Sternal fractures are frequent among polytraumatised patients following high deceleration velocities in a severe vehicle crash

INTRODUCTION: Sternal fractures are a rare entity. We hypothesised that a sternal fracture is an indicator of injury severity following traffic accidents. METHODS: Analysis of technical indicators of the collision, preclinical and clinical data of patients with sternal fractures from 1985 to 2004 among 42,055 injured patients assessed by an Accident Research Unit. RESULTS: Only 267/42,055 patients (0.64%) suffered a sternal fracture within the 20-year period. Soft tissue bruises are most often concomitant injuries (55%), followed by cervical spine injuries (23%), multiple rib fractures (14%) and lung injuries (12%). Eighteen percent of patients were polytraumatised, with 11.2% dying at the scene, 2.3% in hospital. Deceleration velocity (DeltaV) was significantly correlated with injury severity score (ISS, r2=0.92, y=0.408x-4.1573) as with maximal abbreviated injury scale (MAIS, r2=0.81). Patients suffering a sternal fracture being polytraumatised had significantly higher deceleration velocity (60+/-17km/h versus 37+/-16km/h [37.3+/-10.6mph versus 23+/-9.9mph], p=0.0001). Patients dying with a sternal fracture had a significant higher deceleration velocity (61km/h, 37.9mph) versus those surviving (38km/h, 23.6mph, p=0.0001). Regarding the vehicle type, the majority occurred after car accidents in 0.81% (251/31,183 patients), followed by 0.19% (5/2633 patients) driving motorbikes, and 0.11% (4/3258 patients) driving a truck. Only 13% of all passengers suffering a sternal fracture had an airbag on board (33/255 car/trucks), with an airbag malfunction in 18%. 22% were not admitted to hospital, 28% were admitted to a trauma ICU with a sternal fracture. CONCLUSION: In 1/5 of cases sternal fractures encountered in polytraumatised patients following significantly higher deceleration velocities during the crash. Typically car drivers without a functioning airbag suffer a sternal fracture.     

The relationship between illnesses and medical drug consumption with the occurrence of traffic accidents among truck and bus drivers in Tehran, Iran

Purpose: To determine the relationship of illnesses and medical drug consumption with the occurrence of traffic accidents among truck and bus drivers. Methods: This is a cross-sectional study on truck and bus drivers in Tehran, Iran. The criteria for participating in this study were: married males over 30 years old, driving license in grade one, five years of job experience, mental health and non-addiction license. The criterion for not participating in this study was the lack of cooperation in responding to the questions. Six months was spent to collect the latest five years data of driving accidents from 2011 to 2016. A total of 323 truck and bus drivers in Tehran city and the suburbs, Iran were chosen. Among them, 112 were responsible for accidents (accident group) while 211 were not responsible for any accidents or involved in an accident in the last five years (nonaccident group). A specially designed questionnaire was used to investigate the demographic information, medical drug consumption, medical backgrounds and history of accidents. Results: The results revealed that compared with healthy subjects, the occurrence of accidents among people with diabetes (OR = 2.3, p = 0.001) and vision weakness (OR = 1.7, p = 0.020) was significantly higher, while that among people with cardiac (OR = 0.5, p = 0.002) and hypertension (OR = 0.9, p = 0.048) problems was remarkably lower. Moreover, consumption of Gemfibrozil (OR = 1.8, p = 0.010) and Glibenclamide (OR = 2.2, p = 0.002) drugs resulted in significantly higher incidence of accidents than those without. Conclusion: Frequencies of illnesses like cardiovascular and hypertension were not higher in accident drivers than in non-accident drivers; but diabetes, vision weakness and consumption of Gemfibrozil and Glibenclamide lead to more traffic accidents.     

Comparison between civilian burns and combat burns from Operation Iraqi Freedom and Operation Enduring Freedom

OBJECTIVE: To assess outcome differences between locally burned civilians and military personnel burned in a distant combat zone treated in the same facility. SUMMARY BACKGROUND DATA: The United States Army Institute of Surgical Research (USAISR) Burn Center serves as a referral center for civilians and is the sole center for significant burns in military personnel. We made the hypothesis that outcomes for military personnel burned in the current conflict in Iraq and Afghanistan would be poorer because of delays to definitive treatment, other associated injury, and distance of evacuation. METHODS: We reviewed the civilian and military records of patients treated at the USAISR from the outset of hostilities in Iraq in April 2003 to May 2005. Demographics, injury data, mortality, and clinical outcomes were compared. RESULTS:: We cared for 751 patients during this time period, 273 of whom were military (36%). Military injuries occurred in a younger population (41 +/- 19 vs. 26 +/- 7 years for civilian and military respectively, P < 0.0001) with a longer time from injury to burn center arrival (1 +/- 5 days vs. 6 +/- 5, P < 0.0001), a higher Injury Severity Score (ISS 5 +/- 8 vs. 9 +/- 11, P < 0.0001), and a higher incidence of inhalation injury (8% vs. 13%, P = 0.024). Total burn size did not differ. Mortality was 7.1% in the civilian and 3.8% in the military group (P = 0.076). When civilians outside the age range of the military cohort were excluded, civilian mortality was 5.0%, which did not differ from the military group (P = 0.57). Total body surface area (TBSA) burned, age > or =40 years, presence of inhalation injury, and ventilator days were found to be important predictors of mortality by stepwise regression, and were used in a final predictive model with the area under receiver operator characteristic curve of 0.97 for both populations considered together. No significant effect of either group was identified during development. CONCLUSIONS: Mortality does not differ between civilians evacuated locally and military personnel injured in distant austere environments treated at the same center.     

Tree collisions in road traffic accidents - mechanism and pattern of injury

INTRODUCTION: In Germany, the county of Mecklenburg-Vorpommern has got the highest frequency of traffic accidents. 42 % of all deadly injured car accident victims in Mecklenburg-Vorpommern sustained a tree collision. Aim of this study was to analyze tree collisions regarding typical pattern and severity of injury. METHODS: During an on-going prospective, non-interventional accident survey within a defined area of the county of Mecklenburg-Vorpommern tree collisions with minimum one victim sustaining a Maximum Abbreviated Injury Scale of 1-6 injury were analyzed. RESULTS: In between January 2001 and June 2004 287 accidents were documented. 19 % (54) were tree collisions. 81 % of drivers were male. 36 of 54 tree collisions (67 %) occurred on straight roadways. The mean ISS was 31.3 (SD +/- 29.8), 30 % (23) of the passengers died. 70 of 78 individuals sustained more than one injury. With that, the combination of head- and chest trauma was most frequent and associated with the highest injury severity. DISCUSSION: Especially tree collisions lead to severe trauma. Interestingly, most accidents did occur on straight roadways.     

Role of premorbid factors in predicting safe return to driving after severe TBI

Primary objective: The present study explored the possibility of predicting post-injury fitness to safe driving in patients with severe traumatic brain injury (TBI) (n = 66).

Methods and procedure: Sixteen different measures, derived from four domains (demo/biographic, medico-functional, neuropsychological, and psychosocial) were used as predictor variables, whereas driving outcomes were assessed in terms of driving status (post-TBI drivers versus non-drivers) and driving safety (number of post-TBI car accidents and violations).

Main outcomes and results: About 50% of the patients resumed driving after TBI. Compared to post-TBI non-drivers, post-injury drivers had shorter coma duration. With regard to driving safety, the final multiple regression model combined four predictors (years post-injury, accidents and violations before TBI, pre-TBI-risky-personality-index, and pre-TBI-risky-driving-style-index) and explained 72.5% of variance in the outcome measure.

Conclusions: Since the best three predictors of post-injury driving safety addressed patients' premorbid factors, the results suggest that in order to evaluate the actual possibility of safe driving after TBI, it would be advisable to consider carefully patients' pre-TBI histories.     

Does health care insurance affect outcomes after traumatic brain injury? Analysis of the National Trauma Databank

Increasing evidence indicates insurance status plays a role in the outcome of trauma patients; however its role on outcomes after traumatic brain injury (TBI) remains unclear. A retrospective review was queried within the National Trauma Data Bank. Moderate to severe TBI insured patients were compared with their uninsured counterparts with respect to demographics, Injury Severity Score, Glasgow Coma Scale score, and outcome. Multivariate logistic regression analysis was used to determine independent risk factors for mortality. Of 52,344 moderate to severe TBI patients, 41,711 (79.7%) were insured. Compared with the uninsured, insured TBI patients were older (46.1 +/- 22.4 vs. 37.3 +/- 16.3 years, P < 0.0001), more severely injured (ISS > or =16: 78.4% vs. 74.4%, P < 0.0001), had longer intensive care unit length of stay (6.0 +/- 9.4 vs. 5.1 +/- 7.6, P < 0.0001) and had higher mortality (9.3% vs. 8.0%, P < 0.0001). However, when controlling for confounding variables, the presence of insurance had a significant protective effect on mortality (adjusted odds ratio 0.89; 95% confidence interval: 0.82-0.97, P = 0.007). This effect was most noticeable in patients with head abbreviated injury score = 5 (adjusted odds ratio 0.7; 95% confidence interval: 0.6-0.8, P < 0.0001), indicating insured severe TBI patients have improved outcomes compared with their uninsured counterparts. There is no clear explanation for this finding however the role of insurance in outcomes after trauma remains a topic for further investigation.     

Occupational and traffic accidents among veterinary surgeons

A recent large‐scale survey of accidents in German veterinary surgeons was performed. Veterinary work represents a relatively high‐risk occupation involving substantial driving throughout the working week (visiting rural farms, etc.) with high reported rates of driving accidents and of accidents resulting from physical injury through treatment of animals. In this paper the prediction of both driving and other work‐related accidents among veterinary surgeons (N=494) is considered; it is appropriate to consider accident rates for this group separately, as there is evidence that the main predictors of accidents differ between veterinary surgeons and auxiliary veterinary personnel. A series of univariate and multivariate analyses of the data indicate that work‐related accident occurrence is best predicted by work‐related driving distance and risk attitude, with associations also being found with working hours and stress. Driving accident rate is best predicted by risk attitudes, stress and aggression, with associations also being found with age, number of children, work‐related driving distance and safety attitude. Construction of transactional models suggests models in which the effect of work‐related driving distance on driving accident rates is mediated by risk attitude, whilst the effect of working hours on work‐related accidents is mediated by stress. A detailed discussion of the general factors which predict work‐related accidents and specific occupational factors which apply to veterinary workers is also included. Problems associated with the high degree of intercorrelation between individual difference and occupational predictors in the interpretation and modelling of accident data are discussed. The implications for practice are also discussed. Copyright © 2000 John Wiley & Sons, Ltd.     

An epidemiologic survey of road traffic accidents in Iran:analysis of driver-related factors

Road traffic accident (RTA)and its related injuries contribute to a significant portion of the burden of diseases in Iran.This paper explores the association between driver-related factors and RTA in t...     

Prevalence of seat belt and mobile phone use and road accident injuries amongst college students in Kerman, Iran

Objective

To investigate the prevalence of mobile phone and seat belt use in driving in college students aged 18-24 years.

Methods

The study consisted of two phases. In the first phase, a questionnaire was given to 265 college students. The sample contained 188 males and 77 females. In the second phase, the data pertaining to road accident injuries from March 20, 2007 to March 20, 2008 were collected from Bahonar Central Hospital in Kerman, Iran, and analyzed.

Results

There were 14.0% of male and 19.0% of female participants traveled belted while driving on urban roads. It indicated that the participants unbelted or using mobile phone were more involved in accidents in last three years. This study also revealed that 19.0% of male and 4.2% of female drivers considered using mobile phone in driving not hazardous. The highest injury and property damage crash rates were 87 and 137 per 100 000 inhabitants, which occured in male group aged 18–24 years. And 30% of all fatalities were 19–24 years old.

Conclusions

More than 50% of college students traveled unbelted. The females were less involved in road accident injuries. The college students aged 18-24 years had the highest percentages of trauma and head injury.     

New vitals after injury: shock index for the young and age x shock index for the old

BACKGROUND: The traditional view that tachycardia and hypotension accompany hemorrhagic shock following injury has been challenged. This is particularly true at extremes of age. Shock index (SI) may be an alternative indicator of life-threatening bleeding after injury. Because age negatively impacts physiological reserve, we hypothesized that age multiplied by SI (Age x SI) would be a better predictor of 48 h mortality (48 MORT) compared to heart rate (HR), systolic blood pressure (SBP), or SI. METHODS: A Level I trauma center registry was used to identify victims of blunt injury, aged 18-84 (YOUNG < or =55 and OLD >55) admitted from 1996-2005. Patients with head and spinal cord injury injuries were excluded. The main outcome was 48 MORT. Areas under the receiver operating characteristic curves (AUC) for each predictor were determined. RESULTS: Sixteen thousand seventy-seven patients were identified. Forty-eight MORT was 1.27% (0.93% in YOUNG and 3.17% in OLD; P < 0.0001). Overall, SI (AUC 0.812) and Age x SI (AUC 0.831) were better predictors of 48 MORT compared to HR (AUC 0.716, P < 0.0001) or SBP (AUC 0.753, P = 0.0004) alone. In OLD patients, AGE x SI (AUC 0.828) was a better predictor of 48 MORT compared to HR (AUC 0.659 P < 0.0001), SBP (AUC 0.762 P = 0.003), or SI (AUC 0.787 P = 0.0005). CONCLUSION: SI and Age x SI are better predictors of 48 MORT in injured patients than HR or SBP alone. SI and Age x SI should be used to identify patients at risk for early mortality following injury.     

Extremes of white blood cell count do not independently predict outcome among surgical patients with infection

Historically patients with severely depressed or elevated white blood cell (WBC) counts during infection were felt to have worse outcomes. To test this assumption we prospectively analyzed all infections on the surgical services at the University of Virginia hospital between December 1, 1996 and April 1, 1999. Among 1737 infectious episodes 59 presented with leukopenia (WBC count < or = 3,000 cells/microL) whereas 66 presented with leukemoid responses (WBC count > or = 30,000 cells/microL). Compared with other infected patients leukopenic patients had higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (18+/-0.9 vs 12+/-0.2, P < 0.0001) and mortality (23.7% vs 11.4%, P = 0.004). Patients with leukemoid responses also had higher APACHE II scores (21+/-1.0 vs 12+/-0.2, P < 0.0001) and mortality (30.3% vs 11.4%, P < 0.0001). Compared with a control group randomly matched (2:1) by age and APACHE II score, however, there was no significant difference in mortality associated with leukopenia or a leukemoid response. Furthermore logistic regression did not reveal leukopenia or leukemoid responses to be independent predictors of mortality (odds ratio for death with leukopenia = 1.57, 95% confidence interval = 0.63-3.91, P = 0.33; odds ratio for death with leukemoid response = 1.19, 95% confidence interval = 0.70-2.02, P = 0.53). Although very low or very high WBC counts may represent markers of severe illness in infected surgical patients they do not appear to be significant contributors to a worsened outcome.     

Use of social media while driving from an orthopedic resident's perspective

Purpose: To investigate the orthopedic injuries sustained while driving and using social media on cellular phones from an orthopedic resident''s perspective. Methods: A total of 118 patients who presented with a history of road traffic accident secondary to social media usage and suffered from fractures were included in this cross-sectional study. These patients were reported from October 2018 to April 2019. We collected the data including the type of collision, type of social media usage during driving, location of injury, wearing of safety equipment''s such as helmet and seat belt during driving. Results: The mean age of patients was (34.86 ± 12.73) (range 15-71) years. The common types of accident on the basis of collision of vehicles were: car versus motorbike 45 (38.1%), motorbike versus motorbike 28 (23.7%), and motorbike versus pedestrian 22 (18.6%). Most of the accidents (61, 51.7%) occurred due to mistake of motor-bikers. Out of them, 44 (37.3%) occurred on traffic signals, followed by 29 (24.6%) while driving on main roads. The common timing of accident was normal hours with frequency of 44 (37.3%), followed by 39 (33.1%) at late night. According to fracture type, closed injuries were 98 (83.1%) and open fractures were 20 (16.9%). The most common fracture was clavicular fracture (21,22.5%) followed by soft tissue injury in 19 (16.1%) patients. The most common social media application usage during driving was Facebook 43 (36.4%), followed by Whatsapp 24 (20.3%), Google 19 (16.1%), and Instagram 15 (12.7%). Conclusion: This study provides evidence that social media usage while driving put the drivers and other road users'' lives at high risk. The most common social media addiction while driving is Facebook and Whatsapp. So there is a need to make strict rules and penalties for using cell phone during driving so as to save the lives of drivers and other people using road.     

Palatal implants for the treatment of snoring and obstructive sleep apnea/hypopnea syndrome.

OBJECTIVE: Randomized, double-blinded, placebo-controlled, clinical trial to determine the effectiveness of palatal implants for treatment of mild/moderate obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN AND SETTING: Sixty-two non-obese adults with history of snoring, daytime sleepiness, and mild/moderate OSAHS, were randomized to receive palatal implants (n = 31) or placebo procedure (n = 31). Complete follow-up including quality of life (QOL, SF-36), snoring visual analog scale (VAS), and Epworth Sleepiness Scale (ESS) data were obtained in 62 patients. Seven patients refused follow-up polysomnography for a total of 55 patients (29 implant and 26 placebo). RESULTS: The treatment group (change in score of -7.9 +/- 7.7) was significantly improved compared with the placebo group (change in score of 0.9 +/- 4.3) for apnea/hypopnea index (AHI) (P < 0.0001), QOL, SF-36 (P < 0.0001), snoring VAS (P < 0.0001), and ESS (P = 0.0002). CONCLUSIONS: Palatal implants improve AHI, QOL, snoring intensity, and daytime sleepiness for selected patients with mild/moderate OSAHS.     

Prevalence of seat belt and mobile phone use and road accident injuries amongst college students in Kerman,Iran

Objective: To investigate the prevalence of mobile phone and seat belt use in driving in college students aged 18-24 years.Methods: The study consisted of two phases. In the first phase, a questionnaire was given to 265 college students. The sample contained 188 males and 77 females.In the second phase, the data pertaining to road accident injuries from March 20, 2007 to March 20, 2008 were collected from Bahonar Central Hospital in Kerman, Iran, and analyzed.Results: There were 14.0% of male and 19.0% of female participants traveled belted while driving on urban roads. It indicated that the participants unbelted or using mobile phone were more involved in accidents in last three years. This study also revealed that 19.0% of male and 4.2%of female drivers considered using mobile phone in driving not hazardous. The highest injury and property damage crash rates were 87 and 137 per 100 000 inhabitants, which occured in male group aged 18-24 years. And 30% of all fatalities were 19-24 years old.Conclusions: More than 50% of college students traveled unbelted. The females were less involved in road accident injuries. The college students aged 18-24 years had the highest percentages of trauma and head injury.     

The effect of anemia and blood transfusions on mortality in closed head injury patients

BACKGROUND: The purpose of this study was to determine if anemia in isolated head trauma patients results in a higher mortality rate that would justify a more liberal use of blood transfusions. METHODS: A retrospective review of isolated blunt head trauma patients was performed between January 2001 and December 2006. Comparisons were made between survivors and nonsurvivors regarding demographics, laboratory values, transfusions received, and lengths of stay. RESULTS: There were 788 patients with 735 survivors who were significantly younger (46.3 y +/- 21.5 survivors versus 68.9 y +/- 18.8 nonsurvivors, P < 0.0001) and less injured [(ISS: 14.7 +/- 5.2 survivors versus 23.2 +/- 4.7 nonsurvivors, P < 0.0001), (head abbreviated injury severity: 3.7 +/- 0.7 survivors versus 4.7 +/- 0.5 nonsurvivors, P < 0.0001)] than those who died (n = 53). The survivors also had shorter lengths of stay (days) [(ICU: 2.4 +/- 4.2 versus 5.6 +/- 11.7, P = 0.03), (hospital: 6.3 +/- 9.8 versus 7.8 +/- 14.8, P = 0.02)]. Multivariate logistic regression showed age (OR 1.063, CI 1.042-1.084), ISS (OR 1.376, CI 1.270-1.491), minimum hemoglobin (OR 0.855, CI 0.732-1.000), and total blood products transfused (OR 1.073, CI 1.008-1.142) to be independent predictors of mortality with an ROC of 0.942. Outcome was independent of the operative procedures, hematocrit and packed red blood cells transfused at 24, 48, and 72 h. Hemoglobin levels of <8 mg/dL were more predictive of death than >8 mg/dL (P = 0.01). CONCLUSIONS: This study supports the need to balance mild anemia with judicious blood product use in the head trauma patient. Given the risk with blood product use, each transfusion should be carefully considered and the patient re-evaluated regularly to determine the need for further intervention.     

Traffic crash accidents in Tehran, Iran: Its relation with circadian rhythm of sleepiness

Purpose: Road traffic accidents are one of main problems in Iran. Multiple factors cause traffic accidents and the most important one is sleepiness. This factor, however, is given less attention in our country. Road traffic accidents relevant to sleepiness are studied. Methods: In this cross-sectional study, all road traffic accidents relevant to sleepiness, which were reported by police, were studied in Tehran province in 2009. Results: The risk of road traffic accidents due to sleepiness was increased by more than sevenfold (odds ratio=7.33) in low alertness hours (0:00-6:00) compared to other time of day. The risk of road traffic accidents due to sleepiness was decreased by 0.15-fold (odds ratio=0.15) in hours with maximum of alertness (18:00-22:00) of circadian rhythm compared to other time of day. Conclusion: The occurrence of road traffic accidents due to sleepiness has significant statistical relations with driving during lowest point of alertness of circadian rhythm.     

Fast track recovery of high risk coronary bypass surgery patients.

OBJECTIVE: Fast track recovery protocols on younger, low risk patients result in shorter hospital stays and decreased costs. However, data is lacking on the impact of these protocols on high risk patients based on an objective scoring system. METHODS: In this study, a high risk cohort of patients (EuroSCORE >or=6, n=158) was compared with a low risk cohort of patients (EuroSCORE <6, n=1004) to define the safety and efficacy of fast track recovery among high risk patients. A standard perioperative data is collected prospectively for every patient. RESULTS: Time to extubation was longer in the high risk group (299+/-253 vs. 232+/-256min; P=0.003), but intensive care unit (ICU) stay (25.6+/-28.7 vs. 21.5+/-9.4h; P=ns), and postoperative length of stay (5.8+/-2.4 vs. 5.6+/-2.7 days; P=ns) was similar when compared with the low risk group. Of the high risk patients 81% were extubated within 6h, 87% were discharged from the intensive care unit within 24h, and 67% were discharged from the hospital within 5 days. Multiple regression analysis showed that any red blood cell transfusion (P=0.02), and cross clamp time >60min (P=0.03) were the predictors of delayed extubation (>or=6h) in the high risk group. The predictors of extended ICU stay were any red blood cell transfusion (P=0.0001), and peripheral vascular disease (P=0.05). Any red blood cell transfusion was the only predictor for mortality (P=0.02) and readmission to the hospital within the first 30 days (P=0.02) in this cohort of patients. CONCLUSIONS: This study confirms the safety and efficacy of fast track recovery protocol among high risk patients undergoing coronary artery bypass surgery. All patients are basically suitable for fast track recovery and the preoperative risk factors are poor predictors of prolonged ventilation, increased ICU and hospital stay. Red blood cell transfusion is associated with delayed extubation and discharge from the ICU, and increased mortality and hospital readmission rate.     

The effects of road traffic accidents on driving behaviour.

Questionnaires about the effects of accidents on subsequent driving behaviour were sent to 869 people admitted consecutively to a general hospital as a result of involvement in road traffic accidents 4-6 years previously. There were 418 (48 per cent) replies, 67 per cent of delivered questionnaires. One-fifth of the motorcyclists had stopped using a motorcycle. Nearly one-half the motorcyclists and vehicle drivers reported that they now drove more slowly and that they were more cautious. A considerable proportion of replies described emotional distress, avoidance and limitation of activities. Lack of confidence in driving was common immediately after the accident. After 4-6 years, one-third of respondents reported that they still suffered specific anxiety about the place of the accident and about situations similar to the accident. Many people were anxious about being passengers. The findings have implications for road safety, for the recognition and management of a common, and often disabling, clinical problem, and for the assessment of disabilities in medical reports for compensation proceedings.     

Anticoagulation and the elderly head trauma patient

We sought to determine the effect of anticoagulation therapy on outcomes in elderly patients with closed head injury. We retrospectively reviewed elderly closed head injury patients (> or = 65 years) comparing 52 patients on warfarin (AC) with 439 patients not on warfarin (NAC) with subsequent 1:3 propensity matching used to analyze comparable groups. The overall AC group had a higher head abbreviated injury score (AIS) (4.0 +/- 0.7 vs 3.8 +/- 0.7, P = 0.04) compared with the NAC group. After propensity matching, 49 AC patients were compared with 147 NAC patients who were similar for age, gender, injury severity score, and head AIS. Admission INR was higher in the AC group compared to the NAC group (2.5 +/- 1.3 vs 1.1 +/- 0.3, P < 0.0001) and the AC group had a higher mortality rate (38.8% AC (19/49) vs 23.1% NAC (34/147), P = 0.04). In the AC group, survivors and nonsurvivors had similar repeat International Normalized Ratio (INR) values (1.57 +/- 0.65 survivors vs 1.8 +/- 0.72 nonsurvivors, P = 0.31). The AC group experienced greater morbidity after trauma and had higher mortality rates than their NAC counterparts. Prevention of injury and more selective use of warfarin in this patient population are essential to decrease mortality.     

A randomized trial of modafinil for the treatment of fatigue and excessive daytime sleepiness in individuals with chronic traumatic brain injury

BACKGROUND: This study examines the efficacy of modafinil in treating fatigue and excessive daytime sleepiness in individuals with traumatic brain injury (TBI). METHODS: A single-center, double-blind, placebo-controlled cross-over trial, where 53 participants with TBI were randomly assigned to receive up to 400 mg of modafinil, or equal number of inactive placebo tablets. Main eligibility criteria were being at least 1 year post-TBI severe enough to require inpatient rehabilitation. The primary outcome measures were fatigue (Fatigue Severity Scale, FSS) and daytime sleepiness (Epworth Sleepiness Scale, ESS). RESULTS: After adjusting for baseline scores and period effects, there were no statistically significant differences between improvements seen with modafinil and placebo in the FSS at week 4 (-0.5 +/- 1.88; P = .80) or week 10 (-1.4 +/- 2.75; P = .61). For ESS, average changes were significantly greater with modafinil than placebo at week 4 (-1.2 +/- 0.49; P = .02) but not at week 10 (-0.5 +/- 0.87; P = .56). Modafinil was safe and well tolerated, although insomnia was reported significantly more often with modafinil than placebo (P = .03). CONCLUSIONS: While there were sporadic statistically significant differences identified, a clear beneficial pattern from modafinil was not seen at either week 4 or week 10 for any of the 12 outcomes. There was no consistent and persistent clinically significant difference between treatment with modafinil and placebo.