BackgroundExtensive hemorrhage is the leading cause of death in the first few hours following multiple traumas. Therefore, early and aggressive treatment of clotting disorders could reduce mortality. Unfortunately, the availability of results from commonly performed blood coagulation studies are often delayed whereas hemoglobin (Hb) levels are quickly available.ObjectivesIn this study, we evaluated the use of initial hemoglobin (Hb) levels as a guide line for the initial treatment of clotting disorders in multiple trauma patients.Patients and MethodsWe have developed an Hb-driven algorithm to initiate the initial clotting therapy. The algorithm contains three different steps for aggressive clotting therapy depending on the first Hb value measured in the shock trauma room, (SR) and utilizes fibrinogen, prothrombin complex concentrate (PCC), factor VIIa, tranexamic acid and desmopressin. The above-mentioned drugs were stored in a special “coagulation box” in the hospital pharmacy, and this box could be immediately brought to the SR or operating room (OR) upon request. Despite the use of clotting factors, transfusions using red blood cells (RBC) and fresh frozen plasma (FFP) were performed at an RBC-to-FFP ratio of 2:1 to 1:1.ResultsOver a 12-month investigation period, 123 severe multiple trauma patients needing intensive care therapy were admitted to our trauma center (mean age 48 years, mean ISS (injury severity score) 30). Fourteen (11%) patients died; 25 (mean age 51.5 years, mean ISS 53) of the 123 patients were treated using the “coagulation box,” and 17 patients required massive transfusions. Patients treated with the “coagulation box” required an average dose of 16.3 RBC and 12.9 FFP, whereas 17 of the 25 patients required an average dose of 3.6 platelet packs. According to the algorithm, 25 patients received fibrinogen (average dose of 8.25 g), 24 (96%) received PCC (3000 IU.), 14 (56%) received desmopressin (36.6 µg), 13 (52%) received tranexamic acid (2.88 g), and 11 (44%) received factor VIIa (3.7 mg). The clotting parameters markedly improved between SR admission and ICU admission. Of the 25 patients, 16 (64%) survived. The revised injury severity classification (RISC) predicted a survival rate of 41%, which corresponds to a standardized mortality ratio (SMR) of 0.62, which implies a higher survival rate than predicted.ConclusionsAn Hb-driven algorithm, in combination with the “coagulation box” and the early use of clotting factors, could be a simple and effective tool for improving coagulopathy in multiple trauma patients.

Context:The Unexpected-Disturbance Program (UDP) promotes exercises in response to so-called involuntary short- to midlatency disturbances.Objective:This study investigated the effectiveness of the UDP in the last 6 wk of rehabilitation.Design:Pre–post study with 2-tailed paired t tests for limited a priori comparisons to examine differences.Setting:National Sports Institute of Malaysia.Participants:24 Malaysian national athletes.Interventions:7 sessions/wk of 90 min with 3 sessions allocated for 5 or 6 UDP exercises.Main Outcomes:Significant improvements for men and women were noted. Tests included 20-m sprint, 1-repetition-maximum single-leg press, standing long jump, single-leg sway, and a psychological questionnaire.Results:For men and women, respectively, average strength improvements of 22% (d = 0.96) and 29% (d = 1.05), sprint time of 3% (d = 1.06) and 4% (d = 0.58), and distance jumped of 4% (d = 0.59) and 6% (d = 0.47) were noted. In addition, athletes reported improved perceived confidence in their abilities. All athletes improved in each functional test except for long jump in 2 of the athletes. Mediolateral sway decreased in 18 of the 22 athletes for the injured limb.Conclusion:The prevention training with UDP resulted in improved conditioning and seems to decrease mediolateral sway.

Objective: Current return-to-sport decisions are primarily based on elapsed time since surgery or injury and strength measures. Given data that show rates of successful return to competitive sport at around 55%, there is strong rationale for adopting tools that will better inform return to sport decisions. The authors’ objective was to assess reactive strength as a metric for informing return-to-sport decisions. Design: Case-control design. Methods: Fifteen elite athletes from national sports teams (23 [6.0] y) in the final phase of their return-to-sport protocol following a unilateral knee injury and 16 age-matched control athletes (22 [4.6] y) performed a unilateral isometric strength test and 24-cm drop jump test. Pairwise comparisons were used to determine differences between legs within groups and differences in interleg asymmetry between groups. Results: Strength measures did not distinguish the control from the rehabilitation group; however, clear differences in the degree of asymmetry were apparent between the control and rehabilitation groups for contact time (Cohen d = 0.56; −0.14 to 1.27; 8.2%; P = .113), flight time (d = 1.10; 0.44 to 1.76; 16.0%; P = .002), and reactive strength index (d = 1.27; 0.50 to 2.04; 22.4%; P = .002). Conclusion: Reactive strength data provide insight into functional deficits that persist into the final phase of a return-to-sport protocol. The authors’ findings support the use of dynamic assessment tools to inform return-to-sport decisions to limit potential for reinjury.

The Hb-driven algorithm, in combination with the coagulation box and the early use of clotting factors, may be a simple and effective tool for improving coagulopathy in multiple trauma patients.

Low back pain (LBP) is a common disabling health problem that can cause decreased spine proprioception. Stochastic resonance (SR) can influence detection performance, besides improving patients with significant sensory deficits, but have not been thoroughly tested for LBP. This study aimed to examine the application of SR therapy (SRT) and strength training for LBP treatment. The subject was a resistance-trained male in his early thirties. His back pain was unbearable after a strength training session. Standard pain relief alleviated the pain but the LBP developed at a similar intensity after 4 weeks. SRT (4–5 sets ×90 sec, 30-sec rest interval, supine position) was prescribed along with other exercises for 3 weeks (phase 1), and followed by tailor-made strength training for 16 weeks (phase 2). The Oswestry Disability Index was 66.7% (interpreted as “crippled”) prior to first SRT, and reduced to minimal levels of 15.6% and 6.7% after four and seven SRT sessions, respectively. Similarly, pain intensity was ranging from 5 to 9 (distracting-severe) of the Numeric Rating Scale (NRS-11) prior to the first session but this was reduced considerably after four sessions (NRS-11: 0–1). During phase 2, the patient performed without complaining of LBP, two repetitions of bench press exercise at a load intensity of 1.2 his body weight and attained 4 min of plank stabilisation. This LBP management strategy has a clinically meaningful effect on pain intensity, disability, and functional mobility, by receding the recurrent distracting to severe LBP.

A 3-wk UDP can elicit clear enhancements in running sprint speed and concentric-only jump performance. These improvements are suggestive of enhanced explosive strength and are particularly notable given the elite training status of the cohort and relatively short duration of the intervention. Thus, the authors would reiterate the statement by Gruber et al (2004) that sensorimotor training is a "highly efficient" modality for improving explosive strength.

Zusammenfassung: Einmalig bei der ankylosierenden Spondylitis (AS) ist die ungewöhnliche Kombination der pathologischen Grundphänomene Entzündung und Ossifikation, wobei die sekundäre Osteoporose bis heute eine weitgehend ungeklärte Begleiterscheinung darstellt. Ziel der Studie war herauszufinden, [1] wie häufig sich Veränderungen im Sinne einer Osteopenie/Osteoporose bei AS in Abhängig-keit von Krankheitsdauer und -stadium zeigen und [2] den Stellenwert zweier unterschiedlicher Knochendichtemessverfahren bei diesem Krankheitsbild zu beurteilen. Hierzu wurden bei 58 Patienten(innen) zwei unterschiedliche Knochendichtemessmethoden (duale Photonenabsorptionsmetrie = DPX; Single-Energie-quantitative Computertomographie = SE-QCT) angewandt. Sowohl im Initialstadium als auch in fortgeschrittenen Stadien der Erkrankung konnte in einem nicht unerheblichen Prozentsatz eine Minderung der axialen Knochendichte verifiziert werden (DPX: Osteopenie in 13,8 % -Osteoporose in 5,1 %; SE-QCT: Osteopenie in 10,3 % -Osteoporose in 32,8 %). Mittels DPX-Messung war eine periphere Knochendichteminderung im Sinne der Osteopenie in 20,7 % nachweisbar. Im SE-QCT zeigte sich eine Verminderung des Spongiosamineralsalzgehaltes schon im Initialstadium mit weiterer Abnahme im Krankheitsverlauf, wobei die Kortikalis gleiche Tendenz bis zu Stadien der Ankylosierung zeigte. Mittels DPX sind valide Aussagen eher in gering ausgeprägten ankylosierten Stadien einer AS zu erwarten. Da jedoch mit projektiven Verfahren zum Großteil die Kortikalis gemessen wird und im Initialstadium einer Osteoporose zunächst ein Spongiosaverlust eintritt, ist aus unserer Sicht die Methode der SE-QCT aufgrund der selektiven Messung von Spongiosa und Kortikalis zu favorisieren. Insbesondere in Stadien mit fortgeschrittenen Ankylosen im Bereich der Wirbelsäule ist der SE-QCT-Messung eher Vorrang zu gewähren, da mit DPX-Verfahren oft zu hohe Werte gemessen werden und der Ersatz der WK-Spongiosa durch Fettmark nicht standardmäßig erfasst wird. Das Frakturrisiko bei AS kann schon bei DPX-Osteopenie, aber bereits bestehender SE-QCT-Osteoporose erhöht sein.Bone Density Measurement by Dual Photon Absorptiometry (DPX) and Single Energy-Quantitative Computed Tomography (SEQCT) in Ankylosing Spondylitis (AS) -Critical Comments: A unique observation in ankylosing spondylitis (AS) is the unusual combination of the pathological basic phenonema of inflammation and ossification, whereas secondary osteoporosis is still an unclarified concomitant symptom. The aim of the study was [1] to show the frequency of changes in the direction of osteopenia/osteoporosis in AS depending on the duration and stage of the disease, and [2] to assess the ranking of two different methods of bone density measurement in this clinical pattern. We used two different methods of bone density measurement in 58 male and female patients, namely, Dual Photon Absorptiometry (DPX) and Single Energy-Quantitative Computed Tomography (SEQCT). In the initial and advanced stages of the disease, a high-percentage decrease ...

The diabetic foot syndrome (DFS) is an important complication of diabetes mellitus resulting in severe undesired consequences, such as amputation, disability and reduced quality of life. In Germany there are approximately 300,000 patients with lesions of the foot caused by diabetes of which approximately 50% have to be amputated within 4 years of diagnosis. To achieve a reduction of the amputation rate it is necessary to identify the main causes. The use of the Wagner-Armstrong wound classification is well accepted in Germany. Therapy and diagnosis of the diabetic foot syndrome are almost standardized and all procedures are well established. In addition a professional stage-adjusted wound therapy has to take place in an interdisciplinary collaboration at a centre for wound care.