Purpose: To evaluate the prognostic performance of 4 CT scoring systems in pediatric patients with moderate-to-severe traumatic brain injury (TBI) and develop a simplified, interpretable predictive model based on machine learning.
Methods: This retrospective study included 103 pediatric patients with moderate-to-severe TBI admitted to a tertiary children's hospital in Southwest China from September 2020 to December 2023. CT images were assessed using the Marshall score, Rotterdam score, Helsinki score, and Stockholm score. Clinical outcomes were defined by the Glasgow outcome scale (GOS) and categorized as favorable results (GOS 4-5) or unfavorable results (GOS 1-3). The dataset was divided into a training set (n=83) and a test set (n=20). Class imbalance was corrected using the random over-sampling examples method. Eight classification models were compared through 5-fold cross-validation. The Naive Bayes model showed the best performance and was simplified to include 5 key predictors. An interactive online application was developed to provide individualized prognostic estimation and visualization.
Results: The Helsinki score demonstrated the highest predictive accuracy among the 4 CT scores (area under the curve (AUC)=0.906), followed by the Stockholm score (AUC=0.897), Rotterdam score (AUC=0.837), and Marshall score (AUC=0.764). The simplified Naive Bayes model achieved an AUC of 0.930, with 100% sensitivity and 65.9% specificity in the test set. The model enables real-time outcome prediction and visual interpretation of contributing factors.
Conclusions: The simplified Naive Bayes model outperforms traditional CT scoring systems in predicting outcomes of pediatric moderate-to-severe TBI. Its easy use, interpretability, and web-based implementation support its potential for clinical application. Further prospective and multicenter studies are needed to validate these findings.
Avulsion injury of genitalia is rare, particularly in pediatric patients. The reconstruction of necrotic scrotal tissue presents a significant challenge. This case report describes a pediatric patient who experienced complete avulsion of the left inguinal, scrotal, and penile regions, accompanied by multiple pelvic fractures, and the scrotal tissue subsequently became necrotic. We performed scrotal reconstruction using a pedicled anterolateral thigh flap and fixed both testes. Postoperatively, the scrotum had a satisfactory appearance, with no significant reduction in testicular size compared to age-matched peers, indicating a successful repair.
Purpose: Trauma, a leading cause of disability and death globally, underscores the critical importance of timely medical intervention, particularly within the "golden hour" following trauma. Yet, in low-middle-income countries, the absence or fledgling state of emergency medical systems (EMS) exacerbates mortality rates. This study aims to retrospectively analyze mortalities at a level 1 trauma center in India, comparing patients who received prehospital care with those who did not.
Methods: Conducted at a level 1 trauma center in India from April 2019 to April 2020, this retrospective observational study included trauma patients who died during hospitalization. Exclusions comprised (1) patients deceased upon arrival, (2) patients receiving cardiopulmonary resuscitation, and (3) non-trauma deaths. Demographics, clinical profiles, causes of death, and transportation methods were scrutinized. Data encompassed patient transport details, clinical assessments, interventions, length of stay, and causes of death. Statistical analysis was performed using SPSS 14, with statistical significance set at p < 0.05.
Results: Among 55,277 trauma patients, 311 mortalities were recorded. Most were male (n=267, 83.9%), aged 21-40 years (n=133, 42.8%), with blunt trauma being the predominant cause (97.4%). The majority of patients had road traffic injuries (n=180, 57.9%) and falls (n=95, 30.5%). Threatened airway (n=144, 46.3%), tachycardia (n=159, 51.2%), and hypotension (n=74, 23.8%) were common on patients' arrival. Traumatic brain injuries (70.4%) prevailed. Private vehicles transported 46.6% of patients, while only 7.0% arrived within the golden hour. Although patients who received prehospital care experienced delayed hospital arrival, they exhibited higher oxygen saturation and systolic blood pressure.
Conclusion: Augmentation of prehospital care and EMS infrastructure in low-resource settings is crucial to mitigating trauma mortality. Although prehospital care delayed hospital arrival, it positively impacted physiological parameters and potentially improved patient outcomes. This study underscores the imperative of timely interventions and comprehensive EMS development to address the global trauma burden effectively.
Purpose: Traumatic brain injury is a major public health issue and a leading cause of death and disability among the elderly. As a result, traumatic intracerebral abnormalities (tICA) are now frequently diagnosed using cranial computed tomography (cCT), which has led to an overuse of this investigation. The present study aimed to develop and validate the nomogram for predicting tICA in the elderly.
Methods: This was a retrospective cohort study. The study population consisted of patients who met the following inclusion criteria: (1) aged ≥60 years, as defined by the World Health Organization; (2) admitted to a tertiary referral hospital between January 2015 and December 2022; and (3) underwent cCT scanning upon admission. Patients were excluded if (1) patients' images were unavailable or (2) patients died in the emergency department before hospitalization. The total data was divided into the development cohort (2015-2019, n=2052) to develop the nomogram and the validation cohort (2020-2022, n=310) to test the predictability as temporal validation. Binary logistic regression was used in the construction of the nomogram.
Results: There were 2362 patients in the entire cohort. Positive CT scan rates among the elderly amount to 21.3%. Multivariable analysis identified the following factors significantly associated with traumatic intracranial hematoma in the elderly: use of aspirin (odds ratio (OR)=4.49, 95% confidence interval (CI) 3.08-6.54), warfarin usage (OR=6.88, 95% CI 2.99-15.8), traffic accidents (OR=1.98, 95% CI 1.46-2.68), Glasgow coma scale 9-12 (OR=3.24, 95% CI 1.66-6.35), amnesia (OR=1.65, 95% CI 1.17-2.33), nausea or vomiting (OR=12.5, 95% CI 5.56-28.07), seizure (OR=11.42, 95% CI 3.33-39.22), motor weakness (OR=65.45, 95% CI 18.68-229.29), and bleeding per nose or ear (OR=24.81, 95% CI 10.57-14.58). The predictability of the nomogram demonstrated sensitivity, specificity, and an area under the receiver operating characteristic curve of 0.833, 0.788, and 0.889, respectively.
Conclusion: According to the temporal validation, the nomogram had an outstanding performance for tICA prediction in the elderly. In the future, the prediction tool will assist clinicians in making judgments and balancing the rate of cCT in clinical practice.
Purpose: It is often difficult for surgeons to accurately implant the cannulated screws for fixing femoral neck fractures under C-arm fluoroscopy. Our simulation study attempts to help surgeons identify the optimal positions of screws on anteroposterior and lateral radiographs.
Methods: Softwares were used for 3-dimensional reconstruction and cross-sections construction of 60 femoral necks. The contours of all cross-sections along the axis of the femoral neck were stacked to identify a safe zone for screws placement. A simulation experiment was carried out with 3 circles of diameter 6.5 mm in the safe zone. The absolute and relative positions of every screw in the anteroposterior radiographs and lateral radiographs were measured.
Results: The morphologies of the safe zones for screws placement were anteriorly flat ellipses. The best dispersion was obtained with the inverted triangle shape in this zone: the inferior was positioned near the lower 1/10 on the anteroposterior view and near the anterior 3/5 on the lateral view. The anterosuperior and posteriosuperior screws were positioned near the upper 1/5 and 1/4, respectively, on the anteroposterior view, and near the anterior 1/10 and posterior 1/5, respectively, on the lateral view.
Conclusion: Simulated screws implantation demonstrates the distribution characteristics of screws in anteroposterior and lateral radiographs. This can help decrease the risk of perforation and iatrogenic injury.
Purpose: Transverse-posterior wall (TPW) fractures of the acetabulum are complex injuries that require surgical fixation. The transverse component's major fracture line traverses the weight-bearing area and passes over the acetabular dome. The key to a successful outcome is anatomical reduction and rigid internal fixation. The treatment of TPW fractures has shown significant advancements, but there is still debate regarding the best surgical approach.
Methods: The study was conducted in a level 1 tertiary trauma care center, involving patients with an associated TPW fracture of the acetabulum. Between January 2015 and January 2023, a total of 512 acetabulum fractures were treated surgically. Out of which, 87 patients had a TPW fracture. Fifty-five patients who underwent surgical fixation using a single approach-Kocher-Langenbeck (KL) with a minimum 1-year follow-up-were included in this study. The exclusion criteria were patients with isolated transverse fractures, isolated posterior wall fractures, undisplaced fractures that were treated conservatively, TPW of acetabulum fractures treated using a combined surgical approach due to major displacement at the anterior column, open acetabulum fractures, and individuals who were unfit for surgery. Demographic details, epidemiology, fracture patterns, and associated skeletal and non-skeletal injuries were collected. Post-operative radiological results were graded according to the Matta score. Functional outcome analysis was done using the EuroQOL-5D score. The occurrence and rate of complications were evaluated.
Results: TPW fractures had an incidence of 17% among acetabulum fractures. The male-to-female ratio was 50:5, with an overall mean age of 40 years (range: 20-71 years). The mean follow-up was 32 months (range: 12-81 months). Among them, 41.8% had multiple injuries, 36.4% were polytraumatized. On arrival, 63.6% had hip dislocation, 14.5% had sciatic nerve injury. Anatomic reduction was achieved in 84.0% of the patients. Excellent to good functional outcomes were seen in 88.0%. An iatrogenic sciatic nerve injury was seen in 1 patient. Avascular necrosis, heterotrophic ossification, and post-traumatic osteoarthritis were seen in 16.4%, 21.8%, and 20.0% respectively. The rate of conversion to total hip replacement was 10.9%.
Conclusion: Single-approach fixation is adequate for TPW fractures of the acetabulum, where the anterior-column is well reduced, to provide satisfactory radiological results as well as an excellent-to-good functional outcome. Whenever the intraoperative roof-arc-angle is more than 45° and the displacement is less than 2 mm, the anterior column need not be addressed; however, if the roof arc angle is less than 45° and the displacement of more than 2 mm, an additional-lag-screw should be added.
Immune dysregulation is one of the leading causes of mortality in patients with sepsis. T cell immunoglobulin and mucin domain-containing protein 3 (TIM-3), a negative costimulatory molecule, is pivotal for immune regulation during sepsis. The effects of TIM-3 appear to be bidirectional: in the early stages of sepsis, upregulation of TIM-3 may help attenuate inflammation, whereas its sustained overexpression in later stages and ligand binding promotes immune apoptosis or exhaustion, which suppresses immune responses. Furthermore, TIM-3 synergizes with other immune checkpoint molecules (e.g., programmed cell death receptor-1), exacerbates immunosuppression, and increases the risk of secondary infections. Blocking the TIM-3 signaling pathway can restore immune cell function and may be a novel therapeutic strategy for sepsis. Although TIM-3 holds promise as both a biomarker and a therapeutic target, its mechanisms are complex and may vary across disease stages, which necessitates further research to optimize targeted interventions. Future studies should focus on elucidating the dynamic signaling pathways of TIM-3, developing combination immunotherapies, and conducting clinical trials to validate its safety and efficacy in sepsis treatment.
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