BACKGROUND: The percentage of elderly trauma patients under anticoagulation and antiplatelet agents has been rising lately. As newer agents are introduced, each comes with its own advantages and precautions. Our study covered elderly patients admitted to the ED with maxillofacial trauma while on anticoagulation (AC) or antiplatelet therapy (APT). We aimed to investigate the demographic characteristics, causes, and types of maxillofacial trauma, along with concomitant injuries, duration of hospitalisation, haemorrhagic complications, and the overall costs of care in the emergency department (ED).
METHODS: Data were gathered from the ED of Bern University Hospital. In this retrospective analysis, patients over 65 of age were included, who presented at our ED with maxillofacial trauma between 2013 and 2019 while undergoing treatment with therapeutic AC/APT.
RESULTS: The study involved 188 patients with a median age of 81 years (IQR: 81 [74; 87]), of whom 55.3% (n=104) were male. More than half (54.8%, n=103) were aged 80 years or older. Cardiovascular diseases were present in 69.7% (n=131) of the patients, with the most common indications for AC/APT use being previous thromboembolic events (41.5%, n=78) and atrial fibrillation (25.5%, n=48). The predominant cause of facial injury was falls, accounting for 83.5% (n=157) of cases, followed by bicycle accidents (6.9%, n=13) and road-traffic accidents (5.3%, n=10). The most common primary injuries were fractures of the orbital floor and/or medial/lateral wall (60.1%, n=113), zygomatic bone (30.3%, n=57), followed by isolated orbital floor fractures (23.4%, n=44) and nasal bone fractures (19.1%, n=36). Fractures of the mandible occurred in 14.9% (n=28). Facial hematomas occurred in 68.6% of patients (129 cases), primarily in the midface area. Relevant facial bleeding complications were intracerebral haemorrhage being the most frequent (28.2%, n=53), followed by epistaxis (12.2%, n=23) and retrobulbar/intraorbital hematoma (9%, n=17). Sixteen patients (8.5%) experienced heavy bleeding that required emergency treatment. The in-hospital mortality rate was 2.1% (4 cases).
CONCLUSIONS: This study indicates that falls are the leading cause of maxillofacial trauma in the elderly, with the most common diagnoses being orbital, zygomatic, and nasal fractures. Haemorrhagic complications primarily involve facial hematomas, especially in the middle third of the face, with intracerebral haemorrhage being the second most frequent. Surgical intervention for bleeding was required in 8.5% of cases. Given the aging population, it is essential to improve prevention strategies and update safety protocols, particularly for patients on anticoagulant/antiplatelet therapy (AC/APT). This can ensure rapid diagnostic imaging and prompt treatment in emergencies.

BACKGROUND: Computed tomography (CT) of the torso has become increasingly common for assessment of fall patients in the emergency department. Some data suggest that older adults (≥65) may benefit from torso imaging more than younger patients. We sought to evaluate the usage and utility of CT imaging for elderly patients presenting after ground-level falls (GLFs) from 1 meter or less at our level 1 trauma center.
METHODS: Patients ≥18 presenting with GLF in 2015-2019 were included. Data were obtained through chart and trauma registry review. Descriptive statistics were used to summarize the use of CT imaging for patients younger than versus older than 65 y old. Three multivariate logistic regression models with age as a continuous, binary (<65 versus ≥65), or categorical (in multiples of 5) variable were used to investigate whether age is associated with an increased identification of traumatic injury not previously suspected or known based on physical exam (PE) or plain radiograph after GLF.
RESULTS: A total of 522 patients <65 and 673 patients ≥65 y old were included. Older patients were significantly more likely to receive screening chest radiograph, screening pelvic radiograph, brain CT, and neck CT (all P < 0.001), but not torso (chest, abdomen, and pelvis) CT (P = 0.144). On multivariate logistic regression, age was not significantly associated with an increased odds of identification of traumatic injury after torso CT (continuous: adjusted odds ratio [aOR] = 1.01, 95% confidence interval [CI] = 0.99-1.03, P = 0.379; binary: aOR = 0.86, 95% CI = 0.46-1.58, P = 0.619; categorical: aOR = 1.03, 95% CI = 0.94-1.14, P = 0.453). A positive PE was the only variable associated with significantly increased odds of having an abnormal torso CT scan in all models. Only two patients ≥65 y old had injuries identified on torso CT in the context of a negative PE and negative screening imaging.
CONCLUSIONS: The rate of torso injury identification in patients sustaining GLF is not associated with age, but is strongly associated with positive PE findings. In the subset of elderly GLF patients without positive torso PE findings, more conservative use of CT imaging could decrease health-care utilization costs without compromising patient care.

Background and objective Facial fractures represent a growing concern among an aging population prone to falls. In light of this, this study aimed to investigate differential facial fracture patterns and outcomes based on age effects. Determining the differences between the severity and type of facial fractures in populations of different ages will help guide clinical decision-making when managing patients with facial fractures. Methods This was a single-center study involving trauma registry data, from July 1, 2016, to January 31, 2022. The inclusion criteria were based on the International Classification of Diseases (ICD-10) diagnosis of facial fracture. A linear regression was performed to ascertain the effects of predictor variables on the likelihood that a facial fracture trauma patient would experience various age effects on injury location, mortality, and morbidity. Results A total of 1575 patients were included in the analysis. A significant regression equation was found (F(47,1476)=42.46, p<0.01), with an R2 of 0.57. Older facial fracture trauma patients were more likely to be female (β=3.13, p<0.01) with fractures to their zygoma (β=2.57, p=0.02). Higher Abbreviated Injury Scale (AIS) facial region scores (β=2.21, p=0.03), longer hospital length of stay (β=0.07, p=0.02), and in-hospital mortality (β=10.47, p<0.01) were also associated with older age. Older age was additionally associated with a higher level of several morbidity markers. Younger facial fracture trauma patients were more likely to be African American (β=-5.46, p<0.01) or other, non-Caucasian race (β=-8.66, p<0.01) and to have mandible fracture patterns (β=-3.63, p<0.01). The younger patients were more likely to be fully activated (β=-3.10, p<0.01) with a higher shock index ratio (SIR) (β=-7.36, p<0.01). Injury mechanisms in younger facial fracture patients were more likely to be assault (β=-12.43, p<0.01), four-wheeler/ATV accident (β=-24.80, p<0.01), gunshot (β=-15.18, p<0.01), moped accident (β=-13.50, p<0.01), motorcycle accident (β=-12.31, p<0.01), motor vehicle accident (β=-16.52, p<.01), or pedestrian being struck by a motor vehicle (β=-10.69, p=0.02). Conclusions Based on our findings, age effects impact facial fracture patterns and outcomes. Younger patients are more likely to experience multisystem injuries via non-fall trauma. On the other hand, older patients are more likely to experience more severe primary facial injuries. Older patients are also at a higher risk of fall-related trauma. Disparities also exist between genders and races, with male and non-Caucasian patients being at a higher risk of injury from facial fractures at a younger age. With an aging population, the prevalence of falls is likely to increase. Thus, facial fractures represent a growing healthcare burden and warrant future investments related to care and treatment.

Background Falls among the adult population are a major global health concern with severe repercussions for individuals and healthcare systems. The purpose of this study was to investigate the prevalence and associated risk factors of falls in hospitalized patients in order to improve hospital care for elderly adults. Materials and methods The research was conducted at two institutions of tertiary care in Abbottabad, Pakistan. After extensive screening and obtaining informed consent, a total of 210 participants aged 50 and older were enrolled in the study. Mental status, history of falls, ambulation/elimination status, vision, gait/balance, systolic blood pressure, medication use, and predisposing diseases were evaluated using the Long Term Care Fall Risk Assessment Form. Additionally, the Dynamic Gait Index was utilized to evaluate various aspects of gait. Results 58.6% of participants reported a history of falls in the previous year, according to the findings. BMI, imbalance, vertigo, and fear of falling were significantly associated with an increased risk of falls in older individuals. The Long-Term Care Fall Risk Assessment, the Montreal Cognitive Assessment (MoCA), the Dynamic Gait Index (DGI), and the Mini-BESTest scores revealed that patients with a history of falls had inferior functional and cognitive outcomes. Falls were more common among individuals with a robust BMI, especially men. Conclusions The study results highlight the multifactorial nature of falls in the adult population and the need for targeted interventions to address modifiable risk factors. To enhance hospital care for high-risk patients, proactive fall prevention strategies, including regular risk assessments and individualized interventions, should be implemented. This study provides important insights into the prevalence and causes of accidents among hospitalized patients, particularly in developing nations such as Pakistan. ​​​​​​.

Enterococcus faecium is a Gram-positive flora bacterium home to the gastrointestinal tracts of humans. A true ubiquitous pathogen and a member of the intestinal microbiome, formerly known as group D streptococci, this pathogen has been around for over 10 centuries. Enterococcus faecium thrives in the presence of stool and sewage. The ability to cause endocarditis and urinary tract infections (UTIs) has led to morbidity and mortality in the adult population. We report a case of an elderly woman who presented with multiple falls to our trauma bay area. She was initially managed as trauma during multiple visits with superficial scalp lacerations. However, with multiple falls, she was subsequently transferred to medicine to rule out cardiogenic versus neurogenic syncope. She was admitted to the telemetry unit, and a cardiologist was consulted. Orthostatic vitals were negative, and she had no fever or leukocytosis. Abdominal computed tomography (CT) done as part of the standard trauma workup revealed an interesting finding of multiple bladder diverticula.

The risk factors and related negative outcomes associated with falls in the elderly population have been widely researched. Falls in the elderly population can lead to decreased independence and an increased risk of morbidity and mortality. Concomitant factors that can increase the risks of falls in the elderly include polypharmacy, vision impairment, syncope, hyporeflexia, and drug use. Presented is the case of a 79-year-old African American female who arrived at the emergency department after experiencing a syncopal episode at her home. The episode resulted in a non-fatal injurious fall. This case report examines the relationship between chronic drug use in an elderly patient and its predilection for syncopal episodes, which led to a non-fatal injurious fall.

Background Many older adults presenting to the emergency department (ED) after a fall are discharged without adequate assessment of their fall risk. A nurse-initiated protocol was introduced for the early screening of older adults with injurious falls. We aimed to promote osteoporosis education and right-site them to appropriate outpatient resources in the community. Methodology In this study, we included ≥65-year-old adults who attended the ED with injurious falls or near falls between December 2019 and December 2020. An ED nurse trained in basic geriatric care performed the cognitive assessment and provided advice on diet, footwear, fall safety, calcium/vitamin D supplementation, and osteoporosis screening. Results A total of 70 (75.7% female) patients aged 65-93 years were included. In total, 34 (48.6%) were started on calcium/vitamin D supplements and 22 (31.4%) went on to receive outpatient bone mineral density scans. Only three patients reattended the ED for recurrent falls/fractures in the six-month follow-up period. Conclusions A nurse-initiated fall and osteoporosis screening protocol is a feasible model of care for targeted screening and education of older adults who present to the ED with injurious falls.

Reinforcement learning (RL) has been used to study human locomotion learning. One of the current challenges in healthcare is our understanding of and ability to slow the decline due to muscle ageing and its effect on human falls. The purpose of this study was to investigate reinforcement learning for human movement strategies when modifying muscle parameters to account for age-related changes. In particular, human falls with modified physiological factors were modelled and simulated to determine the effect of muscle descriptors for ageing on kinematic behaviour and muscle force control. A 3D musculoskeletal model (8 DoF and 22 muscles) of the human body was used. The deep deterministic policy gradient (DDPG) method was implemented. Different muscle descriptors for ageing were integrated, including changes in maximum isometric force, contraction velocity, the deactivation time constant and passive muscle strain. Additionally, the effects of isometric force reductions of 10, 20 and 30% were also considered independently. An environment for the simulation was developed using the opensim-rl package for Python with the training process completed on Google Compute Engine. The simulation outcomes for healthy young adult and elderly falls under modified muscle behaviours were compared to experimental observations for validation. The result of our elderly simulation for multiple ageing-related factors (M_all) produced a walking speed of 0.26 m/s for the two steps taken prior to the fall. The over activation of the hip extensors and inactivation of knee extensors led to a backward fall for this elderly simulation. The inactivated rectus femoris and right tibialis are main actors of the forward fall. Our simulation outcomes are consistent with experimental observations through the comparison of kinematic features and motion history evolution. We showed in the present study, for the first time, that RL can be used as a strategy to explore the effect of ageing muscle physiological factors on kinematics and muscle control during falls. Our findings show that the elderly fall model for the M_all condition more closely resembles experimental elderly fall data than our simulations which considered age-related reductions of force alone. As future perspectives, the behaviour preceding a fall will be studied to establish the strategies used to avoid falls or fall with minimal consequence, leading to the identification of patient-specific rehabilitation programmes for elderly people.

Introduction Falls are the leading cause of injury-related death among older adults according to the Centers for Disease Control and Prevention (CDC). The Falls Efficacy Scale (FES) and Vulnerable Elder Survey (VES-13) are validated screening tools used to assess concern of falling, health deterioration and functional decline. We set out to determine if the FES or VES-13 could serve as a predictor of falls among older adults in the Emergency Department (ED) setting. Methods This prospective pilot cohort study was conducted at a Level 1 Trauma Center. ED patients aged ≥65 were eligible for the study if they had a mechanical fall risk defined by CDC criteria. After consent and enrollment, FES and the VES surveys were completed. Participants were followed by phone quarterly, and results of the one-year follow-up self-report of fall history described.  Results There were 200 subjects enrolled and after excluding those that were withdrawn, deceased, or lost to follow-up, 184 were available for analysis of their follow-up visit at 12 months. A greater proportion of the participants were women (108 (58.7%) vs 76 (41.3%); P=0.88). The average age of the study participants was 74.2±7.3 years. There was no significant difference in age between men and women (median: 73 vs 73; p=0.47).  At the follow-up visit, 33 (17.9%) had a reported fall. The mean age did not significantly differ when comparing those with versus without a fall (75.6 vs 73.9; p=0.24). There was no significant difference in the proportion with a VES-13 ≥ 3 when comparing those with and without a reported fall (45.5% vs 37.8%; p = 0.41). The median FES score did not differ among those with as compared to without a fall (11 vs 10; p=0.12). Conclusions Subjects who had a VES-13 score of ≥3 were statistically no more likely to have fallen than those with a score of <3. Additionally, the FES score did not statistically differ when comparing those who had fallen to those who had not. Further research into alternative screening methods in the ED setting for fall risk is recommended.

BACKGROUND: Falls are among the leading cause of emergency department (ED) visits.
OBJECTIVE: We set out to determine whether using a bedside decision aid could decrease falls.
METHODS: This randomized controlled trial was conducted on those aged ≥ 65 years who were being discharged home and screened positive for a Centers for Disease Control and Prevention (CDC) fall risk factor. Control-arm subjects were given a CDC brochure about falls. The active-arm subjects received a personalized decision aid intervention. Both groups were followed up via telephone.
RESULTS: A total of 200 subjects were enrolled and, after exclusions, 184 patients were analyzed. There were 76 male (41.3%) and 108 female (58.7%) subjects; 14% of the subjects chose to have their medications reviewed, 13.6% chose to have an eye examination, 22.8% chose to begin an exercise program, and the majority (44.6%) chose to have a home safety evaluation. Patients in the intervention arm chose more interventions to complete compared to control-arm subjects (p < 0.0001), but did not complete more interventions (p = 0.3387) and did not experience fewer falls compared to the control arm (p = 0.5675). At study conclusion, 73 subjects reported at least one fall during the study.
CONCLUSIONS: Overall, in this study, subjects who had their fall-risk interventions facilitated by a decision tool chose to participate in interventions more than control subjects. However, they did not complete the interventions or fall less often than their counterparts in the control arm. Future study is needed to determine the effect of CDC screening guidelines and interventions facilitated by a decision aid on fall outcomes and their application in the ED population.