Traumatic brain injury (TBI) is characterized by a disruption in the normal function of the brain due to an injury following a trauma which can potentially cause severe physical, cognitive and emotional impairment. The primary insult to the brain initiates secondary injury cascades consisting of multiple complex biochemical responses of the brain that significantly influence the overall severity of the brain damage and clinical sequelae. The use of mesenchymal stem cells (MSCs) offers huge potential for application in the treatment of TBI. MSCs have immunosuppressive properties that reduce inflammation in injured tissue. As such, they could be used to modulate the secondary mechanisms of injury and halt the progression of the secondary insult in the brain after injury. Particularly, MSCs are capable of secreting growth factors that facilitate the regrowth of neurons in the brain. The relative abundance of harvest sources of MSCs also makes them particularly appealing. Recently, numerous studies have investigated the effects of infusion of MSCs into animal models of TBI. The results have shown significant improvement in the motor function of the damaged brain tissues. In this review, we summarize the recent advances in the application of MSCs in the treatment of TBI. The review starts with a brief introduction of the anatomy of the human brain and the pathophysiology of TBI, followed by the biology of MSCs, and the application of MSCs in TBI treatment. The challenges associated with the application of MSCs in the treatment of TBI and strategies to address those challenges in the future have also been discussed.

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Mesenchymal Stem Cells in the Treatment of Traumatic Brain Injury.

Background Acute soft tissue injuries are common and costly. The best drug treatment for such injuries is not certain, although non-steroidal anti-inflammatory drugs (NSAIDs) are often recommended. Objectives To assess the effects (benefits and harms) of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014 Issue 8), MEDLINE (1966 to September 2014), EMBASE (1980 to September 2014), CINAHL (1937 to November 2012), AMED (1985 to November 2012), International Pharmaceutical Abstracts (1970 to November 2012), PEDro (1929 to November 2012), and SPORTDiscus (1985 to November 2012), plus internet search engines, trial registries and other databases. We also searched reference lists of relevant articles and contacted authors of retrieved studies and pharmaceutical companies to obtain relevant unpublished data. Selection criteria We included randomised or quasi-randomised controlled trials involving people with acute soft tissue injury (sprain, strain or contusion of a joint, ligament, tendon or muscle occurring up to 48 hours prior to inclusion in the study) and comparing oral NSAID versus paracetamol (acetaminophen), opioid, paracetamol plus opioid, or complementary and alternative medicine. The outcomes were pain, swelling, function, adverse effects and early re-injury. Data collection and analysis At least two review authors independently assessed studies for eligibility, extracted data and assessed risk of bias. We assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Main results We included 16 trials, with a total of 2144 participants. Two studies included children only. The other 14 studies included predominantly young adults, of whom over 60% were male. Seven studies recruited people with ankle sprains only. Most studies were at low or unclear risk of bias; however, two were at high risk of selection bias, three were at high risk of bias from lack of blinding, one was at high risk of bias due to incomplete outcome data, and four were at high risk of selective outcome reporting bias. The evidence was usually either low quality or very low quality, reflecting study limitations, indirectness such from as suboptimal dosing of single comparators, imprecision, or one or more of these. Thus we are either uncertain or very uncertain of the estimates.Nine studies, involving 991 participants, compared NSAIDs with paracetamol. While tending to favour paracetamol, there was a lack of clinically important differences between the two groups in pain at less than 24 hours (377 participants, 4 studies; moderate-quality evidence), at days 1 to 3 (431 participants, 4 studies; low quality), and at day 7 or over (467 participants, 4 studies; low quality). A similar lack of difference between the two groups applied to swelling at day 3 (86 participants, 1 study; very low quality) and at day 7 or over (77 participants, 1 study; low quality). There was little difference between the two groups in return to function at day 7 or over (316 participants, 3 studies; very low quality): based on an assumed recovery of function of 804 per 1000 participants in the paracetamol group, 8 fewer per 1000 recovered in the NSAID group (95% confidence interval (CI) 80 fewer to 73 more). There was low-quality evidence of a lower risk of gastrointestinal adverse events in the paracetamol group: based on an assumed risk of gastrointestinal adverse events of 16 per 1000 participants in the paracetamol group, 13 more participants per 1000 had a gastrointestinal adverse event in the NSAID group (95% CI 0 to 35 more).Four studies, involving 958 participants, compared NSAIDs with opioids. Since a study of a selective COX-2 inhibitor NSAID (valdecoxib) that was subsequently withdrawn from the market dominates the evidence for this comparison (706 participants included in the analyses for pain, function and gastrointestinal adverse events), the applicability of these results is in doubt and we give only a brief summary. There was low quality evidence for a lack of clinically important differences between the two groups regarding pain at less than 24 hours, at days 4 to 6, and at day 7. Evidence from single studies showed a similar lack of difference between the two groups for swelling at day 3 (68 participants) and day 10 (84 participants). Return to function at day 7 or over favoured the NSAID group (low-quality), and there were fewer gastrointestinal adverse events in the selective COX-2 inhibitor NSAID group (very low quality).Four studies, involving 240 participants, compared NSAIDs with the combination of paracetamol and an opioid. The applicability of findings from these studies is partly in question because the dextropropoxyphene combination analgesic agents used are no longer in general use. While the point estimates favoured NSAID, the very low-quality evidence did not show a difference between the two interventions in the numbers with little or no pain at day 1 (51 participants, 1 study), day 3 (149 participants, 2 studies), or day 7 (138 participants, 2 studies). Very low-quality evidence showed a similar lack of difference between the two groups applied to swelling at day 3 (reported in two studies) and at day 7 (reported in two studies), in return to function at day 7 (89 participants, 1 study), and in gastrointestinal adverse events (141 participants, 3 studies).No studies compared NSAIDs with complementary and alternative medicines, and no study reported re-injury rates. Authors' conclusions There is generally low- or very low-quality but consistent evidence of no clinically important difference in analgesic efficacy between NSAIDs and other oral analgesics. There is low-quality evidence of more gastrointestinal adverse effects with non-selective NSAID compared with paracetamol. There is low- or very low-quality evidence of better function and fewer adverse events with NSAIDs compared with opioid-containing analgesics; however, one study dominated this evidence using a now unavailable COX-2 selective NSAID and is of uncertain applicability. Further research is required to determine whether there is any difference in return to function or adverse effects between both non-selective and COX-2 selective NSAIDs versus paracetamol.

Oral non‐steroidal anti‐inflammatory drugs versus other oral analgesic agents for acute soft tissue injury

Objective: The health care setting has been reported to be one main source of weight stigma repeatedly; however, studies comparing different professions have been lacking Methods: 682 health care professionals (HCP) of a large German university hospital were asked to fill out a questionnaire on stigmatizing attitudes, perceived causes of obesity, and work-related impact of obesity Stigmatizing attitudes were assessed on the Fat Phobia Scale (FPS) based on a vignette describing a female obese patient Results: Only 25% graded current health care of obese patients to be ‘good' or ‘very good' 63% of all HCPs ‘somewhat' or ‘strongly' agreed that it was often difficult to get the resources needed in order to care for obese patients The mean FPS score was comparable to that in the general public (M = 359), while nursing staff showed slightly more positive attitudes compared to physicians and therapists Higher age, higher BMI, and ascribing personal responsibility for obesity to the individual were associated with a higher level of stigmatizing attitudes The nursing staff agreed on obesity as an illness to a greater extent while physicians attributed obesity to the individual Conclusions: In summary, by making complex models on the causes of obesity known among health care professionals, stigmatizing attitudes might be reduced Ongoing further education for health care professionals ought to be part of anti-stigma campaigns in the medical field

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Attitudes of health care professionals towards female obese patients.

intRoduction Neither dramatic footage nor horrifying statistics from the most recent Ebola virus (EBOV) outbreak come close to reflecting the true impact of the EBOV disease (EVD) on affected countries, communities, patients, health-care workers, or their friends and families.[1,2] With focus squarely on containing the outbreak and dealing with the immensity of the task at hand, many fail to notice the associated emotional and psychological toll.[3,4] Posttraumatic stress disorder (PTSD) is defined by Diagnostic and Statistical Manual of Mental Disorders, 5th edition as a specified constellation of emotional and behavioral responses to traumatic events.[5] The affected person frequently reports an exposure to death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence. Within this context, one or more of the following are required to meet the diagnosis of PTSD: (a) direct exposure to trauma; (b) witnessing the traumatic act or event in person; (c) indirect involvement, by learning that a close relative or close friend was exposed to trauma; (d) if the event involved actual or threatened death, it must have been violent or accidental; and (e) repeated or extreme indirect exposure to aversive details of the event(s) has occurred, usually in the course of professional duties (e.g., first responders, collecting body parts, social workers repeatedly exposed to details of child abuse).[5] This does not include indirect nonprofessional exposure to above-mentioned events through electronic media, television, movies, or pictures. In this Editorial, we will discuss the very real and well-documented phenomenon of PTSD among EVD survivors, caretakers, and their immediate contacts.

Reflections on the Ebola Public Health Emergency of International Concern, Part 2: The Unseen Epidemic of Posttraumatic Stress among Health-care Personnel and Survivors of the 2014-2016 Ebola Outbreak.

Background Working as a paramedic carries the risk of witnessing events and personal experiences associated with emergency life-threatening circumstances that may result in symptoms associated with posttraumatic stress. This problem is well known but still underestimated. Objectives The specific study objectives were to 1) assess the influence of sociodemographic and occupational factors on posttraumatic stress disorder (PTSD) among paramedics, and 2) suggest preventive strategies in this population. Methods This prospective, descriptive study examined a sample of 100 paramedics who agreed to complete the Author Questionnaire comprising demographic questions and the Impact of Event Scale – Revised. Results The total prevalence of PTSD in the examined group was 40.0% (women = 64.3%, men = 36.1%). It was more frequently reported in paramedics working under an employer's contract than among those who were self-employed. It occurred less frequently in persons with more education. Other sociodemographic factors studied showed no significant impact. A statistically significant effect of exposure to certain types of traumatic events on the incidence of PTSD was found. There was no significant correlation between the prevalence of PTSD and the occurrence of problem situations in respondents' workplaces. Conclusions Polish paramedics who agreed to take part in the survey were shown to have a high rate of PTSD. Multi-center screening and early supportive management is recommended.

Risk Factors for Posttraumatic Stress Disorder in Polish Paramedics: A Pilot Study

Burnout and PTSD are closely linked and often underreported in EMS. EMS classrooms do little or nothing to prepare providers for the inherent emotional stresses of emergency response and the "thick skin" culture of EMS may make many providers apprehensive about sharing their true feelings. Burnout is triggered by many of the same stresses that lead to the symptoms of PTSD and providers experiencing burnout that doesn't resolve within a few weeks may actually be experiencing PTSD. Be mindful of yourself and your fellow coworkers, particularly after a very traumatic response. And remember traumatic responses don't need to be as dramatic as Sept. 11, New Orleans after Hurricane Katrina or the Aurora, CO shootings to bother an EMS worker. In contrast, these are the calls where providers often receive the most attention. Instead, watch for the new father who just performed CPR on an infant the same age as his own, or the provider who just watched his or her friend die following a motor vehicle collision. Pay attention to yourself and colleagues, and be responsible and honest with yourself and others about when coping strategies are enough, and when they aren't. Finally, don't ever be afraid to seek help.

Are you under stress in EMS. Understanding the slippery slope of burnout and PTSD.

Managing the airway does not mean intubation, it means managing the airway. Allowing a patient to breathe on their own with appropriate positioning, bag-valve ventilation and blind insertion devices are all airway management options. The surgical cricothyrotomy is a rare and life-saving procedure when managing patients who are in a "can't intubate, can't ventilate" situation. These patients will die without aggressive and rapid intervention. While not all surgical cricothyrotomies provide a definitive airway, the needle cricothyrotomy is an ineffective means for ventilation and its use is discouraged. Understand the techniques used in your program and that are within your scope of practice as an EMS provider. Provide your patient the best opportunity for survival by knowing your program's surgical airway procedure thoroughly, and practice it regularly.

Snyder

Papers

Are you under stress in EMS. Understanding the slippery slope of burnout and PTSD.

Surgical cricothyrotomies in prehospital care. Surgical airway placement is indicated when you cannot intubate or ventilate.

Troubled mind: the lowdown on increased ICP.

Acute altered mental status in elderly patients: what can cause geriatric AMS and delirium?

Recognizing and defusing aggressive patients.