Prehospital Hypertonic Saline Administration After Severe Traumatic Brain Injury.

A 25-year old male paient was critically injuried in a high speed motor vehicle collision over an hour from the nearest trauma center. Paramedics diagnosed the patient with a traumatic brain injury and increasing intracranial pressure and transported the patient to a predesignated landing zone for helicopter intercept. During transport paramedics initiated a severe traumatic brain injury protocol which included the adminisration of 3% hypertonic saline. The flight crew continued 3% hypertonic saline managment which was later transferred to the receiving trauma team. Upon trauma center arrival the patient was diagnosed with a skull fracture and subdural hematoma. The patient was transitioned to a 3% hypertonic saline infusion for the next 24 h. The need for integrating systems of care is particularly important when managing patients with severe traumatic brain injury. This case report describes a patient with a severe TBI who received prehospital 3% hypertonic saline based on an integrated protocol developed between multiple prehosptial systems and a tertiary care trauma center. Severe traumatic brain injuries (TBIs) are a potentially catastrophic event, and morbidity can rise precipitously without early interventions to prevent hypoxia and hypotension and control for rising intracranial pressure. In recent years, hypertonic saline (HTS) has shown efficacy in lowering intracranial pressures for patients experiencing TBIs, the leading cause of death and disability among children and young adults in the United States.1 Integrating care between health care providers across the acute care continuum, from prehospital systems to discharge, is paramount in providing the best patient outcomes possible, especially in health care system expansions such as air medical transport. The need for integrating systems of care is particularly important when managing patients with severe TBI. Statewide prehospital care protocols vary greatly; 78% provide ventilation guidance, 77.3% have targeted end-tidal carbon dioxide levels below < 35 mm Hg, and only 1 (of 38 reviewed) includes HTS (3%).2 One barrier to consistency in protocol development is the available literature. One trial demonstrated that a prehospital bolus of 7.5% HTS in severe TBI did not improve mortality.3 However, the Brain Foundation guidelines continue to recommend the prehospital use of hyperosmolar therapy for patients with severe TBI and evidence of impending herniation.4 Hyperosmolar therapy is also recommended as an inpatient strategy for lowering increased intracranial pressure (ICP).4 One reason for this apparent disconnect is because the ideal timing of HTS administration and its concentration have not been determined.4 A meta-analysis previously determined no one prehospital fluid is superior to another in improving the outcomes of patients with severe TBI.5 However, none of the reviewed research investigated the continued use of HTS across an integrated system of care. This case report describes a patient with a severe TBI who received 3% HTS initiated in the prehospital setting with the infusion continued upon arrival at the trauma center using a system-wide integrated protocol.

Statistical Shape Modelling the In Vivo Location of Acetabular Wear in Retrieved Hip Implants.

Edge-wear in acetabular cups is known to be correlated with greater volumes of material loss; the location of this wear pattern in vivo is less understood. Statistical shape modelling (SSM) may provide further insight into this. This study aimed to identify the most common locations of wear in vivo, by combining CT imaging, retrieval analysis and SMM. Shape variance was described in 20 retrieved metal-on-metal acetabular surfaces. These were revised after a mean of 90 months, from 13 female and seven male patients. They were positioned with a mean inclination and anteversion of 53° and 30°, respectively. Their orientation, in vivo, was established using their stabilising fins, visible in pre-revision CT imaging. The impact of wear volume, positioning, time, gender and size on the in vivo location of wear was investigated. These surfaces had a mean wear volume of 49.63 mm3. The mean acetabular surface displayed superior edge-wear centred 7° within the posterosuperior quadrant, while more of the volumetric wear occurred in the anterosuperior quadrant. Components with higher inclination had greater superior edge-wear scars, while a relationship was observed between greater anteversion angles and more posterosuperior edge-wear. This SSM method can further our understanding of hip implant function, informing future design and may help to refine the safe zone for implant positioning.

Victims' barriers to discussing domestic violence in clinical consultations: a qualitative enquiry.

Victims of domestic violence frequently attend health care facilities. In many cases, their abusive experience is neither disclosed nor discussed during clinical consultations. This study examined the barriers faced by women when discussing abuse with health care providers, specifically in cases involving Malaysian women with a history of domestic violence. A qualitative study using in-depth interviews was conducted with 10 women with a history of domestic violence residing at a shelter. Purposive sampling was conducted until data saturation. Using the grounded theory approach of analysis, themes that emerged from these interviews were then further analyzed to examine the barriers faced by these women. Women who experienced domestic violence faced multiple barriers while discussing their accounts of abuse with others. Values placed on the privacy of domestic violence; upholding the traditional gender roles; preserving the family unity; minimizing the abuse, the feeling of shame, self-blame; and fearing their abuser generally create internal barriers when discussing their encounters of abuse with health care providers. The perceived unknown role of health care professionals when dealing with patients experiencing domestic violence as well as the previous negative experiences in clinical consultations acted as external barriers for discussing abuse with health care providers. Women with domestic violence experiences faced internal and external barriers to discussing their abuse during clinical consultations. Physicians and health care providers must consider domestic violence in consultations with female patients. A good doctor-patient relationship that encompasses empathy, confidence, trust, support, assurance, confidentiality, and guidance can help patients with abusive backgrounds overcome these barriers, leading to the disclosure and discussion of their abusive encounters. Proper education, guidelines, and support for health care providers are required to help them assist women with histories of domestic violence.

What is the 'dark figure' of child homicide and how can it be addressed in Australia?

Child injury, regardless of intent, is a major public health issue in Australia and elsewhere. Child protection and injury prevention policies and practices are implemented in most countries in an attempt to manage and reduce the incidence of both intentional and unintentional injuries. While these systems are thought to assist in improving protection from violence, injury and neglect, one of the major limitations in understanding the effectiveness of child protection policy in Australia is a lack of reliable national data on child abuse and neglect. As a result there is a lack of an appropriate evidence base on which to guide the development of effective policies. A particular area where official figures may under-represent the true prevalence of child deaths is those which result from homicide. This article provides a review of the recent literature on child homicide, abuse and neglect, with the overall aim of understanding more fully the reasons for the possible under-representation of child homicides and provides recommendations to address this problem in Australia. Improvements in methods of identifying at risk children in addition to systematic investigations of child deaths to understand the risk factors and underlying contributing factors are required.

Ordering in stretch-tunable polymeric opal fibers.

We demonstrate the production of high-quality polymer opal fibers in an industrially-scalable process. These fibers exhibit structural color, based on the self-assembly of sub-micron core-shell particles, with a spectrum which is stretch-tunable across the visible region. The internal substructure and ordering of fibers, as inferred from variations in spectral bandwidth, is studied using dark-field microscopy. We employ a granular model to examine flow and shear forces during the extrusion process, and the effects on particle ordering. In both theory and experiment, a concentric zone of the fiber near the exposed surface develops particularly strong structural color. Such elastically-tuned structurally colored fibers are of interest for many applications.

Low Reynolds number turbulence in nonlinear Maxwell-model fluids.

A generalized nonlinear Maxwell model which had previously been analyzed for plane Couette geometry is here applied to a lid-driven cavity flow. The full three-dimensional hydrodynamical problem is treated numerically. Depending on the relevant model parameters, both smooth laminar and low Reynolds number turbulent flows are found, strikingly similar to the experimentally observed elastic turbulence phenomena in polymer solutions. Representative results of the calculated flow patterns, as well as measures for the turbulent nature of the flow are presented graphically.

'It's been really, really hard': a qualitative study of the health problems of people receiving emergency relief in Australia.

The aim of the research reported in this paper was to explore the perspectives and insights of emergency relief recipients in relation to their complex health problems, which had contributed to their position of needing to seek emergency relief. The sample consisted of 20 adults aged between 19 and 51 years who had received emergency relief in a regional city in Victoria, Australia. Non-probability sampling was used, employing the convenience sampling procedure. A qualitative, exploratory research approach utilising in-depth interviews was selected to obtain data from the respondents. The method of data analysis used involved open, axial and selective coding. The main findings were that the participants experienced abuse and neglect in childhood, the effects of mental health problems, going without food, lack of access to and the high cost of health care, and the interactive aspects of health problems and poverty. Implications for policy and service delivery are outlined.

Shear-induced chaos in nonlinear Maxwell-model fluids.

A generalized model for the behavior of the stress tensor in non-Newtonian fluids is investigated for spatially homogeneous plane Couette flow, showing a variety of nonlinear responses and deterministic chaos. Mapping of chaotic solutions is achieved through the largest Lyapunov exponent for the two main parameters: The shear rate and the temperature and/or density. Bifurcation diagrams and stability analysis are used to reveal some of the rich dynamics that can be found. Suggested mechanisms for stability loss in these complex fluids include Hopf, saddle-node, and period-doubling bifurcations.

Identification of a novel FcgammaRIII receptor that is up-regulated in fetal wound healing.

The mid-gestation fetus is able to heal skin wounds rapidly and without scarring, an ability that is lost as development proceeds. The aim of this study was to identify novel genes involved in this process. We established an ex vivo wound model from embryonic rats and showed that over 72 hours, embryonic day 17 wounds reepithelialized and closed whereas day 19 wounds did not. To investigate the molecular basis of this phenomenon we analyzed changes in gene expression using differential display polymerase chain reaction. We characterized one transcript that was strongly up-regulated in the healing response of wounded, day 17 skin. It encodes a protein of 249 amino acids with striking similarity to the human low-affinity receptor for the Fc portion of IgG (FcgammaRIII), suggesting that it is a novel member of the FcgammaR family, which we named FcgammaRIII-X. A wound-healing timecourse shows that FcgammaRIII-X was up-regulated in healing, wounded day 17 skin but not in nonhealing, wounded day 19 skin and that its up-regulation was accelerated in skin with multiple wounds. We suggest that up-regulation of FcgammaRIII-X may contribute to scarless healing of fetal skin.

Nipple-areolar pigmentation: histology and potential for reconstitution in breast reconstruction.

The makeup of nipple-areolar skin, in terms of its melanin and melanocyte content has not previously been established. This histological information is required if pigmentation of the reconstructed nipple-areola is to be successful in post-mastectomy breast reconstruction. We describe examination of 200 parallel sections of nipple-areolar skin of 20 women using histochemical (Masson-Fontana) and immunohistochemical (Mel-5) techniques, evaluated using quantitative image analysis. The amount of melanin present per length of basement membrane was 2.14 times higher in areolar skin than breast skin. The ratio of melanocytes to keratinocytes was 1:9.7 in areolar skin vs. 1:14.7 in breast skin. We also describe a cell culture and skin construct method using autologous human serum without toxic growth promoting additives, which could be used in the clinical setting of nipple-areolar reconstruction.

Betacellulin promotes growth of the gastrointestinal organs and effects a diuresis in normal rats.

Betacellulin is a relatively new member of the epidermal growth factor peptide family, however, its function remains poorly defined. We investigated its physiological effects in rats implanted with pumps to deliver vehicle or recombinant rat betacellulin [46 microg/day] for 7 days. At kill, blood and gastrointestinal tissues were collected for determinations of betacellulin levels, proliferation (bromodeoxyuridine-BrdU incorporation) and growth. Plasma betacellulin levels were increased 8-fold compared to vehicle, whilst serum insulin, body weight and food intake were decreased by 32, 15 and 9%, respectively. Water intake, urine and faecal output and small intestinal weight were respectively increased by 36, 78, 47 and 24%. Ileal and proximal colonic crypt depths were increased by 25 and 51% although the BrdU labelling index was unaffected. Betacellulin stimulated gastrointestinal growth, the increased responsiveness of the terminal ileum and colon suggesting therapeutic potential in disease conditions in which ileal or colonic re-growth is desirable. Betacellulin further stimulated a diuresis suggesting an additional role in fluid homeostasis.