (296/565) occurred while the cheerleader was attempting a stunt, and 24% (132/563) occurred while the cheerleader was basing or spotting 1 or more cheerleaders. Lower extremity injuries (30%, 168/565) and strains and sprains (53%, 302/565) were most common. Collegiate cheerleaders were more likely to sustain a concussion (P = .01, rate ratio [RR] = 2.98, 95% confidence interval [CI] = 1.34, 6.59), and All Star cheerleaders were more likely to sustain a fracture or dislocation (P = .01, RR = 1.76, 95% CI = 1.16, 2.66) than were cheerleaders on other types of teams. Overall injury rates for practices, pep rallies, athletic events, and cheerleading competitions were 1.0, 0.6, 0.6, and 1.4 injuries per 1000 athlete-exposures, respectively.

CONCLUSIONS

We are the first to report cheerleading injury rates based on actual exposure data by type of team and event. These injury rates are lower than those reported for other high school and collegiate sports; however, many cheerleading injuries are preventable.

Psychiatric morbidity in adult Kashmiri migrants living in a migrant camp at Jammu

BACKGROUND

There are 14.9 million refugees and 22 million internally displaced persons in the world. The clinical and research literature shows a significant degree of psychological stress among refugees with relatively high levels of physical and psychological dysfunction in them.

AIMS

To determine the prevalence of various psychiatric disorders among Kashmiri migrants settled in a migrant camp at Jammu

MATERIALS AND METHODS

This study was conducted on adults of Kashmiri migrant families residing in Muthi camp at Jammu. Three hundred families (150 each from two camps) were taken up for the study. Psychopathology was measured using Mini International Neuropsychiatry Interview Schedule (MINI). The data was categorized according to age, sex, education. The data was analyzed using Chi-square test with Yate's correction wherever required. P-value less than 0.05 was taken as significant.

RESULTS

Psychiatric morbidity was more in migrant population 33.66% (n=208) than in controls 26% (n=52) with major depressive episode being the most common diagnosis

CONCLUSIONS

Depression, post-traumatic stress disorders (PTSD) and generalized anxiety disorders (GAD) were statistically more prevalent among migrants than in controls.

Polymorphisms in CRHR1 and the serotonin transporter loci: gene x gene x environment interactions on depressive symptoms

Gene x environment (G x E) interactions mediating depressive symptoms have been separately identified in the stress-sensitive serotonergic (5-HTTLPR) and corticotropin-releasing hormone (CRHR1) systems. Our objective was to examine whether the effects of child abuse are moderated by gene x gene (G x G) interactions between CRHR1 and 5-HTTLPR polymorphisms. We used an association study examining G x G x E interactions of CRHR1 and 5-HTTLPR polymorphisms and measures of child abuse on adult depressive symptomatology. The participant population (N = 1,392) was African-American, of low socioeconomic status (60% with <$1,000/month family income), and with high rates of childhood and lifetime trauma. Depressive symptoms were measured with Beck Depression Inventory (BDI) and history of Major Depression by Structure Clinical Interview based on DSM-IV (SCID). We first replicated an interaction of child abuse and 5-HTTLPR on lifetime SCID diagnosis of major depression in a subsample (N = 236) of the study population-the largest African-American 5-HTTLPR cohort reported to date. We then extended our previously reported interaction with both a CRHR1 SNP (rs110402) and TCA haplotype interacting with child abuse to predict current symptoms (N = 1,059; P = 0.0089). We found that the 5-HTTLPR S allele interacted with CRHR1 haplotypes and child abuse to predict current depressive symptoms (N = 856, P = 0.016). These data suggest that G x E interactions predictive of depressive symptoms may be differentially sensitive to levels of childhood trauma, and the effects of child abuse are moderated by genetic variation at both the CRHR1 and 5-HTTLPR loci and by their G x G interaction.

Can the blood alcohol concentration be a predictor for increased hospital complications in trauma patients involved in motor vehicle crashes?

The goal of this report is to assess the relationship of varying levels of blood alcohol concentration (BAC) and hospital complications in patients admitted after motor vehicle crashes. Data for the study was collected by a retrospective review of the University of Wisconsin Hospital trauma registry between 1999 and 2007 using the National Trauma Registry of the American College of Surgeons (NTRACS). Of 3729 patients, 2210 (59%) had a negative BAC, 338 (9%) <100 mg/dL, 538 (14%) 100-199 mg/dL, and 643 (17%) >200 mg/dL. Forty-six percent of patients had one or more hospital related complications. The odds ratio (OR) for the occurrence of alcohol withdrawal in the three alcohol groups compared to the no alcohol group was 12.02 (CI 7.0-20.7), 16.81 (CI 10.4-27.2), and 30.96 (CI 19.5-49.2) as BAC increased with a clear dose response effect. While there were no significant differences in the frequency of the total hospital events following trauma across the four groups, rates of infections, coagulopathies, central nervous system events and renal complications were lower in the high BAC group. Prospective studies are needed to more precisely estimate the frequency of hospital complications in patients with alcohol use disorders and in persons intoxicated at the time of the motor vehicle accident. The study supports the use of routine BAC to predict patients at high risk for alcohol withdrawal and the early initiation of alcohol detoxification.

Demographic and Financial Analysis of EMTALA Hand Patient Transfers

In the United States, the Emergency Medical Treatment and Active Labor Act (EMTALA) effectively requires Level I trauma centers to accept hand trauma transfers for higher level of care if capacity exists. However, patient transfer for non-medical reasons, such as ability to pay, is still perceived as a common practice. We hypothesized that EMTALA would cause selective transfer of hand patients who were underinsured or uninsured, thus, effectively burdening a Level I trauma center. A dedicated transfer center documented the demographics and outcomes of all calls for hand trauma transfers from December 2003 to September 2005. This data registry was reviewed for age, gender, race, insurance status, and length of hospital stay. This data was compared with direct admissions to the emergency room for hand emergencies during that same time period. During the 2-year time period, a total of 151 calls for EMTALA transfer were received for hand emergencies. Our institution accepted 92 of these patients for transfer. Reasons for not accepting transfer included lack of bed availability and unavailability of the on-call surgeon due to other emergency operative cases. Compared with hand emergency patients brought directly to our emergency department during the same time period, transferred patients were younger and had a shorter length of stay. Interestingly, they were very similar in terms of sex, race, and insurance status. These data suggest that the primary motivations for EMTALA hand trauma transfers are truly complexity of patient care and specialist availability. Given the often urgent nature of hand trauma surgery and the limited resources available, expansion and development of hand and microsurgery regional centers will be vital to adequately meet demand without overburdening existing centers.

The first sport injuries in the history of medicine

Medical science is as old as human history and the need for disease treatment. Archivists, researchers and historians are collaborating in the project to preserve the documentary inheritance and make the medical science useful to the public. This research aims to identify and analyze the first registered sport injuries in the history of medicine. After a review of the literature, the Homeric epics, the texts of the first historical period of ancient Greece, were identified and analyzed as the texts which contain the first sport injuries in world history.

NPY moderates the relation between hurricane exposure and generalized anxiety disorder in an epidemiologic sample of hurricane-exposed adults

BACKGROUND

Neuropeptide Y (NPY) has been found to be anxiolytic in animals and humans. A recent study found NPY expression to be inversely correlated with trait anxiety. We examined whether rs16147, a functional single nucleotide polymorphism in the promoter region of NPY, moderated the relationship between hurricane exposure and risk for generalized anxiety disorder (GAD) in an epidemiologic sample of adults living in areas affected by the 2004 Florida hurricanes.

METHODS

Data from this study comes from 616 adults from the 2004 Florida Hurricanes study who returned buccal DNA samples via mail. Selection of participants occurred via random digit-dial procedures. Participants were interviewed via telephone about hurricane exposure and post-hurricane GAD symptoms. The outcome measure was DSM-IV GAD diagnosis, assessed via structured interview.

RESULTS

Rs16147 in NPY was associated with increased risk of GAD diagnosis under conditions of high hurricane exposure (P<.01). This gene by environment interaction remained significant after adjustment for sex, ancestry (as determined by Bayesian clustering of genotypes), and age.

CONCLUSIONS

NPY rs16147 modifies risk of post-disaster GAD under conditions of high stressor (hurricane) exposure. This is the first demonstration of gene-environment interaction for this locus.

Aversive imagery in posttraumatic stress disorder: trauma recurrence, comorbidity, and physiological reactivity

BACKGROUND

Posttraumatic stress disorder (PTSD) is characterized as a disorder of exaggerated defensive physiological arousal. The novel aim of the present research was to investigate within PTSD a potential dose-response relationship between past trauma recurrence and current comorbidity and intensity of physiological reactions to imagery of trauma and other aversive scenarios.

METHODS

A community sample of principal PTSD (n = 49; 22 single-trauma exposed, 27 multiple-trauma exposed) and control (n = 76; 46 never-trauma exposed, 30 trauma exposed) participants imagined threatening and neutral events while acoustic startle probes were presented and the eye-blink response (orbicularis occuli) was recorded. Changes in heart rate, skin conductance level, and facial expressivity were also indexed.

RESULTS

Overall, PTSD patients exceeded control participants in startle reflex, autonomic responding, and facial expressivity during idiographic trauma imagery and, though less pronounced, showed heightened reactivity to standard anger, panic, and physical danger imagery. Concerning subgroups, control participants with and without trauma exposure showed isomorphic patterns. Within PTSD, only the single-trauma patients evinced robust startle and autonomic responses, exceeding both control participants and multiple-trauma PTSD. Despite greater reported arousal, the multiple-trauma relative to single-trauma PTSD group showed blunted defensive reactivity associated with more chronic and severe PTSD, greater mood and anxiety disorder comorbidity, and more pervasive dimensional dysphoria (e.g., depression, trait anxiety).

CONCLUSIONS

Whereas PTSD patients generally show marked physiological arousal during aversive imagery, concordant with self-reported distress, the most symptomatic patients with histories of severe, cumulative traumatization show discordant physiological hyporeactivity, perhaps attributable to sustained high stress and an egregious, persistent negative affectivity that ultimately compromises defensive responding.

Causes and incidence of destructive eye procedures in north-eastern ghana

OBJECTIVE

To determine the causes and incidence of destructive ophthalmic procedures as seen at a major reference eye centre in northern Ghana

METHODS

Retrospective case series involving a review of surgical records of all evisceration and enucleation procedures done between January 2002 and December 2006 at the Bawku Hospital Eye Department. Information collected included basic demographic data, diagnosis, visual acuity at diagnosis and the eye affected. The aetiology responsible was determined from history, clinical examination and investigations as contained in the existing records. The primary clinical indications for evisceration were categorized into degenerative lesions, infections, trauma, neoplasms, and others. Statistical analysis was done using the Epi Info software.

RESULTS

A total of 337 eyes of 336 patients made up of 217 (64.6%) males and 119 (35.4%) females were removed during the study period. Mean age was 36.4 with a range of 1-90 years. Children under 15 years constituted 25.1% of whom 9.3% were under 5 years. The elderly (>/=60 years) comprised 26.3%. The most common cause of destructive procedure was endophthalmitis /panophthalmitis (47.9%), ocular injuries (23.2%), degenerative lesions (8.9%) and neoplasms (5.1%). Regarding neoplasms, females were more likely to be enucleated while the reverse was so for traumas (p=0.04 and p=0.02, Chi(2) test, respectively). Compared to the total number of surgeries done each year the crude incidence was computed at 26.6% per 1000 cases per year.

CONCLUSION

Most causes of destructive procedures in this part of Ghana are preventable and serious preventive strategies are needed to reverse this trend.

Identifying persons at risk for PTSD after trauma with TSQ in the Netherlands

In The Netherlands about 80% of the population experience a traumatic event while about 14% develop post traumatic stress disorder (PTSD). Considering this high prevalence the prevention or early treatment of posttraumatic stress is important from a health as well as cost-benefit perspective. The aim of this study was to examine whether we could identify subjects at risk of developing PTSD. We included 100 Dutch victims of different civil traumas that contacted the Victim Support Foundation. The trauma screening questionnaire (TSQ), was used as a screening tool. The results show that a cut-off score of 7 on the TSQ correctly identified most subjects with PTSD. We found a moderate positive correlation between PTSD and the severity of complaints. We also found a significant relationship between the TSQ and depression symptoms. This study indicates that the Dutch version of the TSQ is a useful instrument for identifying future cases of PTSD.

Working with Children Affected by Hurricane Katrina: Two Case Studies in Play Therapy

In August 2005 Hurricane Katrina hit the Louisiana and Mississippi Gulf Coast Regions. Throughout history, mental health professionals have primarily focused on adults as the identified victims of natural disasters. More recently, mental health professionals are focused on integrating mental health services to children and adolescents. This article discusses the impact natural disasters have on children, and the related traumatic stress response and post traumatic stress disorder often experienced by children. Treating children can be complicated and a developmentally appropriate intervention is needed. Evidenced-based research has shown play therapy to be a developmentally effective intervention with traumatised children. This article presents two case studies of play therapy with children affected by Hurricane Katrina.

Pediatric spinal cord injury in infant piglets: description of a new large animal model and review of the literature

OBJECTIVE

To develop a new, clinically relevant large animal model of pediatric spinal cord injury (SCI) and compare the clinical and experimental features of pediatric SCI.

METHODS

Infant piglets (3-5 weeks old) underwent contusive SCI by controlled cortical impactor at T7. Severe complete SCI was induced in 6 piglets, defined as SCI with no spontaneous return of sensorimotor function. Eight piglets received incomplete SCI, which was followed by partial recovery. Somatosensory evoked potentials, magnetic resonance imaging, neurobehavioral function, and histopathology were measured during a 28-day survival period.

RESULTS

Mean SCI volume (defined as volume of necrotic tissue) was larger after complete compared with incomplete SCI (387 +/- 29 vs 77 +/- 38 mm3, respectively, P < 0.001). No functional recovery occurred after complete SCI. After incomplete SCI, piglets initially had an absence of lower extremity sensorimotor function, urinary and stool retention, and little to no rectal tone. Sensory responses recovered first (1-2 days after injury), followed by spontaneous voiding, lower extremity motor responses, regular bowel movements, and repetitive flexion-extension of the lower extremities when crawling. No piglet recovered spontaneous walking, although 4 of 8 animals with incomplete injuries were able to bear weight by 28 days. In vivo magnetic resonance imaging was performed safely, yielded high-resolution images of tissue injury, and correlated closely with injury volume seen on histopathology, which included intramedullary hemorrhage, cellular inflammation, necrosis, and apoptosis.

CONCLUSION

Piglets performed well as a reproducible model of traumatic pediatric SCI in a large animal with chronic survival and utilizing multiple outcome measures, including evoked potentials, magnetic resonance imaging, functional outcome scores, and histopathology.

Mimetics of hormetic agents: stress-resistance triggers

Mimetics of hormetic agents offer a novel approach to adjust dose to minimize the risk of toxic response, and maximize the benefit of induction of at least partial physiological conditioning. Nature selected and preserved those organisms and triggers that promote tolerance to stress. The induced tolerance can serve to resist that challenge and can repair previous age, disease, and trauma damage as well to provide a more youthful response to other stresses. The associated physiological conditioning may include youthful restoration of DNA repair, resistance to oxidizing pollutants, protein structure and function repair, improved immunity, tissue remodeling, adjustments in central and peripheral nervous systems, and altered metabolism. By elucidating common pathways activated by hormetic agent's mimetics, new strategies for intervention in aging, disease, and trauma emerge. Intervention potential in cancer, diabetes, age-related diseases, infectious diseases, cardiovascular diseases, and Alzheimer's disease are possible. Some hormetic mimetics exist in pathways in primitive organisms and are active or latent in humans. Peptides, oligonucleotides, and hormones are among the mimetics that activate latent resistance to radiation, physical endurance, strength, and immunity to physiological condition tolerance to stress. Co-activators may be required for expression of the desired physiological conditioning health and rejuvenation benefits.

The role of traumatic event history in non-medical use of prescription drugs among a nationally representative sample of US adolescents

BACKGROUND

Building on previous research with adolescents that examined demographic variables and other forms of substance abuse in relation to non-medical use of prescription drugs (NMUPD), the current study examined potentially traumatic events, depression, posttraumatic stress disorder (PTSD), other substance use, and delinquent behavior as potential correlates of past-year non-medical use of prescription drugs.

METHOD

A nationally representative sample of 3,614 non-institutionalized, civilian, English-speaking adolescents (aged 12-17 years) residing in households with a telephone was selected. Demographic characteristics, traumatic event history, mental health, and substance abuse variables were assessed. NMUPD was assessed by asking if, in the past year, participants had used a prescription drug in a non-medical manner. Multivariable logistic regressions were conducted for each theoretically derived predictor set. Significant predictors from each set were then entered into a final multivariable logistic regression to determine significant predictors of past-year NMUPD.

RESULTS

NMUPD was endorsed by 6.7% of the sample (n = 242). The final multivariable model showed that lifetime history of delinquent behavior, other forms of substance use/abuse, history of witnessed violence, and lifetime history of PTSD were significantly associated with increased likelihood of NMUPD.

CONCLUSIONS

Risk reduction efforts targeting NMUPD among adolescents who have witnessed significant violence, endorsed abuse of other substances and delinquent behavior, and/or endorsed PTSD are warranted. Interventions for adolescents with history of violence exposure or PTSD, or those adjudicated for delinquent behavior, should include treatment or prevention modules that specifically address NMUPD.

Evaluation of local MCP-1 and IL-12 nanocoatings for infection prevention in open fractures

The increasing incidence of bacterial infection and the appearance of Staphylococcus aureus (S. aureus) strains that are resistant to commonly used antibiotics has made it important to develop non-antibiotic approaches for infection prevention. The aim of this study was to develop local monocyte chemoattractant protein-1 (MCP-1) and interleukin-12 p70 (IL-12 p70) therapies to prevent S. aureus infection by enhancing the recruitment and activation of macrophages, which are believed to play an important role in infection prevention as the first line of defense against invading pathogens. Nanocoating systems for MCP-1 and IL-12 p70 deliveries were prepared, and their release characteristics desirable for infection prevention in open fractures were explored. Local MCP-1 therapy reduced S. aureus infection and influenced white blood cell populations, and local IL-12 p70 treatment had a more profound effect on preventing S. aureus infection. No synergistic relationship in decreasing S. aureus infection was observed when MCP-1 and IL-12 p70 treatments were combined. This reported new approach may reduce antibiotic use and antibiotic resistance.

Interleukin-6 plasmatic levels in patients with head trauma and intracerebral hemorrhage

The exact role of inflammatory response in hemorrhagic contusions is not fully characterized. The present study quantified IL-6 plasmatic levels in patients with closed head trauma and hemorrhagic contusions during the first 6 to 12 hours postrauma. The association between the plasmatic IL-6 levels, severity of trauma according to the Glasgow Coma Scale, volume of intracerebral hemorrhage and patient's clinical evolution were investigated. Although inflammation is a multifactorial process, a strong correlation between IL-6 levels, volume of traumatic hemorrhage and in-hospital evolution could be observed. A correlation between the IL-6 levels quantified 6 hours postrauma and progression of lesion volume between admission and 12 hours postrauma is suggested. The present study reinforces the importance of IL-6 in influencing the clinical conditions of a patient with cerebral injuries, particularly hemorrhagic contusions.

Differences in outcome between obese and nonobese patients following severe blunt trauma are not consistent with an early inflammatory genomic response

OBJECTIVES

Obesity has been demonstrated to alter a number of acute and chronic medical conditions. The effect of obesity on severely injured patients, however, remains incompletely defined. We sought to unravel potential physiologic and genomic alterations induced by obesity in severely injured blunt trauma patients.

DESIGN

A retrospective review of clinical and genomic information contained in the Inflammation and the Host Response to Injury multicenter trauma-related database examining the relationship between body mass index and the early genomic response from peripheral blood leukocytes to patient outcome following severe blunt trauma was performed.

SETTING

Multicenter collaboration between university-based academic trauma centers.

PATIENTS

Severely injured blunt trauma patients enrolled in the database.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Univariate analysis of 455 severely injured trauma patients using the National Institutes of Health/World Health Organization body mass index classification system revealed significant increases in morbidity, including longer intensive care unit stays and a greater number of ventilator days, cardiac arrests, episodes of acute renal failure, and patients developing multiple organ failure. Regression modeling identified body mass index class as being independently associated with adverse outcomes and increased morbidity but an inverse relationship with mortality in patients who suffered severe blunt traumatic injury. Initial leukocyte genomic expression patterns between 163 patients in the four different body mass index groupings did not differ; however, analysis of gene differences between body mass index classes occurring over time demonstrated significant changes in 513 probe sets with significant pathway differences being related to cellular metabolism.

CONCLUSIONS

Increasing body mass index is associated with increased morbidity following severe blunt trauma. The initial blood leukocyte inflammatory response to blunt trauma does not appear to differ significantly between patients despite increasing body mass index. Resolution of the inflammatory response may differ between patients on the basis of body mass index; however, additional work is needed to clarify the potential causality of this finding.

A new method for managing emergency calls

Available methods for managing territorial medical emergencies are nowadays very effective. Nevertheless, resources are limited, and such methods are far from being perfect. It could be difficult, sometimes, to ensure adequate and prompt medical care to the community when emergency is taking place in such short times as those recommended for cardiocirculatory arrest or a trauma. The major intent of this project is to implement some drawbacks of the current management of medical rescue on the territory improving overall response times to emergencies and providing the delivery of qualified pre-hospital patient care. This may include (but not be limited to) the institution of a database, on a voluntary basis, for trained personnel. Such database should include resuscitation specialists, physicians, but also anyone who has undergone recognized training. Upon receiving a medical emergency call, an off-duty operator can be selected from the database (in a cooperative, non-competitive manner with the dedicated emergency services), based on current position of his/her cellular phone and his/her training profile. Finally, the operator who is both closest to and best prepared for the emergency is contacted via cellular phone. If the operator is available he/she can precede or join the mobile unit on site, managing the emergency according to his/her profile, possibly in cooperation with the ambulance personnel and even up to hospital admission.

Optimal use of blood in trauma patients

Injury is rapidly becoming the leading cause of death worldwide, and uncontrolled hemorrhage is the leading cause of potentially preventable death. In addition to crystalloid and/or colloid based resuscitation, severely injured trauma patients are routinely transfused RBCs, plasma, platelets, and in some centers either cryoprecipitate or fibrinogen concentrates or whole blood. Optimal timing and quantity of these products in the treatment of hypothermic, coagulopathic and acidotic trauma patients is unclear. The immediate availability of these components is important, as most hemorrhagic deaths occur within the first 3-6h of patient arrival. While there are strongly held opinions and longstanding traditions in their use, there are little data within which to logically guide resuscitation therapy. Many current recommendations are based on euvolemic elective surgery patients and incorporate laboratory data parameters not widely available in the first few minutes after patient arrival. Finally, blood components themselves have evolved over the last 30 years, with great attention paid to product safety and inventory management, yet there are surprisingly limited clinical outcome data describing the long term effects of these changes, or how the components have improved clinical outcomes compared to whole blood therapy. When focused on survival of the rapidly bleeding trauma patient, it is unclear if current component therapy is equivalent to whole blood transfusion. In fact data from the current war in Iraq and Afghanistan suggest otherwise. All of these factors have contributed to the current situation, whereby blood component therapy is highly variable and not driven by long term patient outcomes. This review will address the issues raised above and describe recent trauma patient outcome data utilizing predetermined plasma:platelet:RBC transfusion ratios and an ongoing prospective observational trauma transfusion study.

Dissociative disorders among Chinese inpatients diagnosed with schizophrenia

The purpose of this study was to assess the prevalence of dissociative disorders in a sample of Chinese psychiatric inpatients. Participants in the study were 569 consecutively admitted inpatients at Shanghai Mental Health Center, China, of whom 84.9% had a clinical diagnosis of schizophrenia based on the Chinese Classification and Diagnostic Criteria of Mental Disorders, Version 3. All participants completed a self-report measure of dissociation (the Dissociative Experiences Scale), and none had a prior diagnosis of a dissociative disorder. A total of 96 randomly selected participants were interviewed with a structured interview (the Dissociative Disorders Interview Schedule) and a clinical interview. These 96 patients did not differ significantly from the 473 patients who were not interviewed on any demographic measures or who did not complete the self-report dissociation measure. A total of 28 patients (15.3%, after weighting of the data) received a clinical diagnosis of a dissociative disorder based on Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) criteria. Dissociative identity disorder was diagnosed in 2 patients (0.53%, after weighting). Compared to the patients without a dissociative disorder, patients with dissociative disorders were significantly more likely to report childhood abuse (57.1% vs. 22.1%), but the 2 groups did not differ significantly on any demographic measures. Dissociative disorders were readily identified in an inpatient psychiatric population in China.

Sleep disturbance immediately prior to trauma predicts subsequent psychiatric disorder

STUDY OBJECTIVES

This study investigated the extent to which sleep disturbance in the period immediately prior to a traumatic event predicted development of subsequent psychiatric disorder.

DESIGN

Prospective design cohort study.

SETTING

Four major trauma hospitals across Australia.

PATIENTS

A total of 1033 traumatically injured patients were initially assessed during hospital admission and followed up at 3 months (898) after injury.

MEASURES

Lifetime psychiatric disorder was assessed in hospital with the Mini-International Neuropsychiatric Interview. Sleep disturbance in the 2 weeks prior to injury was also assessed using the Sleep Impairment Index. The prevalence of psychiatric disorder was assessed 3 months after traumatic injury.

RESULTS

There were 255 (28%) patients with a psychiatric disorder at 3 months. Patients who displayed sleep disturbance prior to the injury were more likely to develop a psychiatric disorder at 3 months (odds ratio: 2.44, 95% CI: 1.62-3.69). In terms of patients who had never experienced a prior disorder (n = 324), 96 patients (30%) had a psychiatric disorder at 3 months, and these patients were more likely to develop disorder if they displayed prior sleep disturbance (odds ratio: 3.16, 95% CI: 1.59-4.75).

CONCLUSIONS

These findings provide evidence that sleep disturbance prior to a traumatic event is a risk factor for development of posttraumatic psychiatric disorder.

Sympathetic modulation of the host defense response to infectious challenge during recovery from hemorrhage

BACKGROUND

Trauma/hemorrhage (TxHem) is associated with an immediate pro-inflammatory response that, if exaggerated or prolonged, is thought to contribute to the subsequent immunosuppression that characterizes the period after injury. Previously we have demonstrated that chemical sympathectomy (SNSx) accentuates this immediate pro-inflammatory response to TxHem. These findings suggest that the noradrenergic system plays a critical role in limiting the magnitude of the inflammatory response during TxHem and preserving the integrity of the host defense response to a subsequent infectious challenge during the period after TxHem.

OBJECTIVE

To examine the contribution of tissue norepinephrine to the host defense response to an infectious challenge during recovery from TxHem.

METHODS

Male Sprague-Dawley rats underwent SNSx (6-hydroxydopamine, i.p. daily for 3 days) prior to vascular catheter implantation. Conscious, unrestrained rats were subjected to traumatic injury (muscle crush) prior to a fixed-pressure hemorrhage (40 mm Hg for 60 min) and fluid resuscitation followed 24 h later by cecal ligation and puncture (CLP).

RESULTS

SNSx impaired the hemodynamic and thermoregulatory response to hemorrhage as indicated by decreased basal blood pressure, impaired blood pressure recovery during fluid resuscitation, and greater hypothermia after CLP. Furthermore, SNSx accentuated the TNF-alpha, IL-1, IL-6, and IL-10 response to TxHem + infection in plasma 6 h after CLP and in peritoneal lavage fluid 24 h after CLP.

CONCLUSION

These results indicate that the integrity of the noradrenergic system is necessary for adequate hemodynamic, thermoregulatory, and inflammatory responses to infection during the period following TxHem.