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Journal of Neurology, Neurosurgery, and... Nov 2019Traumatic brain injury (TBI) leads to increased rates of dementia, including Alzheimer's disease. The mechanisms by which trauma can trigger neurodegeneration are... (Review)
Review
Traumatic brain injury (TBI) leads to increased rates of dementia, including Alzheimer's disease. The mechanisms by which trauma can trigger neurodegeneration are increasingly understood. For example, diffuse axonal injury is implicated in disrupting microtubule function, providing the potential context for pathologies of tau and amyloid to develop. The neuropathology of post-traumatic dementias is increasingly well characterised, with recent work focusing on chronic traumatic encephalopathy (CTE). However, clinical diagnosis of post-traumatic dementia is problematic. It is often difficult to disentangle the direct effects of TBI from those produced by progressive neurodegeneration or other post-traumatic sequelae such as psychiatric impairment. CTE can only be confidently identified at postmortem and patients are often confused and anxious about the most likely cause of their post-traumatic problems. A new approach to the assessment of the long-term effects of TBI is needed. Accurate methods are available for the investigation of other neurodegenerative conditions. These should be systematically employed in TBI. MRI and positron emission tomography neuroimaging provide biomarkers of neurodegeneration which may be of particular use in the postinjury setting. Brain atrophy is a key measure of disease progression and can be used to accurately quantify neuronal loss. Fluid biomarkers such as neurofilament light can complement neuroimaging, representing sensitive potential methods to track neurodegenerative processes that develop after TBI. These biomarkers could characterise endophenotypes associated with distinct types of post-traumatic neurodegeneration. In addition, they might profitably be used in clinical trials of neuroprotective and disease-modifying treatments, improving trial design by providing precise and sensitive measures of neuronal loss.
Topics: Biomarkers; Brain; Brain Injuries, Traumatic; Chronic Traumatic Encephalopathy; Clinical Trials as Topic; Dementia; Disease Progression; Humans; Nerve Degeneration
PubMed: 31542723
DOI: 10.1136/jnnp-2017-317557 -
Mediastinum (Hong Kong, China) 2021Penetrating transmediastinal injury (TMI) is associated with a high mortality rate and presents a challenging diagnostic scenario. Previous dogma mandated surgical... (Review)
Review
Penetrating transmediastinal injury (TMI) is associated with a high mortality rate and presents a challenging diagnostic scenario. Previous dogma mandated surgical exploration or extensive and invasive investigations for all patients sustaining transmediastinal penetrating trauma, regardless of hemodynamic status. Since the late 1990s, the paradigm has changed, with most centers adopting a tiered approach to management based on clinical presentation. Transmediastinal penetrating trauma is a rare injury pattern and can result from gunshot wounds, stab wounds, blast injuries, and other missiles. The most predominant source, however, remains gunshot wounds, accounting for the vast majority of these injuries. A systematic approach in the emergency department to diagnosis and management should be undertaken and patients in extremis or with hemodynamic compromise rapidly identified. The unstable patient forgoes further investigations and the surgeon must use knowledge about the hypothesized trajectory, results of limited imaging, chest tube output, and anticipation of resuscitative maneuvers to select the best operative approach. In patients who are sufficiently stable to undergo CT angiogram (CTA) of the chest, the trajectory of the missile or impalement can often be deduced and this is used to guide further investigation or operation. In those where ambiguity remains, more focused tests such as echocardiography, pericardial window, esophagoscopy or esophagography, and bronchoscopy can be used to assess the mediastinal structures. For the stable patient, management proceeds with cautious and expeditious investigations to determine the extent of underlying organ-specific injuries. Thus, in patients with this injury pattern, determination of the patient's clinical status is critical to determine the appropriate course of management.
PubMed: 35118330
DOI: 10.21037/med-21-14 -
Journal of Education & Teaching in... Apr 2022This scenario was developed to educate emergency medicine residents on the various presentations and management of a patient struck by lightning.
AUDIENCE
This scenario was developed to educate emergency medicine residents on the various presentations and management of a patient struck by lightning.
INTRODUCTION
Annually, there are approximately 1.4 billon lightning strikes around the world; of these, an estimated 24,000 strikes cause significant injury or death.1 In the United States, there are approximately 400 lightning-related injuries every year resulting in 40 average annual deaths.1 Although only one in approximately 14,000 people will ever be struck by lightning, this still represents a significant injury mechanism for which emergency department providers must be prepared.2 Lightning is formed by static electricity built up due to ice crystals in clouds which creates a differential charge between the cloud and another object, such as the ground. Approximately one in every five lightning strikes is a cloud-to-ground strike which can result in injury or death. Lightning current flows may be as high as 100,000 amperes; this is survived 90% of the time only because the strong current of the bolt is applied in a very small timeframe, limiting the amount of energy transferred.3 Even so, with such large amperages, substantial injuries or death are possible. Not limited to a single mechanism, lightning can harm people in a variety of ways, including a direct strike, side-splash, ground current or upward streamers from the ground, or cause blast-type injury.2 The large electric currents involved can generate non-perfusing cardiac rhythms resulting in death if the patient is not immediately resuscitated through cardiopulmonary resuscitation (CPR) techniques with respiratory support.2.
EDUCATIONAL OBJECTIVES
At the conclusion of the simulation session, learners will be able to: 1) Describe how to evaluate for scene safety in an outdoor space during a thunderstorm, 2) Obtain a relevant focused physical examination of the lightning strike patient, 3) Describe the various manifestations of thermo-electric injury, 4) Discuss the management of the lightning strike patient, including treatment and disposition, 5) Outline the principles of reverse triage for lightning strike patients, and 6) Describe long-term complications of lightning strike injuries.
EDUCATIONAL METHODS
This session was conducted using a simulation scenario with a mix of high-fidelity manikins and standardized patients followed by a debriefing session on the presentation, differential diagnosis, and management of lightning strike patients. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques. This scenario may also be run as an oral board examination case.
RESEARCH METHODS
The residents are provided a survey at the completion of the debriefing session to rate different aspects of the simulation, as well as to provide qualitative feedback on the scenario. This survey is specific to the local institution's simulation center.
RESULTS
Feedback from the residents was overwhelmingly positive, although several learners struggled with identifying Lichtenberg figures and keraunoparalysis either due to the low-light setting, unfamiliarity of the pathology, or that the depictions were not as expected. The subsequent debriefings allowed for multiple areas of discussion. Debriefing topics included the comparing and contrasting low voltage/high voltage/lightning strike injuries, possible clinical presentations of the lightning strike patient, reverse triage principles, categorizing blast injuries, discussion of disposition, and the determination of prehospital scene safety.The local institution's simulation center feedback form is based on the Center of Medical Simulation's Debriefing Assessment for Simulation in Healthcare (DASH) Student Version Short Form4 with the inclusion of required qualitative feedback if an element was scored less than a 6 or 7. Thirty-one learners completed a feedback form. This session received all 6 and 7 scores (consistently effective/very good and extremely effective/outstanding, respectively) other than one isolated 5 score. The statement, "Before the simulation, the instructor set the stage for an engaging learning experience," received the lowest average score with 6.81, while "The instructor structured the debriefing in an organized way" received an average score of 6.94.The form also includes an area for general feedback about the case at the end. Illustrative examples of feedback include: "Absolutely loved this sim. Tested multiple aspects of massCal care. Communication, critical care, scene safety, etc., nailed it," and "Very engaging and fun with a lot (of) good debriefing."
DISCUSSION
This is an easily reproducible method for reviewing management of the lightning strike patient. Faculty may choose to use a combination of high- or low-fidelity manikins, task trainers, standardized patients, or confederate actors/volunteers as patients. There are multiple potential presentations and complications of the lightning strike patient to further customize the experience for learners' needs. For those who are looking to scale down the scenario, victims may be limited to one or two individuals, using whatever preferred mixture of manikins or standardized patients is needed or desired.
TOPICS
Medical simulation, lightning strike patient, thermo-electrical burn, wilderness first-aid, blast injuries, wilderness medicine, emergency medicine, austere medicine.
PubMed: 37465437
DOI: 10.21980/J8SD2M -
Frontiers in Neurology 2021
PubMed: 34220697
DOI: 10.3389/fneur.2021.702431 -
Bone & Joint Research Jan 2020Bone is one of the most highly adaptive tissues in the body, possessing the capability to alter its morphology and function in response to stimuli in its surrounding...
Bone is one of the most highly adaptive tissues in the body, possessing the capability to alter its morphology and function in response to stimuli in its surrounding environment. The ability of bone to sense and convert external mechanical stimuli into a biochemical response, which ultimately alters the phenotype and function of the cell, is described as mechanotransduction. This review aims to describe the fundamental physiology and biomechanisms that occur to induce osteogenic adaptation of a cell following application of a physical stimulus. Considerable developments have been made in recent years in our understanding of how cells orchestrate this complex interplay of processes, and have become the focus of research in osteogenesis. We will discuss current areas of preclinical and clinical research exploring the harnessing of mechanotransductive properties of cells and applying them therapeutically, both in the context of fracture healing and de novo bone formation in situations such as nonunion. Cite this article: 2019;9(1):1-14.
PubMed: 32435450
DOI: 10.1302/2046-3758.91.BJR-2019-0043.R2 -
Journal of Experimental Neuroscience 2019Traumatic brain injury (TBI) is a well-known consequence of participation in activities such as military combat or collision sports. But the wide variability in... (Review)
Review
Traumatic brain injury (TBI) is a well-known consequence of participation in activities such as military combat or collision sports. But the wide variability in eliciting circumstances and injury severities makes the study of TBI as a uniform disease state impossible. Military Service members are under additional, unique threats such as exposure to explosive blast and its unique effects on the body. This review is aimed toward TBI researchers, as it covers important concepts and considerations for studying blast-induced head trauma. These include the comparability of blast-induced head trauma to other mechanisms of TBI, whether blast overpressure induces measureable biomarkers, and whether a biodosimeter can link blast exposure to health outcomes, using acute radiation exposure as a corollary. This examination is contextualized by the understanding of concussive events and their psychological effects throughout the past century's wars, as well as the variables that predict sustaining a TBI and those that precipitate or exacerbate psychological conditions. Disclaimer: The views expressed in this article are solely the views of the authors and not those of the Department of Defense Blast Injury Research Coordinating Office, US Army Medical Research and Development Command, US Army Futures Command, US Army, or the Department of Defense.
PubMed: 31548796
DOI: 10.1177/1179069519872213