Head Injury Mechanisms

Head injury is a major cause of death and disability in young, active population. It may introduce energy through the skin to the deepest structures of the brain. The entered energy may cause direct or primary injury, or result in other, secondary, events to the tissues. These are mechanical loads and are classified as static when the duration of loading is more than 200 ms and dynamic when less than this. The dynamic loads are further classified as impact if the injurious agent has contact with the head or impulsive when the load exerted to other body part/s results in damage to the brain by the change in speed of the head motion. Impact loads can either exert their effect with direct contact to the tissue or may cause inertial loads. The direct contact can cause deformation of the skull or induce energy stress waves to the head and brain. All of these events will result in tissue strain due to compression, tension, or shear. The strain will culminate in injury, which may be a scalp abrasion, laceration, skull fracture, or different kinds of intracranial traumatic lesions

Traumatic arteriovenous malformation of scalp: A case report

Scalp arteriovenous malformation (SAVM) as a rare lesion may be a complication of head injury. A case and its management are presented in this article and literature is reviewed. A 27-year-old man came to us with a slowly growing pulsatile mass in his right retroauricular and parietal region of the scalp. On examination, there was a compressible mass with loud bruit. Paraclinical studies revealed a large, tortuous tuft of vessels with two different feeders. Intracranial vessels were 3 normal. The lesion excised totally by direct surgical intervention after ligation of its feeders. The patient recovered and discharged without any abnormal findings. Increased number of reports of SAVM in the past decade may be due to improved diagnostic facilities; however, the high incidence of trauma and even its increasing pattern in developing countries may be another important factor

Predicting number of traumas using the seasonal time series model

Background: Road accidents and casualties resulted are among the current challenges of human societies, which have imposed a high cost on the economies of countries. Objectives: Prediction of accidents caused by driving incidents helps planners achieve a suitable model to reduce the occurrence of traumas resulted from the driving accidents. Materials and Methods: In this study, a seasonal time series model was used for predicting the number of road accident traumas. Data related to the patients referring to Imam Khomeini Hospital in Ilam Province were evaluated from March 2012 to June 2017. Results: The results showed that during November and October in 2015 and 2016, we had the highest number of accidents due to high traffic during New Year's Vacation, summer trips, and religious pilgrimages including the Arbaeen. Moreover, the results depicted that the seasonal Arima model was effective in predicting the number of traumas due to accidents. Furthermore, forecasting the model showed an ascending trend in the number of accidents in the following 3 years. Conclusion: The number of accident traumas in the forthcoming months can be predicted through time series models. Of course, these models can be used by managers as appropriate tools for traffic analysis. Furthermore, the increasing trend in the number of traumas indicates that serious consideration for planning and managing such events seems necessary for the administrators in the near future

Epidural hematoma in computed tomography scan-based scoring systems of traumatic brain injury

Dear Editor Traumatic brain injury (TBI) is a harmful condition that permanently or temporarily damages brain functions and imposes enormous costs on health systems. Computed tomography (CT) scan is the preferred modality to detect injuries and determine TBI patients' prognoses in emergency departments. Thus far, some scoring systems have been introduced for grading TBI based on CT scan findings, including the Marshal,[1] Rotterdam,[2] Helsinki,[3] Stockholm,[4] and NeuroImaging Radiological Interpretation System (NIRIS) [Table 1].[5] This letter aims to briefly raise issues regarding the scoring of epidural hematoma (EDH) in CT scan-based scoring systems of TBI.Epidural hematoma is the gathering of blood between the dura mater and the skull. This intracranial hematoma usually occurs following the bleeding from the middle meningeal artery and, less commonly, from the dural venous sinuses.[6] Some studies have shown that EDH positively affects the outcome, so patients with EDH would have a better overall prognosis.[2] A typical EDH's prognosis is good if diagnosed early and managed before deterioration. Gennarelli et al., showed that the EDH death rate is approximately one-tenth of subdural hematoma.[7] Bricolo et al., reported that mortality should be zero in uncomplicated EDH.[8]On the other hand, EDH can be potentially life-threatening. EDH of venous origin can gradually spread, and its findings may appear late, leading to a delayed diagnosis and treatment. Consequently, EDH expansion can lead to herniation, permanent neurological damage, and death.[9] EDH with a size greater than 30 ml or a midline shift of more than 10 mm does not have a good prognosis.[9] The swirl sign indicating active bleeding also worsens the prognosis.[10]The presence or absence of EDH is evaluated in four CT scan-based scoring systems of TBI [Table 1]. Three scoring systems, including Rotterdam, Helsinki, and Stockholm, consider the presence of EDH as a favorable prognostic factor, i.e., patients with EDH on their brain CT scans get a lower score. However, in the NIRIS, EDH is scored as an adverse prognostic factor based on its volume, leading to a higher score.Hence, EDH cannot always be a favorable prognostic indicator. For instance, the presence of EDH along with diffuse axonal injury (DAI) worsens the outcome.[11] However, according to Rotterdam, Helsinki, and Stockholm systems, the association of EDH with DAI would have a lower score than DAI alone. Besides, high-volume EDH can worsen the situation by causing a midline shift and brain herniation.[9] Nonetheless, the specific size of EDH is not checked in any of these three systems.The scoring systems have been developed from the statistical weighting of variables. However, it is necessary to look at the issue more dynamically and comprehensively for a more accurate outcome prediction. Adjusting CT scoring systems with clinical characteristics and scales such as the Glasgow Coma Scale (GCS) and head injury biomechanics may also be helpful

Predicting the quality of life of patients with mild traumatic brain injury: A study based on psychological variables

Background: Recognizing the factors related to psychological disorders such as depression, stress, anxiety, and other related problems in a mild traumatic brain injury (MTBI) can be helpful in designing more effective treatment protocols. This study aimed at examining the effect of some prevalent psychological issues on predicting the quality of life of the MTBI patients. Methods: In this descriptive correlational study, 322 MTBI patients (mean age, 38.8 ± 10.8 years) who had admitted to the emergency and neurosurgery departments of Kashan Shahid Beheshti Hospital during April-July 2017 were selected using the convenient sampling method. Data were collected using the quality of life (WHOQOL-BREF) questionnaire (as a dependent variable), mental fatigue questionnaire, and depression, anxiety and stress scale (DASS-21). Finally, the data were analyzed in SPSS-23 by multiple regression analysis. Results: The results of the study showed that the regression model was significant (P Conclusion: The findings of this study show that there is a negative relationship between psychological factors and quality of life among the MBTI patients. Thus, it is suggested to design more specific psychological-based rehabilitation programs with regard to gender differences to improve the quality of life among these patients after discharging from the hospital

A comparison of difficulties in emotional regulations of patients with mild traumatic brain injury and normal controls

Background: Many individuals with traumatic brain injury experience difficulties with social behavior, some of which are attributed to difficulties in regulation of emotions. Objectives: The aim of this study was to compare the difficulties in emotional regulations of patients with mild traumatic brain injury (MTBI) and normal controls. Patients and Methods: In this cohort study, 72 patients with MTBI and 72 normal controls with similar gender were selected. Difficulties in Emotion Regulation Scale (DERS) and Positive and Negative Affect Schedule (PANAS) questionnaires were completed for both the study groups at the beginning of the study and 6 months later. The data were analyzed using multiple linear regression, Chi-square, and paired t-test. Results: The results showed that there was a significant difference between MTBI patients and normal controls in all subscales 6 months after MTBI, and in the total score of DERS, except for the nonaccepted scale and PANAS (P = 0.001), in which no significant difference was observed. In addition, the results of multivariate regression showed that trauma (β = 0.493), age (β = 0.196), familial history of mental disorders (β = 0.185), and financial status could predict emotional regulation (β = 0.148). Conclusions: It seems that mild traumatic brain injuries may be the cause of problems in social behaviors

Procalcitonin and Proinflammatory Cytokines in Early Diagnosis of Bacterial Infections after Bronchoscopy

BACKGROUND: Fiberoptic bronchoscopy (FOB) guided bronchoalveolar lavage (BAL) remains as the chief diagnostic tool in respiratory disorders. 1.2-16% of patients frequently experience fever after bronchoscopy. To exclude the need for multiple antibiotic prescribing in patients with post-bronchoscopy fever, the presence of the self-limiting inflammatory responses should be excluded. AIM: The current study was conducted to test the serum of patients undergoing bronchoscopy for some proinflammatory cytokines including Tumor Necrosis Factor-alpha (TNF-ɑ), Interleukin-1beta (IL-1β), Interleukin-8 (IL-8) and Interleukin-6 (IL-6) and the value of Procalcitonin (PCT). MATERIAL AND METHODS: Current case-control study was conducted at the National Research Institute of Tuberculosis and Lung Disease in Iran. Nineteen patients (48.72%) that attended with a reasonable sign for a diagnostic bronchoscopy from January 2016 to December 2017 were included in the case group. The control group consisted of 20 patients who underwent a simple bronchoscopy and without FOB-BAL. The laboratory findings for PCT concentrations and cytokine levels in the three serum samples (before FOB-BAL (t0), after 6 hr. (t1), and at 24 hr. past (t2) FOB-BAL) were compared between two groups. RESULTS: The frequency of post-bronchoscopy fever was 5.12, and the prevalence of post-bronchoscopy infectious fever was 2.56%. PCT level was considerably higher in the patient with a confirmed bacterial infection when compared to other participants (p-value < 0. 05). Interestingly, IL-8 level in the bacterial infection proven fever patient was higher than in other patients (p < 0.001). IL-8 levels displayed a specificity of 72.7% and a sensitivity of 100%, at the threshold point of 5.820 pg/ml. PCT levels had a specificity of 84% and a sensitivity of 81%, at the threshold point of 0.5 ng/ml. CONCLUSION: The present findings show that in patients with fever after bronchoscopy, PCT levels and IL-8 levels are valuable indicators for antibiotic therapy, proving adequate proof for bacterial infection. The current findings also illustrate that to monitor the serum levels of PCT and proinflammatory cytokines in the patients undergoing FOB-BAL, the best time is the 24-hour postoperative bronchoscopy

The association between the outcomes of trauma, education and some socio-economic indicators

Background: There are many debates on socioeconomic indicators influencing trauma outcomes.Objectives: This study aimed to determine the association between education as a socioeconomic indicator and trauma outcomes.Methods: This descriptive-analytical study was conducted on 30,448 trauma patients during 2016-2021. The data were based on the minimum dataset of the National Trauma Registry of Iran (NTRI) from six different trauma centers in various cities of the country. The variables used in this study included age, education level, marital status, cause of injury, Glasgow Coma Scale (GCS), intensive care unit (ICU) admission, Injury Severity Score (ISS), and in-hospital mortality. Logistic regression was used to investigate the association between independent variables and trauma outcomes.Results: The study included 30,448 trauma patients with male predominance (75.8%). The mean age was 36.9 years. The most frequent education level was secondary education, with 14,228 (46.6%). Education levels had significant relationships with ISS, death, and ICU admission (P<0.001). Moreover, after applying the multiple logistic regression, the odds of deaths for trauma patients with no formal, primary, and secondary education levels were 3.36, 5.03, and 3.65 times, respectively, more than the odds of deaths at the higher education level after controlling for other factors (all Ps<0.05). However, there were no such relationships between education levels and the odds of ICU admission.Conclusion: Findings of the present study showed a significant association between the education levels and trauma outcomes. Adjusted for other covariates, the chance of death for trauma patients with no formal, primary, or secondary education levels was higher than that at the higher education level

Cerebral state index versus Glasgow coma scale as a predictor for in-hospital mortality in brain-injured patients

【Abstract】Objective: To compare the value of Glasgow coma scale (GCS) and cerebral state index (CSI) on predicting hospital discharge status of acute braininjured patients. Methods:In 60 brain-injured patients who did not receive sedatives, GCS and CSI were measured daily during the first 10 days of hospitalization. The outcome of prognostic cut-off points was calculated by GCS and CSI using receiver operating characteristic (ROC) curve regarding the time of admission and third day of hospitalization. Sensitivity, specificity and other predictive values for both indices were calculated. Results: Of the 60 assessed patients, 14 patients had mild, 13 patients had moderate and 33 patients had severe injuries. During the course of the study, 17 patients (28.3%) deteriorated in their situation and died. The mean GCS and CSI in patients who deceased during hospitalization was significantly lower than those who were discharged from the hospital. GCS&lt;4.5 and CSI&lt;64.5 at the time of admission was associated with higher mortality risk in traumatic brain injury patients and GCS was more sensitive than CSI to predict in-hospital death in these patients. For the first day of hospitalization, the area under ROC curve was 0.947 for GCS and 0.732 for CSI. Conclusion: GCS score at ICU admission is a good predictor of in-hospital mortality. GCS&lt;4.5 and CSI&lt;64.5 at the time of admission is associated with higher mortality risk in traumatic brain injury patients and GCS is more sensitive than CSI in predicting death in these patients. Key words: Brain injuries; Glasgow coma scale; Outcome assessmen

Factors Influencing Probation in Graduated Students of Kashan Faculty of Nursing and Midwifery

Introduction: One of the major problems in educational systems is students' probation during their course of study. With regard to the importance of identifying factors affecting the incidence of probation, this study was performed to determine the status of incidence of probation and its related factors in all graduated students of Kashan Faculty of Nursing and Midwifery. Methods: All graduated students of Kashan Faculty of Nursing and Midwifery (n=1174) during the years 1981 till 2003 were selected through census in this cross-sectional study. The data was gathered by a questionnaire including demographic information and probation status (probation records, probation semester, and the number of probation semesters). Incidence of probation was calculated and odds ratio and difference percentage were used for analyzing the status of probable related factors. Results: Probation record was argued in 46 students (3.9%) that 26 of them (2.2%) were probated just for one semester, 11 of them (0.9%) for two semesters, 8 of them (0.7%) for three semesters, and, 1 of them (0.1%) for four semesters. The utmost frequency was related to the second academic semester and then, the first semester. The average score of high school diploma and age were different in probated and not probated graduated students. The most expectancy of probation risk was related to master program and nursing discipline. Conclusion: Demographic features, educational background, and admission criteria are among factors affecting probation. Therefore, with regard to their role, it is necessary to identify at risk students and support them