BACKGROUND:Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and health care costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. METHODS:A preliminary literature search informed a need for updated guidelines. Methodologists experienced in TBI guidelines supported 2 co-chairs, a diverse steering committee and three expert working groups. Over half of our panelists were active service military or military veterans and they addressed twenty-six Key Questions (KQs). We searched Ovid MEDLINE®, EMBASE, and Cochrane CENTRAL from inception to August 31, 2022, reference lists, and clinical trial registries. Penetrating, perforating and tangential penetrating brain injuries were included. Predefined criteria were used to identify studies; pre-specified methods were used to assess study quality and strength of evidence for key outcomes. Effects were analyzed qualitatively and quantitatively where appropriate. RESULTS:125 studies provided evidence and another 80 studies provided contextual data for these guidelines. In general there was a paucity of literature and most of the identified evidence was judged to be high risk of bias due to study design. We did not identify any studies meeting inclusion criteria for 12 KQs. The highest quality evidence, rated moderate in strength, was identified for four KQs that covered: cerebral angiography vs computed tomography angiography, the relationship between bihemispheric injury in adult pTBI and mortality, the ability of the Surviving Penetrating Injury to the Brain (SPIN) score to predict mortality, and the relationship between infection and cerebrospinal fluid fistula. Evidence for most KQs came from case series. CONCLUSIONS:The development of up-to-date evidence and consensus based clinical care guidelines and algorithms for pTBI provide guidance to care providers in the prehospital and emergency medicine, surgical and intensive care settings. Few moderately strong conclusions on the benefit of specific management strategies for penetrating brain injury could be made. Detailed reporting of patient outcomes in future studies could advance the field by providing greater evidence for specific treatments by patient population, mechanism of injury, severity of injury, and specific interventions employed.
OBJECTIVE:This consensus statement provides evidence-based visual guidance in graphic algorithms and a summary of evidence and considerations to assist health care professionals with the diagnosis and management of adults with prediabetes and diabetes mellitus in shared decision making to improve care. METHODS:The American Association of Clinical Endocrinology (AACE) selected a task force of medical experts to update the 2023 AACE Comprehensive Type 2 Diabetes Management Algorithm and align this algorithm update with related AACE clinical guidance. RESULTS:This algorithm for management of adults with type 2 diabetes (T2D) includes 11 sections: (1) Principles for the Management of Adults With T2D; (2) Prediabetes Algorithm (3) Diabetes Classification Algorithm (new); (4) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Dyslipidemia; (5) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Hypertension; (6) Comorbidities- and Complications-Centric Glycemic Control Algorithm; (7) Glucose-Centric Glycemic Control Algorithm; (8) Initiating and Titrating Insulin Algorithm; (9) Profiles of Pharmacotherapy for T2D; (10) Profiles of Pharmacotherapy for Obesity; and (11) Vaccine Recommendations for Adults With T2D. CONCLUSIONS:This 2026 update emphasizes lifestyle modification and treatment of overweight/obesity as key pillars in the management of prediabetes and T2D. It also provides guidance on the management of atherosclerotic risk factors of dyslipidemia and hypertension. A new algorithm was added to ensure that other causes and classes of diabetes are considered beyond T2D. There continues to be an emphasis on a complications- and comorbidities-centric approach, beyond glucose levels, to frame decisions regarding first-line and subsequent pharmacological choices for treating adults with T2D.
Purpose The Limb Injury Measurement Battery for Quality of Life (LIMB-QOL) was developed to comprehensively assess patient reported outcomes (PRO) for research and clinical use with individuals who have sustained major extremity trauma and limb loss.Methods A mixed-methods approach was used that included qualitative focus groups with civilians, service members, and clinicians as well as quantitative PRO data collection with individuals with a history of major traumatic limb injury or limb-loss due to such trauma or sudden-onset illness. Individuals with dysvascular and other chronic disease causes were excluded. Qualitative data were collected via focus groups (n = 56 individuals with major extremity trauma; n = 34 clinicians) and cognitive debriefing interviews (n = 41 individuals with major extremity trauma). Quantitative data were obtained through structured phone interviews with a large sample representing the target limb trauma and limb loss population (n = 603). Newly developed item banks were calibrated using graded response model item response theory analysis.Results LIMB-QOL includes 25 measurement scales including 10 new, targeted item banks developed with and for individuals with major limb trauma and 15 existing PRO item banks measuring salient physical, emotional, and social aspects of health-related QOL. Computer adaptive tests and short forms were programmed into the Assessment Center application programming interface and are now available through REDCap and other platforms.Conclusion LIMB-QOL provides a comprehensive and standardized system of PRO assessments for individuals with amputation or limb preservation due to sudden-onset limb injury. Research and clinical applications are discussed.
Combined examination of mental workload and biomechanics during dual-task walking in individuals with lower-limb loss is limited to fixed, but not self-modulated walking pace, for which the latter enables dynamic cognitive-motor behavior as typically engaged during community ambulation. By assessing electroencephalography (EEG) (theta, low/high-alpha power) and biomechanics (gait speed, double limb support, stride width), the cerebral cortical activity underlying mental workload and walking mechanics were examined when individuals with and without lower-limb loss executed a cognitive task (assessed via response time and accuracy) under variable demand (seated and walking). Both populations maintained walking mechanics (unchanged gait speed, double limb support, stride width) during dual-task walking across demand and exhibited similarly elevated neurocognitive engagement (e.g., attention, action monitoring) indicated by similar theta power increase and low/high-alpha power decrease when facing greater demand. However, injured individuals exhibited relative performance decrement (degraded response time/accuracy), which suggests attenuated cognitive-motor efficiency relative to uninjured (i.e., similar cortical activity across groups with degraded performance). Moreover, while uninjured individuals during dual-task walking could robustly engage neurocognitive processes to maintain walking mechanics and successfully attend to the concurrent cognitive task, those with lower-limb loss did not exhibit such a robust recruitment (i.e., unchanged frontal/temporal high-alpha power). Such alterations in individuals with lower-limb loss leads to maintenance of walking at the cost of a concurrent task. The present work informs rehabilitation practice and reveals specific cognitive-motor outcomes for individuals with lower-limb loss in an enhanced ecological context.
Sharing research code in an open access version-controlled repository offers significant benefits for both science as a whole and for individual researchers. In this article, we focus on this practice, which is fully aligned with the NIH's Gold Standard Science (GSS) program as well as FAIR (findable, accessible, interoperable, reusable) and TRUST (transparency, responsibility, user focus, sustainability, technology) principles. Gold Standard Science supports open science by emphasizing transparency, reproducibility, and the use of best practices that enable others to verify and extend research. Pairing a research article's cited data snapshot with a versioned, environment-specific code release, deposited in a companion code repository, ensures that, upon submission to a medical journal, readers and reviewers can directly verify results. An executable and updatable companion code repository complements, rather than replaces, established research data repositories. When code underlying medical research results is made openly available, then other scientists can inspect, run, and validate analyses. These activities enhance reproducibility, which is a core aim of GSS. Shared code also facilitates collaborative innovation by allowing researchers to extend the utility of the code to new datasets and applications. For researchers, code sharing can increase visibility, credibility, and citation impact. Demonstrating transparency through shared executable and updatable code builds trust with journal readers, peer reviewers, funders, and peers. Shared code in an open access repository signals adherence to high standards of scientific integrity and attracts opportunities for collaboration. A researcher who shares code receives recognition as a leader in reproducible, trustworthy research consistent with NIH's GSS principles.
