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1.  Sideline Coverage 
Sports Health  2014;6(3):274-278.
Sidelines coverage presents unique challenges in the evaluation of injured athletes. Health care providers may be confronted with the question of when to obtain radiographs following an injury. Given that most sidelines coverage occurs outside the elite level, radiographs are not readily available at the time of injury, and the decision of when to send a player for radiographs must be made based on physical examination. Clinical tools have been developed to aid in identifying injuries that are likely to result in radiographically important fractures or dislocations.
Evidence Acquisition:
A search for the keywords x-ray and decision rule along with the anatomic locations shoulder, elbow, wrist, knee, and ankle was performed using the PubMed database. No limits were set regarding year of publication. We selected meta-analyses, randomized controlled trials, and survey results. Our selection focused on the largest, most well-studied published reports. We also attempted to include studies that reported the application of the rules to the field of sports medicine.
Study Design:
Retrospective literature review.
Level of Evidence:
Level 4.
The Ottawa Foot and Ankle Rules have been validated and implemented and are appropriate for use in both pediatric and adult populations. The Ottawa Knee Rules have been widely studied, validated, and accepted for evaluation of knee injuries. There are promising studies of decision rules for clinically important fractures of the wrist, but these studies have not been validated. The elbow has been evaluated with good outcomes via the elbow extension test, which has been validated in both single and multicenter studies. Currently, there are no reliable clinical decision tools for traumatic sports injuries to the shoulder to aid in the decision of when to obtain radiographs.
Clinical decision tools have been developed to aid in the diagnosis and management of injuries commonly sustained during sporting events. Tools that have been appropriately validated in populations outside the initial study population can assist sports medicine physicians in the decision of when to get radiographs from the sidelines.
PMCID: PMC4000478  PMID: 24790698
clinical decision tools; sidelines; extremity injury; radiographs
2.  A Standardized Protocol for the Initial Evaluation and Documentation of Mild Brain Injury 
Journal of Athletic Training  1999;34(1):34-42.
To present a protocol for the initial assessment and documentation of mild brain injury, a protocol that is used within the Department of Physical Education at the United States Military Academy.
Recently, much attention has been given to the assessment and management of mild brain injury by the sports medicine community. Although the classification of and management strategies for mild brain injury have been well disputed, most experts agree on the essentials of the sideline or initial evaluation. According to leading experts, if an athlete has experienced an episode of mild brain injury, the initial signs and symptoms, as well as the course of those signs and symptoms, should be documented.
Although many athletic training texts formerly discussed techniques for evaluating an episode of mild brain injury, few present an objective protocol to follow. Our protocol includes 3 components. The first component is the initial evaluation, which incorporates serial observations during the first 20 minutes after injury, with neurologic checks every 5 minutes. The second component includes a take-home sheet for athletes not referred to a physician for further evaluation. The third part of the protocol is a 24-hour postinjury follow-up examination for any signs or symptoms of postconcussion syndrome. Finally, we present the indications for referral to a physician for further evaluation.
Clinical Advantages/Recommendations:
Using a standard protocol to guide evaluation and to document the initial course of signs and symptoms after mild brain injury allows the sports medicine staff to make better management decisions. In addition, patient instructions and the course of follow-up evaluations can be improved if a standard protocol is employed. Our protocol has been developed to meet the needs both of athletes who are exposed to mild brain injury on a daily basis and of the certified athletic trainers who initially evaluate them; the protocol can be adapted to the individual needs of each athletic training setting.
PMCID: PMC1322872  PMID: 16558546
concussion; sideline; neurologic
The new graduate, or the licensed physical therapist with general orthopedic experience, is not qualified to provide sideline coverage at athletic events. Additional or advanced training in emergency care is essential to provide aid in acute situations. Completion of the First Responder certification prepares an individual to react appropriately to any emergency on the sidelines, in the clinic, or in the community. The highest qualification that a physical therapist can attain to ensure adequate preparation for the practice of Sports Physical therapy is the ABPTS Sports Certified Specialist (SCS) designation. This professional designation indicates that this individual is highly qualified to care for athletes at any level, from on the sidelines, through rehabilitation and return to play, regardless of the injury, age of the athlete, or skill level.
PMCID: PMC3273887  PMID: 22319685
Emergency care; sideline coverage; sports physical therapist
4.  Fourth Cranial Nerve Palsy in a Collegiate Lacrosse Player: A Case Report 
Journal of Athletic Training  2010;45(4):407-410.
To present the case of a National Collegiate Athletic Association Division I men's lacrosse athlete with fourth cranial nerve injury as the result of a minor traumatic blow.
The athlete was struck on the right side of his head during a lacrosse game. On-field evaluation revealed no cervical spine involvement or loss of consciousness. He complained of headache and dizziness, with delayed reports of visual disturbance. Sideline visual acuity and cranial nerve screenings appeared within normal limits. Consultation with the team physician indicated that immediate referral to the emergency department was unnecessary.
Differential Diagnosis:
Concussion, third cranial nerve palsy, fourth cranial nerve palsy.
The certified athletic trainer safely removed the athlete from the playing field and monitored him on the sideline. After being seen by the team physician, the patient was referred to a neurologist, ophthalmologist, and finally a neuro-ophthalmologist before a definitive diagnosis was made. The palsy did not necessitate surgical intervention, resolving with conservative treatment. The athlete was able to return to full athletic ability at his preinjury level by 8 months postinjury.
Superior oblique palsy as the result of fourth cranial nerve injury is the most frequent isolated cranial nerve palsy; however, these palsies are often underdiagnosed by health professionals. Such palsies are uncommon within the athletic realm, making timely diagnosis even less likely.
Cranial nerve palsy may present very subtly in patients. Therefore, on-field health care providers should be aware of the descriptions and types of compensations that signal nerve injury.
PMCID: PMC2902036  PMID: 20617917
trochlear nerve; neurologic injuries; visual disturbances
5.  Liver Laceration in an Intercollegiate Football Player 
Journal of Athletic Training  1995;30(4):324-326.
Serious abdominal injuries in athletics, including liver trauma, are relatively rare. When they do occur, the athletic trainer and the team physician must be able to recognize the signs and symptoms and employ the appropriate first aid and follow-up care. In this paper, we present a case study of a football player who suffered a lacerated liver as a result of a forceful blow to the right side of the chest. Although his case was typical of most isolated liver injuries and he did not experience massive internal bleeding, the potential for life-threatening exsanguination exists and must be recognized by by sports health care practitioners. Most isolated liver injuries can be treated nonsurgically. However, those patients with multiple organ trauma, deteriorating vital signs, or diminishing hemodynamic stability generally require immediate surgery. Athletes with persistent right upper quadrant pain, especially when accompanied by referred pain to the right shoulder, abdominal rigidity, guarding, or rebound pain should be considered to have a liver injury until ruled out by CT scan and liver enzyme studies. Our subject was typical of most athletic liver patients and he was able to resume light exercise after 5 weeks and full activity after 3 months.
PMCID: PMC1318002  PMID: 16558356
6.  Certified Athletic Trainers in Secondary Schools: Report of the Council on Scientific Affairs, American Medical Association 
Journal of Athletic Training  1999;34(3):272-276.
In June 1997, the American Academy of Pediatrics introduced a resolution asking the American Medical Association (AMA) to support efforts to place certified athletic trainers in all secondary schools. The AMA Council on Scientific Affairs studied that resolution and presented this report to the AMA House of Delegates in June 1998.
To identify the professional responsibilities, educational requirements, and current use of certified athletic trainers in the prevention and care of high school sports injuries.
Data Sources:
MEDLINE and HealthSTAR databases were searched for English-language articles published from 1980 to 1998. Additional references were derived from references in pertinent articles, communication with experts, and the Internet sites of athletic training and sports medicine associations.
Data Synthesis:
One in 5 of approximately 6 million adolescents who participate in high school sports each year sustains a sport-related injury. Most of these injuries are minor and occur during practices rather than competitions. Approximately 1 of every 100000 high school athletes will sustain a catastrophic injury. About 35% of US high schools use the services of a certified athletic trainer, who, under a physician's supervision, is responsible for the prevention and care of athletic injuries and coordination of the school athletic health program.
Emphasis should be given to ensuring the health, safety, and well-being of participants in high school sports. Whereas most high school sports injuries are minor, adequately trained personnel should be present on site to ensure that such injuries are recognized early, treated immediately, and allowed to heal properly, thereby reducing the risk of more serious injury or reinjury. For such care, team physicians and coaches should have the assistance of a certified athletic trainer.
PMCID: PMC1322922  PMID: 16558576
athletic injuries; athletic training; high school sports; injury prevention; adolescent health
7.  Pancreatic Laceration in a Female Collegiate Soccer Athlete: A Case Report 
Journal of Athletic Training  2013;48(2):271-276.
To characterize the diagnosis of pancreatic trauma in an athletic population and to raise awareness among health care providers of the possibility of this life- and organ-threatening injury.
An 18-year-old, previously healthy female collegiate soccer athlete sustained a direct blow from an opponent's knee between the left and right upper abdominal quadrants while attempting to head the ball. She initially presented with only minimal nausea and discomfort, but this progressed to abdominal pain, tenderness, spasm, and vomiting. She was referred to the emergency department, where she was diagnosed with a pancreatic laceration.
Differential Diagnosis:
Duodenal, hepatic, or splenic contusion or laceration; hemorrhagic ovarian cyst.
The patient underwent a distal pancreatectomy and total splenectomy.
Pancreatic injuries, particularly those severe enough to warrant surgical intervention, are extremely rare in athletes.
Recognition of a pancreatic injury can be very challenging outside the hospital setting. This is problematic, because a delay in diagnosis is a significant source of preventable morbidity and mortality after this rare injury. Thus, early identification depends on a high index of suspicion, a thorough examination, and close observation. It is imperative that athletic trainers and other health care professionals be able to identify this condition so that referral and management can occur without delay.
PMCID: PMC3600930  PMID: 23672392
abdomen; blunt trauma; cholangiopancreatography; pancreatectomy; splenectomy
8.  Dissecting Inflammatory Complications in Critically Injured Patients by Within-Patient Gene Expression Changes: A Longitudinal Clinical Genomics Study 
PLoS Medicine  2011;8(9):e1001093.
By studying gene expression changes over time in a cohort of trauma patients, Keyur Desai and colleagues identify genes and pathways strongly associated with longer-term complications, which could lead to improved outcome prediction in the first 80 hours after injury.
Trauma is the number one killer of individuals 1–44 y of age in the United States. The prognosis and treatment of inflammatory complications in critically injured patients continue to be challenging, with a history of failed clinical trials and poorly understood biology. New approaches are therefore needed to improve our ability to diagnose and treat this clinical condition.
Methods and Findings
We conducted a large-scale study on 168 blunt-force trauma patients over 28 d, measuring ∼400 clinical variables and longitudinally profiling leukocyte gene expression with ∼800 microarrays. Marshall MOF (multiple organ failure) clinical score trajectories were first utilized to organize the patients into five categories of increasingly poor outcomes. We then developed an analysis framework modeling early within-patient expression changes to produce a robust characterization of the genomic response to trauma. A quarter of the genome shows early expression changes associated with longer-term post-injury complications, captured by at least five dynamic co-expression modules of functionally related genes. In particular, early down-regulation of MHC-class II genes and up-regulation of p38 MAPK signaling pathway were found to strongly associate with longer-term post-injury complications, providing discrimination among patient outcomes from expression changes during the 40–80 h window post-injury.
The genomic characterization provided here substantially expands the scope by which the molecular response to trauma may be characterized and understood. These results may be instrumental in furthering our understanding of the disease process and identifying potential targets for therapeutic intervention. Additionally, the quantitative approach we have introduced is potentially applicable to future genomics studies of rapidly progressing clinical conditions.
Trial Registration NCT00257231
Please see later in the article for the Editors' Summary
Editors' Summary
Trauma—a serious injury to the body caused by violence or by an accident—is a major global health problem. Every year, events that include traffic collisions, falls, blows, and fires cause injuries that kill more than 5 million people (9% of annual global deaths). Road traffic accidents alone are responsible for 1.3 million deaths a year and, if current trends continue, will be the fifth leading cause of death worldwide by 2030. Moreover, in many countries, including the US, trauma is the number one killer of individuals aged 1–44 y. Trauma can kill people rapidly through loss of blood or serious physical damage to internal organs, but it can also lead to localized infections and to sepsis, an infection of the bloodstream that is characterized by an amplified, body-wide (systemic) inflammatory response. Inflammation—redness, pain, and swelling—is an immune system response that normally provides protection against infections, but systemic inflammation can result in multiple organ failure (MOF) and death.
Why Was This Study Done?
Inflammatory complications of trauma are responsible for more than half of late trauma deaths, but at present it is impossible to predict which patients with major injuries will recover and which will spiral down into MOF and death, because the biological processes that underlie post-injury inflammatory complications are poorly understood. If the changes in gene expression (the process that converts the information encoded in genes into functional proteins) that accompany systemic inflammation could be elucidated, it might be possible to improve the diagnosis of MOF and to develop better treatments for post-trauma inflammatory complications. In this prospective, longitudinal clinical genomics study (part of the Inflammation and Host Response to Injury multi-disciplinary research program [IHRI]), the researchers developed an approach to associate early within-patient gene expression changes with later clinical outcomes. A prospective study is one in which patients with a specific condition are enrolled and then followed to see how various factors affect their outcomes; a longitudinal study analyzes multiple samples taken at different times from individual patients; a clinical genomics study investigates how genes and gene expression affect clinical outcomes.
What Did the Researchers Do and Find?
The researchers followed 168 patients for up to 28 d after they experienced blunt-force trauma (injuries caused when the human body hits or is hit by a large object such as a car). Using a molecular biology tool called a DNA microarray, they determined gene expression patterns in leukocytes (a type of immune system cell) isolated from multiple blood samples collected from each patient during the first few days after injury. Using clinical information collected by trained nurses, they organized the patients into five outcome categories based on a measure of MOF known as the Marshall score. Finally, they developed a statistical method (an analysis framework) to associate the early changes in gene expression with clinical outcomes.
A quarter of the patients' genes showed early expression changes that were associated with longer-term post-injury inflammatory complications. Among the associations revealed by this analysis, down-regulation (reduced expression) of MHC-class II genes (which encode proteins involved in antigen presentation, the process by which molecules from foreign invaders are presented to immune cells to initiate an immune response) and up-regulation of genes encoding components of the p38 MAPK signaling pathway (which helps to drive inflammatory responses) between 40 and 80 h post-injury were particularly strongly associated with longer-term post-injury complications and provided the strongest discrimination between patient outcomes.
What Do These Findings Mean?
The statistical approach used in this study to link the early changes in gene expression that occur after trauma to clinical outcomes provides a detailed picture of genome-wide gene expression responses to trauma. These findings could help scientists understand why some patients develop inflammatory complications of trauma while others do not, and they could help to identify those patients most at risk of developing complications. They could also help to identify targets for therapy, although further studies are needed to confirm and extend these findings. Importantly, the quantitative approach developed by the researchers for analyzing associations between within-patient gene changes over time and clinical outcomes should provide more robust predictions of outcomes than single measurements of gene expression and could be applicable to genomic studies of other rapidly progressing clinical conditions.
Additional Information
Please access these websites via the online version of this summary at
More details about the Inflammation and Host Response to Injury research program are available; the program's website includes a link to an article that explains how genomics can be used to understand the inflammatory complications of trauma
The World Health Organization provides information on injuries and on violence and injury prevention (in several languages)
The US National Institutes of Health has a factsheet on burns and traumatic injury in the USA
The US Centers for Disease Control and Prevention has information on injury and violence prevention and control
MedlinePlus provides links to further resources on injuries
PMCID: PMC3172280  PMID: 21931541
9.  A Comparison of Sideline Versus Clinical Cognitive Test Performance in Collegiate Athletes 
Journal of Athletic Training  2000;35(2):155-160.
To test whether performance on 5 cognitive tests administered in a controlled clinical environment differed compared with administration in an uncontrolled sideline environment. Additionally, we investigated the effect of testing environment order on the learning effect for each cognitive test.
Design and Setting:
Athletes were assessed on 2 test occasions (8 ± 2 days apart), once in a sports medicine research laboratory and once on a lacrosse practice field site.
A total of 59 Division I collegiate student-athletes participated in this study.
Normative data were collected on 5 cognitive tests (Stroop Test, Trail-Making Test part A, Trail-Making Test part B, Wechsler Digit-Span Forward Test, and Digit-Span Backward Test).
An independent-samples t test for environment difference on test day 1 revealed no significant differences between tests performed in the controlled environment and those performed in the uncontrolled environment. A repeated- measures analysis of variance test revealed a significant learning effect for all 5 tests, as subjects tended to improve approximately 11 points on the Stroop Test, 3 seconds on the Trail-Making A Test, 7 seconds on the Trail-Making B Test, and 1 point each on the Wechsler Digit Span Forward and Backward Tests. A paired-samples t test using delta scores (first test minus second test), sorted by order of testing environment, revealed a significant difference for the Stroop Test, but not for the remaining cognitive tests.
There appears to be no difference in cognitive testing performance completed in a controlled clinical environment versus that performed in an uncontrolled sideline environment. This finding suggests that clinicians can administer cognitive tests to athletes with mild head injuries in uncontrolled sideline environments and expect valid results. Thus, clinicians can more thoroughly evaluate mildly head-injured athletes during the most crucial period after injury so that a safe return-to-play decision can be based on quantifiable, objective data.
PMCID: PMC1323412  PMID: 16558625
concussion; mild head injury; neuropsychological testing
10.  National Athletic Trainers' Association Position Statement: Management of Asthma in Athletes 
Journal of Athletic Training  2005;40(3):224-245.
Objective: To present guidelines for the recognition, prophylaxis, and management of asthma that lead to improvement in the quality of care certified athletic trainers and other heath care providers can offer to athletes with asthma, especially exercise-induced asthma.
Background: Many athletes have difficulty breathing during or after athletic events and practices. Although a wide variety of conditions can predispose an athlete to breathing difficulties, the most common cause is undiagnosed or uncontrolled asthma. At least 15% to 25% of athletes may have signs and symptoms suggestive of asthma, including exercise-induced asthma. Athletic trainers are in a unique position to recognize breathing difficulties caused by undiagnosed or uncontrolled asthma, particularly when asthma follows exercise. Once the diagnosis of asthma is made, the athletic trainer should play a pivotal role in supervising therapies to prevent and control asthma symptoms. It is also important for the athletic trainer to recognize when asthma is not the underlying cause for respiratory difficulties, so that the athlete can be evaluated and treated properly.
Recommendations: The recommendations contained in this position statement describe a structured approach for the diagnosis and management of asthma in an exercising population. Athletic trainers should be educated to recognize asthma symptoms in order to identify patients who might benefit from better management and should understand the management of asthma, especially exercise-induced asthma, to participate as active members of the asthma care team.
PMCID: PMC1250269  PMID: 16284647
airway hyperresponsiveness; airway obstruction; exercise-induced asthma; exercise-induced bronchospasm; pulmonary function tests; certified athletic trainer
11.  BMI and Risk of Serious Upper Body Injury Following Motor Vehicle Crashes: Concordance of Real-World and Computer-Simulated Observations 
PLoS Medicine  2010;7(3):e1000250.
Shankuan Zhu and colleagues use computer crash simulations, as well as real-world data, to evaluate whether driver obesity is associated with greater risk of body injury in motor vehicle crashes.
Men tend to have more upper body mass and fat than women, a physical characteristic that may predispose them to severe motor vehicle crash (MVC) injuries, particularly in certain body regions. This study examined MVC-related regional body injury and its association with the presence of driver obesity using both real-world data and computer crash simulation.
Methods and Findings
Real-world data were from the 2001 to 2005 National Automotive Sampling System Crashworthiness Data System. A total of 10,941 drivers who were aged 18 years or older involved in frontal collision crashes were eligible for the study. Sex-specific logistic regression models were developed to analyze the associations between MVC injury and the presence of driver obesity. In order to confirm the findings from real-world data, computer models of obese subjects were constructed and crash simulations were performed. According to real-world data, obese men had a substantially higher risk of injury, especially serious injury, to the upper body regions including head, face, thorax, and spine than normal weight men (all p<0.05). A U-shaped relation was found between body mass index (BMI) and serious injury in the abdominal region for both men and women (p<0.05 for both BMI and BMI2). In the high-BMI range, men were more likely to be seriously injured than were women for all body regions except the extremities and abdominal region (all p<0.05 for interaction between BMI and sex). The findings from the computer simulation were generally consistent with the real-world results in the present study.
Obese men endured a much higher risk of injury to upper body regions during MVCs. This higher risk may be attributed to differences in body shape, fat distribution, and center of gravity between obese and normal-weight subjects, and between men and women.
Please see later in the article for the Editors' Summary
Editors' Summary
Worldwide, accidents involving motor vehicles kill 1.2 million people and injure as many as 50 million people every year. Collisions between motor vehicles, between vehicles and stationary objects, or between vehicles and pedestrians are responsible for one in 50 deaths and are the 11th leading cause of death globally. Many factors contribute to the risk of motor traffic accidents and the likelihood of subsequent injury or death. These risk factors include vehicle design, vehicle speeds, road design, driver impairment through, for example, alcohol use, and other driver characteristics such as age. Faced with an ever-increasing death toll on their roads, many countries have introduced lower speed limits, mandatory seat belt use, and greater penalties for drunk driving to reduce the carnage. Road design and traffic management initiatives have also been introduced to try to reduce the incidence of road traffic accidents and cars now include many features that provide protection in crashes for their occupants such as airbags and crumple zones.
Why Was This Study Done?
Although these measures have reduced the number of crashes and casualties, a better understanding of the risk factors associated with motor vehicle crashes is needed to deal with this important public-health problem. Another major public-health problem is obesity—having excess body fat. Obesity increases the risk of heart disease and diabetes but also contributes to the severity of motor vehicle crash injuries. Men with a high body mass index (an individual's weight in kilograms divided by height in meters squared; a BMI of 30 or more indicates obesity) have a higher risk of death after a motor vehicle accident than men with a normal BMI (18.5–24.9). This association between death and obesity is not seen in women, however, possibly because men and women accumulate fat on different parts of their body and the resultant difference in body shape could affect how male and female bodies move during traffic collisions and how much protection existing car safety features afford them. In this study, therefore, the researchers investigated how driver obesity affects the risk of serious injuries in different parts of the body following real and simulated motor vehicle crashes in men and women.
What Did the Researchers Do and Find?
The researchers extracted data about injuries and BMIs for nearly 11,000 adult men and women who were involved in a frontal motor vehicle collision between 2001 and 2005 from the Crashworthiness Data System of the US National Automotive Sampling System. They then used detailed statistical methods to look for associations between specific injuries and driver obesity. The researchers also constructed computer models of obese drivers and subjected these models to simulated crashes. Their analysis of the real-world data showed that obese men had a substantially higher risk of injury to the upper body (the head, face, chest, and spine) than men with a normal weight. Serious injury in the abdominal region was most likely at low and high BMIs for both men and women. Finally, obese men were more likely to be seriously injured than obese women for all body regions except the extremities and the abdominal region. The researchers' computer simulations confirmed many of these real-world findings.
What Do These Findings Mean?
These findings suggest that obese men have a higher risk of injury, particularly to their upper body, from motor vehicle crashes than men with a normal body weight or than obese women. The researchers suggest that this higher risk may be attributed to differences in body shape, fat distribution, and center of gravity between obese and normal weight individuals and between men and women. These findings, although limited by missing data, suggest that motor vehicle safety features should be adjusted to take into account the ongoing obesity epidemic. Currently, two-thirds of people in the US are overweight or obese, yet a crash test dummy with a normal BMI is still used during the design of car cabins. Finally, although more studies are needed to understand the biomechanical responses of the human body during vehicle collisions, the findings in this study could aid the identification of groups of people at particularly high risk of injury or death on the roads who could then be helped to reduce their risk.
Additional Information
Please access these Web sites via the online version of this summary at
Wikipedia has a page on traffic collision (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Health Organization has information about road traffic injuries as a public-health problem; its World report on road traffic injury prevention is available in several languages
The US Centers for Disease Control and Prevention provides detailed information about overweight and obesity (in several languages)
MedlinePlus provides links to further resources about obesity (in English and Spanish)
The US National Automotive Sampling System Crashworthiness Data System contains detailed data on thousands of US motor vehicle crashes
PMCID: PMC2846859  PMID: 20361024
12.  Red Blood Cell Transfusion and Mortality in Trauma Patients: Risk-Stratified Analysis of an Observational Study 
PLoS Medicine  2014;11(6):e1001664.
Using a large multicentre cohort, Pablo Perel and colleagues evaluate the association of red blood cell transfusion with mortality according to the predicted risk of death for trauma patients.
Please see later in the article for the Editors' Summary
Haemorrhage is a common cause of death in trauma patients. Although transfusions are extensively used in the care of bleeding trauma patients, there is uncertainty about the balance of risks and benefits and how this balance depends on the baseline risk of death. Our objective was to evaluate the association of red blood cell (RBC) transfusion with mortality according to the predicted risk of death.
Methods and Findings
A secondary analysis of the CRASH-2 trial (which originally evaluated the effect of tranexamic acid on mortality in trauma patients) was conducted. The trial included 20,127 trauma patients with significant bleeding from 274 hospitals in 40 countries. We evaluated the association of RBC transfusion with mortality in four strata of predicted risk of death: <6%, 6%–20%, 21%–50%, and >50%. For this analysis the exposure considered was RBC transfusion, and the main outcome was death from all causes at 28 days. A total of 10,227 patients (50.8%) received at least one transfusion. We found strong evidence that the association of transfusion with all-cause mortality varied according to the predicted risk of death (p-value for interaction <0.0001). Transfusion was associated with an increase in all-cause mortality among patients with <6% and 6%–20% predicted risk of death (odds ratio [OR] 5.40, 95% CI 4.08–7.13, p<0.0001, and OR 2.31, 95% CI 1.96–2.73, p<0.0001, respectively), but with a decrease in all-cause mortality in patients with >50% predicted risk of death (OR 0.59, 95% CI 0.47–0.74, p<0.0001). Transfusion was associated with an increase in fatal and non-fatal vascular events (OR 2.58, 95% CI 2.05–3.24, p<0.0001). The risk associated with RBC transfusion was significantly increased for all the predicted risk of death categories, but the relative increase was higher for those with the lowest (<6%) predicted risk of death (p-value for interaction <0.0001). As this was an observational study, the results could have been affected by different types of confounding. In addition, we could not consider haemoglobin in our analysis. In sensitivity analyses, excluding patients who died early; conducting propensity score analysis adjusting by use of platelets, fresh frozen plasma, and cryoprecipitate; and adjusting for country produced results that were similar.
The association of transfusion with all-cause mortality appears to vary according to the predicted risk of death. Transfusion may reduce mortality in patients at high risk of death but increase mortality in those at low risk. The effect of transfusion in low-risk patients should be further tested in a randomised trial.
Trial registration NCT01746953
Please see later in the article for the Editors' Summary
Editors' Summary
Trauma—a serious injury to the body caused by violence or an accident—is a major global health problem. Every year, injuries caused by traffic collisions, falls, blows, and other traumatic events kill more than 5 million people (9% of annual global deaths). Indeed, for people between the ages of 5 and 44 years, injuries are among the top three causes of death in many countries. Trauma sometimes kills people through physical damage to the brain and other internal organs, but hemorrhage (serious uncontrolled bleeding) is responsible for 30%–40% of trauma-related deaths. Consequently, early trauma care focuses on minimizing hemorrhage (for example, by using compression to stop bleeding) and on restoring blood circulation after blood loss (health-care professionals refer to this as resuscitation). Red blood cell (RBC) transfusion is often used for the management of patients with trauma who are bleeding; other resuscitation products include isotonic saline and solutions of human blood proteins.
Why Was This Study Done?
Although RBC transfusion can save the lives of patients with trauma who are bleeding, there is considerable uncertainty regarding the balance of risks and benefits associated with this procedure. RBC transfusion, which is an expensive intervention, is associated with several potential adverse effects, including allergic reactions and infections. Moreover, blood supplies are limited, and the risks from transfusion are high in low- and middle-income countries, where most trauma-related deaths occur. In this study, which is a secondary analysis of data from a trial (CRASH-2) that evaluated the effect of tranexamic acid (which stops excessive bleeding) in patients with trauma, the researchers test the hypothesis that RBC transfusion may have a beneficial effect among patients at high risk of death following trauma but a harmful effect among those at low risk of death.
What Did the Researchers Do and Find?
The CRASH-2 trail included 20,127 patients with trauma and major bleeding treated in 274 hospitals in 40 countries. In their risk-stratified analysis, the researchers investigated the effect of RBC transfusion on CRASH-2 participants with a predicted risk of death (estimated using a validated model that included clinical variables such as heart rate and blood pressure) on admission to hospital of less than 6%, 6%–20%, 21%–50%, or more than 50%. That is, the researchers compared death rates among patients in each stratum of predicted risk of death who received a RBC transfusion with death rates among patients who did not receive a transfusion. Half the patients received at least one transfusion. Transfusion was associated with an increase in all-cause mortality at 28 days after trauma among patients with a predicted risk of death of less than 6% or of 6%–20%, but with a decrease in all-cause mortality among patients with a predicted risk of death of more than 50%. In absolute figures, compared to no transfusion, RBC transfusion was associated with 5.1 more deaths per 100 patients in the patient group with the lowest predicted risk of death but with 11.9 fewer deaths per 100 patients in the group with the highest predicted risk of death.
What Do These Findings Mean?
These findings show that RBC transfusion is associated with an increase in all-cause deaths among patients with trauma and major bleeding with a low predicted risk of death, but with a reduction in all-cause deaths among patients with a high predicted risk of death. In other words, these findings suggest that the effect of RBC transfusion on all-cause mortality may vary according to whether a patient with trauma has a high or low predicted risk of death. However, because the participants in the CRASH-2 trial were not randomly assigned to receive a RBC transfusion, it is not possible to conclude that receiving a RBC transfusion actually increased the death rate among patients with a low predicted risk of death. It might be that the patients with this level of predicted risk of death who received a transfusion shared other unknown characteristics (confounders) that were actually responsible for their increased death rate. Thus, to provide better guidance for clinicians caring for patients with trauma and hemorrhage, the hypothesis that RBC transfusion could be harmful among patients with trauma with a low predicted risk of death should be prospectively evaluated in a randomised controlled trial.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Druin Burch
The World Health Organization provides information on injuries and on violence and injury prevention (in several languages)
The US Centers for Disease Control and Prevention has information on injury and violence prevention and control
The National Trauma Institute, a US-based non-profit organization, provides information about hemorrhage after trauma and personal stories about surviving trauma
The UK National Health Service Choices website provides information about blood transfusion, including a personal story about transfusion after a serious road accident
The US National Heart, Lung, and Blood Institute also provides detailed information about blood transfusions
MedlinePlus provides links to further resources on injuries, bleeding, and blood transfusion (in English and Spanish)
More information in available about CRASH-2 (in several languages)
PMCID: PMC4060995  PMID: 24937305
13.  Fracture Through the Distal Femoral Epiphysis 
Journal of Athletic Training  1995;30(2):154-157.
Injuries to the distal femoral epiphysis are not common, but when they do occur, at least half of them occur in sports. Many athletic trainers work with skeletally immature athletes, thereby increasing the likelihood that they will face this type of injury. The case of a 14-year-old football player who sustained a Salter-Harris III fracture of his medial femoral condyle is presented to illustrate the classic natural history and prognosis of this injury. To properly evaluate this injury, the athletic trainer must understand the anatomy of the immature skeleton and be able to recognize signs that epiphyseal injury has occurred. These injuries frequently result in long-term complications such as leg-length discrepancy, although this and other complications can be minimized or eliminated through proper immediate treatment. Athletic trainers must be aware of these injuries and include them in their differential evaluation, since immediate treatment can mean the difference between permanent leg-length discrepancy or deformity and an uncomplicated recovery with the athlete returning to full athletic activity.
PMCID: PMC1317849  PMID: 16558327
14.  Cervical stenosis in a professional rugby league football player: a case report 
This paper describes a case of C7 radiculopathy in a professional rugby league player after repeated cervical spine trauma. The report outlines the management of the patient following an acute cervical hyperflexion injury with chiropractic manipulation and soft tissue therapies. It also presents a change in approach to include distractive techniques on presentation of a neurological deficit following re-injury. The clinical outcomes, while good, were very dependent upon the athlete restricting himself from further trauma during games, which is a challenge for a professional athlete.
Case presentation
A 30-year old male front row Australian rugby league player presented complaining of neck pain after a hyperflexion and compressive injury during a game. Repeated trauma over a four month period resulted in radicular pain. Radiographs revealed decreased disc height at the C5-C6 and C6-C7 levels and mild calcification within the anterior longitudinal ligament at the C6-C7 level. MRI revealed a right postero-lateral disc protrusion at the C6-C7 level causing a C7 nerve root compression.
Recommendations from the available literature at the present time suggest that conservative management of cervical discogenic pain and disc protrusion, including chiropractic manipulation and ancillary therapies, can be successful in the absence of progressive neurological deficit. The current case highlights the initial successful management of a football athlete, and the later unsuccessful management. This case highlights the issues involvement in the management of a collision sport athlete with a serious neck injury.
PMCID: PMC1185557  PMID: 16078999
manipulation, chiropractic; non operative treatment; cervical, radiculopathy; sport, injury; rugby league
15.  Traumatic Hyphema in an Intercollegiate Baseball Player: A Case Report 
Journal of Athletic Training  1999;34(1):25-28.
To present the case of a collegiate baseball player struck in the right eye.
While attempting a bunt, a 20-year-old collegiate baseball player was hit in the right eye when the ball was deflected off the bat. The athlete bled from the nose, and the right eye swelled shut from eyelid edema. Initial nasal hemorrhage was controlled, and the athlete was referred to the emergency room for further care due to pain in the inferior orbit.
Differential Diagnosis:
Eyelid contusion, traumatic iritis, or traumatic microhyphema to the right eye secondary to blunt trauma.
Immediate treatment consisted of controlling the nasal bleeding with sterile gauze pads. Because of palpable tenderness over the inferior orbit, the athlete was immediately transported to the emergency room.
Hyphema is one of the most common sport-related eye injuries: the incidence is 12.2 cases per 100,000 population, with approximately 37% resulting from sports injury. Racquet sports, baseball, and softball account for more than half of all hyphema injuries in athletics. Individuals with traumatic hyphema rarely require surgery; however, proper initial care, treatment, and referral are imperative to a good prognosis.
Athletic trainers need to be able to recognize the signs and symptoms of hyphema and seek medical evaluation immediately in order to avoid secondary complications. With proper recognition, initial care and referral, and appropriate, well-fitted protective eyewear as needed, hyphema can have minimal complications, and the athlete may be able to compete again within 1 to 2 weeks.
PMCID: PMC1322870  PMID: 16558544
cycloplegia; fundoscopy; gonioscopy; limbal tissue; tonometry
16.  In-game Management of Common Joint Dislocations 
Sports Health  2014;6(3):246-255.
Sideline management of sports-related joint dislocations often places the treating medical professional in a challenging position. These injuries frequently require prompt evaluation, diagnosis, reduction, and postreduction management before they can be evaluated at a medical facility. Our objective is to review the mechanism, evaluation, reduction, and postreduction management of sports-related dislocations to the shoulder, elbow, finger, knee, patella, and ankle joints.
Evidence Acquisition:
A literature review was performed using the PubMed database to evaluate previous and current publications focused on joint dislocations. This review focused on articles published between 1980 and 2013.
Study Design:
Clinical review.
Level of Evidence:
Level 4.
The clinician should weigh the benefits and risks of on-field reduction based on their knowledge of the injury and the presence of associated injuries.
When properly evaluated and diagnosed, most sports-related dislocations can be reduced and initially managed at the game.
PMCID: PMC4000468  PMID: 24790695
sport; dislocation; joint; reduction; sideline; review
17.  Sports dentistry 
Sports dentistry is one of the most recent and upcoming field in dentistry. It mainly includes the prevention and management of athletics-related orofacial injuries and associated oral diseases. The sports or team dentist assists athletes in the prevention, treatment, and diagnosis of oral injuries. The most significant aspect in preventing sports-related orofacial injuries is wearing basic protective devices such as properly-fitting helmets, face masks and/or mouth guards. Dental injuries are the most common type of orofacial injury sustained during participation in sports. Many athletes are not aware of the health implications of a traumatic injury to the mouth or of the potential for incurring severe head and orofacial injuries while playing. The dentist can play an imperative role in informing athletes, coaches and patients about the importance of preventing orofacial injuries in sports. The aim of this paper is to increase professional awareness and interest for orientation toward sports dentistry.
PMCID: PMC3343409  PMID: 22639498
Dental injury; sports; mouth gaurd
18.  Classification of Sport-Related Head Trauma: A Spectrum of Mild to Severe Injury 
Journal of Athletic Training  2001;36(3):236-243.
To identify the types of injuries the human brain incurs as a result of traumatic forces applied to the cranium. In athletic events and endeavors, the full spectrum of intracranial hemorrhages in various compartments, raised intracranial pressure, and diffuse nonhemorrhagic damage may be seen. In this review, we describe these serious injuries and the more common mild traumatic brain injury in their clinical presentations and relate concussion classification to the overall picture of traumatic brain injury.
Our cumulative experience with athletic injuries, both at the catastrophic and mild traumatic brain injury levels, has led us to a management paradigm that serves to guide us in the classification and treatment of these athletes.
The occurrence of intracranial injuries in sports has now been well documented. Intracranial hematomas (epidural, subdural, and parenchymal) and cerebral contusions can result from head injury. Many patients sustain a diffuse brain injury, resulting in elevated intracranial pressures, without a blood clot or mass lesion. The classification of concussion and the use of concussion guidelines are not uniform. However, the major emphases are agreed upon: the close and careful scrutiny of the athlete, an expeditious but reliable neurologic examination, and proper on-field management. Return-to-play decisions are based on many factors that affect normal functioning, both on and off the playing field.
Sufficient knowledge now exists to allow us to carefully evaluate the injured athlete, to place him or her in the management scheme to minimize the potential for permanent cerebral dysfunction, and to know when the athlete can safely return to contact sport participation.
PMCID: PMC155412  PMID: 12937490
diffuse brain injury; hematoma
19.  An Economic Evaluation of Venous Thromboembolism Prophylaxis Strategies in Critically Ill Trauma Patients at Risk of Bleeding 
PLoS Medicine  2009;6(6):e1000098.
Using decision analysis, Henry Stelfox and colleagues estimate the cost-effectiveness of three venous thromboembolism prophylaxis strategies in patients with severe traumatic injuries who were also at risk for bleeding complications.
Critically ill trauma patients with severe injuries are at high risk for venous thromboembolism (VTE) and bleeding simultaneously. Currently, the optimal VTE prophylaxis strategy is unknown for trauma patients with a contraindication to pharmacological prophylaxis because of a risk of bleeding.
Methods and Findings
Using decision analysis, we estimated the cost effectiveness of three VTE prophylaxis strategies—pneumatic compression devices (PCDs) and expectant management alone, serial Doppler ultrasound (SDU) screening, and prophylactic insertion of a vena cava filter (VCF)—in trauma patients admitted to an intensive care unit (ICU) with severe injuries who were believed to have a contraindication to pharmacological prophylaxis for up to two weeks because of a risk of major bleeding. Data on the probability of deep vein thrombosis (DVT) and pulmonary embolism (PE), and on the effectiveness of the prophylactic strategies, were taken from observational and randomized controlled studies. The probabilities of in-hospital death, ICU and hospital discharge rates, and resource use were taken from a population-based cohort of trauma patients with severe injuries (injury severity scores >12) admitted to the ICU of a regional trauma centre. The incidence of DVT at 12 weeks was similar for the PCD (14.9%) and SDU (15.0%) strategies, but higher for the VCF (25.7%) strategy. Conversely, the incidence of PE at 12 weeks was highest in the PCD strategy (2.9%), followed by the SDU (1.5%) and VCF (0.3%) strategies. Expected mortality and quality-adjusted life years were nearly identical for all three management strategies. Expected health care costs at 12 weeks were Can$55,831 for the PCD strategy, Can$55,334 for the SDU screening strategy, and Can$57,377 for the VCF strategy, with similar trends noted over a lifetime analysis.
The attributable mortality due to PE in trauma patients with severe injuries is low relative to other causes of mortality. Prophylactic placement of VCF in patients at high risk of VTE who cannot receive pharmacological prophylaxis is expensive and associated with an increased risk of DVT. Compared to the other strategies, SDU screening was associated with better clinical outcomes and lower costs.
Please see later in the article for Editors' Summary
Editors' Summary
For patients who have been seriously injured in an accident or a violent attack (trauma patients), venous thromboembolism (VTE)—the formation of blood clots that limit the flow of blood through the veins—is a frequent and potentially fatal complication. The commonest form of VTE is deep vein thrombosis (DVT). “Distal” DVTs (clots that form in deep veins below the knee) affect about half of patients with severe trauma; “proximal” DVTs (clots that form above the knee) develop in one in five trauma patients. DVTs cause pain and swelling in the affected leg and can leave patients with a painful condition called post-thrombotic syndrome. Worse still, part of the clot can break off and travel to the lungs where it can cause a life-threatening pulmonary embolism (PE). Distal DVTs rarely embolize but, if untreated, half of patients who present with a proximal DVT will develop a PE, and 2%–3% of them will die as a result.
Why Was This Study Done?
VTE is usually prevented by using heparin, a drug that stops blood clotting, but clinicians treating critically ill trauma patients have a dilemma. Many of these patients are at high risk of serious bleeding complications so cannot be given heparin to prevent VTE. Nonpharmacological ways to prevent VTE include the use of pneumatic compression devices to keep the blood moving in the legs (clots often form in patients confined to bed because of the sluggish blood flow in their legs), repeated screening for blood clots using Doppler ultrasound, and the insertion of a “vena cava filter” into the vein that takes blood from the legs to the heart. This last device catches blood clots before they reach the lungs but increases the risk of DVT. Unfortunately, no-one knows which VTE prevention strategy works best in trauma patients who cannot be given heparin. In this study, therefore, the researchers use decision analysis (the systematic evaluation of the most important factors affecting a decision) to estimate the costs and likely clinical outcomes of these strategies.
What Did the Researchers Do and Find?
The researchers used cost and clinical data from patients admitted to a Canadian trauma center with severe head/neck and/or abdomen/pelvis injuries (patients with a high risk of bleeding complications likely to make heparin therapy dangerous for up to two weeks after the injury) to construct a Markov decision analysis model. They then fed published data on the chances of patients developing DVT or PE, and on the effectiveness of the three VTE prevention strategies, into the model to obtain estimates of the costs and clinical outcomes of the strategies at 12 weeks after the injury and over the patients' lifetime. The estimated incidence of DVT at 12 weeks was 15% for the pneumatic compression device and Doppler ultrasound strategies, but 25% for the vena cava filter strategy. By contrast, the estimated incidence of PE was 2.9% with the pneumatic compression device, 1.5% with Doppler ultrasound, but only 0.3% with the vena cava filter. The expected mortality with all three strategies was similar. Finally, the estimated health care costs per patient at 12 weeks were Can$55,334 and Can$55,831 for the Doppler ultrasound and pneumatic compression device strategies, respectively, but Can$57,377 for the vena cava filter strategy; similar trends were seen for lifetime health care costs.
What Do These Findings Mean?
As with all mathematical models, these findings depend on the data fed into the model and on the assumptions included in it. For example, because data from one Canadian trauma unit were used to construct the model, these findings may not be generalizable. Nevertheless, these findings suggest that, although VTE is common among patients with severe injuries, PE is not a major cause of death among these patients. They also suggest that the use of vena cava filters for VTE prevention in patients who cannot receive heparin should not be routinely used because it is expensive and increases the risk of DVT. Finally, these results suggest that, compared with the other strategies, serial Doppler ultrasound is associated with better clinical outcomes and lower costs.
Additional Information
Please access these Web sites via the online version of this summary at
The US National Heart Lung and Blood Institute provides information (including an animation) on deep vein thrombosis and pulmonary embolism
MedlinePlus provides links to more information about deep vein thrombosis and pulmonary embolism (in several languages)
The UK National Health Service Choices Web site has information on deep vein thrombosis and on embolism (in English and Spanish)
The Eastern Association for the Surgery of Trauma working group document Practice Management Guidelines for the Management of Venous Thromboembolism in Trauma Patients can be downloaded from the Internet
PMCID: PMC2695771  PMID: 19554085
20.  Management of Cervical Spine Injuries in Athletes 
Journal of Athletic Training  2007;42(1):126-134.
Objective: Although the incidence of catastrophic cervical spine injury in sport has been significantly reduced over the past 3 decades, the injury warrants continued attention because of the altered quality of life that often accompanies such an injury. The purpose of our literature review was to provide athletic trainers with an understanding of the mechanisms, anatomical structures, and complications often associated with sport-related cervical spine injury. We also present the most current recommendations for management and treatment of these potentially catastrophic injuries.
Data Sources: A review of the most pertinent literature between 1970 and 2005 was conducted using MEDLINE and the search terms spinal cord injury, cervical spine injury, neurosurgical trauma, cervical spinal stenosis, and catastrophic spine injury.
Data Synthesis: Flexion of the head places the cervical spine into a straight line and prevents the neck musculature from assisting in force absorption. This mechanism is the primary cause of cervical fracture, dislocation, and quadriplegia. The most serious of the syndromes described in the literature involves a complete spinal cord injury with transverse myelopathy. This injury typically results in total loss of spinal function below the level of the lesion.
Conclusions/Recommendations: Spinal trauma may result in a variety of clinical syndromes, according to the type and severity of the impact and bony displacement, as well as subsequent secondary insults such as hemorrhage, ischemia, and edema. Athletic trainers should be prepared to promptly recognize these potentially catastrophic injuries and follow the recommendations of the Inter-Association Task Force for the Appropriate Care of the Spine Injured Athlete in managing such injuries.
PMCID: PMC1896065  PMID: 17597954
neck injury; spinal stenosis; quadriplegia; catastrophic injuries
21.  Partial Posterior Cruciate Ligament Tear in a Collegiate Basketball Player: A Case Report 
Journal of Athletic Training  1997;32(2):155-158.
To present a case of a collegiate basketball player treated conservatively for an incomplete tear of the posterior cruciate ligament (PCL).
The PCL is the strongest ligament of the knee, but PCL injuries are rare during athletic activity especially when compared with anterior cruciate ligament (ACL) injuries.
Differential Diagnosis:
ACL injury, confusion.
Treatment options include either conservative management or surgical intervention. Although controversy exists as to which method produces the best results, it appears that good functional outcomes can result from aggressive rehabilitation alone.
The athlete was reluctant to report the injury because she thought it was only a bruise. Once assessed with a PCL sprain, the athlete adamantly refused to see a physician for a definitive diagnosis. The infrequent occurrence and the apparent lack of knowledge regarding mechanism and clinical presentation of PCL injuries often result in misdiagnosis. Subsequently, patients with unrecognized involvement of the PCL may respond inadequately to rehabilitation measures.
Based on the literature, it appears that athletes who suffer isolated PCL injuries can achieve good functional results when treated conservatively. A vital component to the success of managing PCL injuries is the athletic trainer's being well versed in the recognition of signs, symptoms, and mechanisms of injury, as well as being knowledgeable in evaluation techniques that lead to assessment of this infrequent injury.
PMCID: PMC1319820  PMID: 16558447
basketball injuries; female basketball injuries; knee injuries; knee evaluation; conservative knee rehabilitation
22.  The kSORT Assay to Detect Renal Transplant Patients at High Risk for Acute Rejection: Results of the Multicenter AART Study 
PLoS Medicine  2014;11(11):e1001759.
Minnie Sarwal and colleagues developed a gene expression assay using peripheral blood samples to detect patients with renal transplant at high risk for acute rejection.
Please see later in the article for the Editors' Summary
Development of noninvasive molecular assays to improve disease diagnosis and patient monitoring is a critical need. In renal transplantation, acute rejection (AR) increases the risk for chronic graft injury and failure. Noninvasive diagnostic assays to improve current late and nonspecific diagnosis of rejection are needed. We sought to develop a test using a simple blood gene expression assay to detect patients at high risk for AR.
Methods and Findings
We developed a novel correlation-based algorithm by step-wise analysis of gene expression data in 558 blood samples from 436 renal transplant patients collected across eight transplant centers in the US, Mexico, and Spain between 5 February 2005 and 15 December 2012 in the Assessment of Acute Rejection in Renal Transplantation (AART) study. Gene expression was assessed by quantitative real-time PCR (QPCR) in one center. A 17-gene set—the Kidney Solid Organ Response Test (kSORT)—was selected in 143 samples for AR classification using discriminant analysis (area under the receiver operating characteristic curve [AUC] = 0.94; 95% CI 0.91–0.98), validated in 124 independent samples (AUC = 0.95; 95% CI 0.88–1.0) and evaluated for AR prediction in 191 serial samples, where it predicted AR up to 3 mo prior to detection by the current gold standard (biopsy). A novel reference-based algorithm (using 13 12-gene models) was developed in 100 independent samples to provide a numerical AR risk score, to classify patients as high risk versus low risk for AR. kSORT was able to detect AR in blood independent of age, time post-transplantation, and sample source without additional data normalization; AUC = 0.93 (95% CI 0.86–0.99). Further validation of kSORT is planned in prospective clinical observational and interventional trials.
The kSORT blood QPCR assay is a noninvasive tool to detect high risk of AR of renal transplants.
Please see later in the article for the Editors' Summary
Editors' Summary
Throughout life, the kidneys filter waste products (from the normal breakdown of tissues and food) and excess water from the blood to make urine. If the kidneys stop working for any reason, the rate at which the blood is filtered decreases, and dangerous amounts of creatinine and other waste products build up in the blood. The kidneys can fail suddenly (acute kidney failure) because of injury or poisoning, but usually failing kidneys stop working gradually over many years (chronic kidney disease). Chronic kidney disease is very common, especially in people who have high blood pressure or diabetes and in elderly people. In the UK, for example, about 20% of people aged 65–74 years have some degree of chronic kidney disease. People whose kidneys fail completely (end-stage kidney disease) need regular dialysis (hemodialysis, in which blood is filtered by an external machine, or peritoneal dialysis, which uses blood vessels in the abdominal lining to do the work of the kidneys) or a renal transplant (the surgical transfer of a healthy kidney from another person into the patient's body) to keep them alive.
Why Was This Study Done?
Our immune system protects us from pathogens (disease-causing organisms) by recognizing specific molecules (antigens) on the invader's surface as foreign and initiating a sequence of events that kills the invader. Unfortunately, the immune system sometimes recognizes kidney transplants as foreign and triggers transplant rejection. The chances of rejection can be minimized by “matching” the antigens on the donated kidney to those on the tissues of the kidney recipient and by giving the recipient immunosuppressive drugs. However, acute rejection (rejection during the first year after transplantation) affects about 20% of kidney transplants. Acute rejection needs to be detected quickly and treated with a short course of more powerful immunosuppressants because it increases the risk of transplant failure. The current “gold standard” method for detecting acute rejection if the level of creatinine in the patient's blood begins to rise is to surgically remove a small piece (biopsy) of the transplanted kidney for analysis. However, other conditions can change creatinine levels, acute rejection can occur without creatinine levels changing (subclinical acute rejection), and biopsies are invasive. Here, the researchers develop a noninvasive test for acute kidney rejection called the Kidney Solid Organ Response Test (kSORT) based on gene expression levels in the blood.
What Did the Researchers Do and Find?
For the Assessment of Acute Rejection in Renal Transplantation (AART) study, the researchers used an assay called quantitative polymerase chain reaction (QPCR) to measure the expression of 43 genes whose expression levels change during acute kidney rejection in blood samples collected from patients who had had a kidney transplant. Using a training set of 143 samples and statistical analyses, the researchers identified a 17-gene set (kSORT) that discriminated between patients with and without acute rejection detected by kidney biopsy. The 17-gene set correctly identified 39 of the samples taken from 47 patients with acute rejection as being from patients with acute rejection, and 87 of 96 samples from patients without acute rejection as being from patients without acute rejection. The researchers validated the gene set using 124 independent samples. Then, using 191 serial samples, they showed that the gene set was able to predict acute rejection up to three months before detection by biopsy. Finally, the researchers used 100 blood samples to develop an algorithm (a step-wise calculation) to classify patients as being at high or low risk of acute rejection.
What Do These Findings Mean?
These findings describe the early development of a noninvasive tool (kSORT) that might, eventually, help clinicians identify patients at risk of acute rejection after kidney transplantation. kSORT needs to be tested in more patients before being used clinically, however, to validate its predictive ability, particularly given that the current gold standard test against which it was compared (biopsy) is far from perfect. An additional limitation of kSORT is that it did not discriminate between cell-mediated and antibody-mediated immune rejection. These two types of immune rejection are treated in different ways, so clinicians ideally need a test for acute rejection that indicates which form of immune rejection is involved. The authors are conducting a follow-up study to help determine whether kSORT can be used in clinical practice to identify acute rejection and to identify which patients are at greatest risk of transplant rejection and may require biopsy.
Additional Information
Please access these websites via the online version of this summary at
The US National Kidney and Urologic Diseases Information Clearinghouse provides links to information about all aspects of kidney disease; the US National Kidney Disease Education Program provides resources to help improve the understanding, detection, and management of kidney disease (in English and Spanish)
The UK National Health Service Choices website provides information for patients on chronic kidney disease and about kidney transplants, including some personal stories
The US National Kidney Foundation, a not-for-profit organization, provides information about chronic kidney disease and about kidney transplantation (in English and Spanish)
The not-for-profit UK National Kidney Federation provides support and information for patients with kidney disease and for their carers, including information and personal stories about kidney donation and transplantation
World Kidney Day, a joint initiative between the International Society of Nephrology and the International Federation of Kidney Foundations, aims to raise awareness about kidneys and kidney disease
MedlinePlus provides links to additional resources about kidney diseases, kidney failure, and kidney transplantation; the MedlinePlus encyclopedia has a page about transplant rejection
PMCID: PMC4227654  PMID: 25386950
23.  The Biomechanical Properties of Concussions in High School Football 
Sport concussion represents the majority of brain injuries occurring in the United States with 1.6 to 3.8 million cases annually. Understanding the biomechanical properties of this injury will support the development of better diagnostics and preventative techniques.
We monitored all football related head impacts in 78 high school athletes (mean age 16.7 years) from 2005 through 2008 in order to better understand the biomechanical characteristics of concussive impacts.
Using the Head Impact Telemetry System (HITS), a total of 54,247 impacts were recorded and 13 concussive episodes captured for analysis. A classification and regression tree (CART) analysis of impacts indicated that rotational acceleration (>5582.3 rad/s2), linear acceleration (>96.1 g), and impact location (front, top, back) yielded the highest predictive value of concussion.
These threshold values are nearly identical to those reported at the collegiate and professional level. If the HITS were implemented for medical use, sideline personnel can expect to diagnose one of every five athletes with a concussion when the impact exceeds these tolerance levels. Why all athletes did not sustain a concussion when the impacts generated variables in excess of our threshold criteria is not entirely clear, although individual differences between participants may play a role. A similar threshold to concussion in adolescent athletes compared to their collegiate and professional counterparts suggests an equal concussion risk at all levels of play.
PMCID: PMC2943536  PMID: 20351593
mild traumatic brain injury; head acceleration; sport injury; classification and regression tree (CART) analysis
24.  Incidence of Injury in Professional Mixed Martial Arts Competitions 
Journal of Sports Science & Medicine  2006;5(CSSI):136-142.
Mixed Martial Arts (MMA) competitions were introduced in the United States with the first Ultimate Fighting Championship (UFC) in 1993. In 2001, Nevada and New Jersey sanctioned MMA events after requiring a series of rule changes. The purpose of this study was to determine the incidence of injury in professional MMA fighters. Data from all professional MMA events that took place between September 2001 and December 2004 in the state of Nevada were obtained from the Nevada Athletic Commission. Medical and outcome data from events were analyzed based on a pair-matched case-control design. Both conditional and unconditional logistic regression models were used to assess risk factors for injury. A total of 171 MMA matches involving 220 different fighters occurred during the study period. There were a total of 96 injuries to 78 fighters. Of the 171 matches fought, 69 (40.3%) ended with at least one injured fighter. The overall injury rate was 28.6 injuries per 100 fight participations or 12.5 injuries per 100 competitor rounds. Facial laceration was the most common injury accounting for 47.9% of all injuries, followed by hand injury (13.5%), nose injury (10.4%), and eye injury (8.3%). With adjustment for weight and match outcome, older age was associated with significantly increased risk of injury. The most common conclusion to a MMA fight was a technical knockout (TKO) followed by a tap out. The injury rate in MMA competitions is compatible with other combat sports involving striking. The lower knockout rates in MMA compared to boxing may help prevent brain injury in MMA events.
Key PointsMixed martial arts (MMA) has changed since the first MMA matches in the United States and now has increased safety regulations and sanctioning.MMA competitions have an overall high rate of injury.There have been no MMA deaths in the United States.The knockout (KO) rate in MMA appears to be lower than the KO rate of boxing matches.MMA must continue to be supervised by properly trained medical professionals and referees to ensure fighter safety in the future.
PMCID: PMC3863915  PMID: 24357986
Brain injury; ultimate; boxing; jiu jitsu
25.  Abdominal injuries in a low trauma volume hospital - a descriptive study from northern Sweden 
Abdominal injuries occur relatively infrequently during trauma, and they rarely require surgical intervention. In this era of non-operative management of abdominal injuries, surgeons are seldom exposed to these patients. Consequently, surgeons may misinterpret the mechanism of injury, underestimate symptoms and radiologic findings, and delay definite treatment. Here, we determined the incidence, diagnosis, and treatment of traumatic abdominal injuries at our hospital to provide a basis for identifying potential hazards in non-operative management of patients with these injuries in a low trauma volume hospital.
This retrospective study included prehospital and in-hospital assessments of 110 patients that received 147 abdominal injuries from an isolated abdominal trauma (n = 70 patients) or during multiple trauma (n = 40 patients). Patients were primarily treated at the University Hospital of Umeå from January 2000 to December 2009.
The median New Injury Severity Score was 9 (range: 1–57) for 147 abdominal injuries. Most patients (94%) received computed tomography (CT), but only 38% of patients with multiple trauma were diagnosed with CT < 60 min after emergency room arrival. Penetrating trauma caused injuries in seven patients. Solid organ injuries constituted 78% of abdominal injuries. Non-operative management succeeded in 82 patients. Surgery was performed for 28 patients, either immediately (n = 17) as result of operative management or later (n = 11), due to non-operative management failure; the latter mainly occurred with hollow viscus injuries. Patients with multiple abdominal injuries, whether associated with multiple trauma or an isolated abdominal trauma, had significantly more non-operative failures than patients with a single abdominal injury. One death occurred within 30 days.
Non-operative management of patients with abdominal injuries, except for hollow viscus injuries, was highly successful in our low trauma volume hospital, even though surgeons receive low exposure to these patients. However, a growing proportion of surgeons lack experience in decision-making and performing trauma laparotomies. Quality assurance programmes must be emphasized to ensure future competence and quality of trauma care at low trauma volume hospitals.
PMCID: PMC4237946  PMID: 25124882
Abdominal injuries; Low trauma volume hospital; Non-operative management

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