Injury
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Teriparatide [PTH (1-34)] is a genetically engineered analog of human parathyroid hormone that acts as an anabolic drug by increasing activity in both osteoblasts and osteoclasts. Intermittent (once-daily) doses of teriparatide seem to stimulate osteoblast activity and therefore result in a net increase of bone formation. It is recommended for use in post-menopausal women (PMW), men with hypogonadal osteoporosis, as well as men and women with glucocorticoid-induced osteoporosis. ⋯ In the following scenarios, teriparatide might be considered in patients with osteoporosis and a fracture: (1) patients with severe osteoporosis with use of bisphosphonates for a number of years with a fracture not expected to predictably unite, e.g. atypical femur fracture or open tibia fracture, (2) in cases where an osteoporotic patient has failed fracture healing and is considering surgical treatment e.g. non-union surgery. It seems prudent to reevaluate these patients frequently and reconsider which drug class of osteoporotic drug is best for the patient. Finally, it must be stressed that we do not recommend teriparatide in osteoporotic patients that may be well treated with bisphosphonates and a fracture is expected to heal uneventfully, nor when patients with metabolically normal bone have a fracture.
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Prognosis in patients with traumatic brain injury (TBI) and Glasgow Coma Scale (GCS) score of 3 is poor, raising concern regarding the utility of aggressive operative neurosurgical management. Our purpose was to describe outcomes in a propensity matched population with TBI and GCS3 treated with operative neurosurgical procedures of craniotomy or craniectomy (CRANI). ⋯ Survival was achieved in 65% of patients that underwent surgical intervention for subdural and epidural haematoma, despite a presenting GCS of 3. These results demonstrate prompt operative neurosurgical management of mass lesion is warranted for selected patients with a GCS of 3, contributing to a significant 4-fold survival benefit. In the absence of mass lesion the effect of immediate neurosurgery on outcomes is inconclusive.
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In 2009, a commercial airplane crashed near Amsterdam. This longitudinal study aims to investigate (1) the proportion of survivors of the airplane crash showing a probable posttraumatic stress disorders (PTSD) or depressive disorder, and (2) whether symptoms of PTSD and depression were predicted by trauma characteristics. Identifying these trauma characteristics is crucial for early detection and treatment. ⋯ There were no differences in seating position between participants at high risk vs. participants at low risk for PTSD or depression. Mixed design ANOVAs showed also no association between the course of symptoms of PTSD and depression 2 and 9 months after the crash and ISS or hospitalisation. This suggests that health care providers need to be aware that survivors may be at risk for PTSD or depression, regardless of the objective severity of their physical injuries.
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Whole-body CT (WBCT) has become routine practice in the assessment of major trauma patients. Whilst this may be associated with increased survival, several studies report high rates of negative scans. As no national guideline exists, selection criteria for WBCT vary widely. This study aims to (1) produce a scoring system that improves patient selection for WBCT (2) quantify patient radiation doses and their concomitant risk of malignancy. ⋯ After including neurological deficit, our scoring system had a sensitivity of 97% (95% CI 88-99%) and specificity of 56% (95% CI 49-64%) for significant injury. We propose this is used to stratify the use of trauma radiographs, focused CT and WBCT for major trauma patients. Although not intended to replace clinical judgement, our scoring system adds an objective component to decision-making. We believe this will safely reduce the number of unnecessary CT scans performed on a relatively young cohort of patients.
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Bisphosphonates (BPs) have been in use for many years for the treatment of osteoporosis, multiple myeloma, Paget's disease, as well as a variety of other diseases in which there is reduced bone mineral density. Given that bisphosphonates inhibit bone resorption, an important stage of fracture healing; this class of compounds has been widely studied in preclinical models regarding their influence on fracture healing. In animal models, bisphosphonate treatment is associated with a larger fracture callus, coincident with a delay in remodeling from primary woven bone to lamellar bone, but there is no delay in formation of the fracture callus. ⋯ Rarely, patients with long term use of Bisphosphonates may develop an atypical fracture and delay in fracture healing has been observed. In summary, bisphosphonates appear safe for use in the setting of acute fracture management in the upper and lower extremity in humans. While much remains unknown about the effects on healing of long-term bisphosphonates, use prior to "typical" fracture, in the special case of atypical fracture, evidence suggests that bisphosphonates negatively influence healing.