Afr Health Sci. 2011 Sep; 11(3): 486-92
Azodo C, Ezeja E, Ehikhamenor E

To determine the prevalence of workplace violence in Oral healthcare centres against Nigerian dental professionals.A questionnaire-based cross-sectional survey of 175 randomly selected dental professionals working in Oral healthcare centres of University Teaching Hospitals in Southern Nigeria was conducted.The survey response rate was 78.9%. The respondents were dentists (58.0%), dental nurses (18.1%), dental technologists (12.3%), dental therapists (8.0%) and dental record officers (3.6%). The prevalence of violence in Nigerian Oral healthcare centres was 31.9%. There was no statistically significant difference in the prevalence of violence against dentist and dental auxiliaries. Violence was often associated with long waiting time (27.3%), cancellation of appointment (13.6%), outcome of patient's treatment (11.4%), alcohol intoxication (9.1%), psychiatric patient (6.8%,) patient's bill (4.5%) and others (27.3%). Non-physical violence in form of loud shouting (50.0%) threat (22.7%), sexual harassment (6.8%) and swearing (2.3%) constituted the majority while physical violence in form of bullying and hitting constituted the remaining 18.2%. The main perpetrators of the violence were patients (54.5%) and patient's relatives/friends (18.2%). The expressed impact of violence among the respondents include fear (18.2%), impaired job performance (15.9%), psychological problems (13.6%) and off duty (9.1%). No impact was declared by 43.2% of respondents.The prevalence of workplace violence in Oral healthcare centres against dental professionals in Southern Nigeria was significant and had a substantial effect on dental professionals' well-being thus necessitating urgent attention.

J Med Assoc Thai. 2011 Nov; 94(11): 1365-72
Wipassakornwarawut S, Suwonmontri P, Thokaow S

Traumatic brain injury is one of the major problems and leading cause of death worldwide. The present study was aimed to identify factors responsible for mortality by comparing survivors and nonsurvivors in patients that had a low probability of mortality.A nested case-control study was conducted at Sawanpracharak Hospital from January 1, 2007 to December 31, 2007. All head injury deaths that had TRISS-PS greater than 0.5 were enrolled as the "case" patients. Head injured patients with TRISS-PS greater than 0.5 and that survived were chosen as the "control" patients. The number of controls per case was 2:1. Patients with ages < 15 were excluded from the present study.Six factors associated with increased mortality are age > or = 45 years (OR = 1.61, 95% CI = 1.1-2.3), alcohol intoxication (OR = 3.11, 95% CI = 1.4-6.9), admission GCS 3-8 (OR = 4.16, 95% CI = 2.4-7.2), arrival GCS-M < or = 4 (OR = 1.46, 95% CI = 1.0-2.0), Head-AIS > or = 4 (OR = 3.31, 95% CI = 1.3-8.3), and admission SBP < 90 mmHg (OR = 13.36, 95% CI = 3.2-56.3).Head injury continues to be a substantial public health problem. Deaths that met criteria for low probability of mortality, especially in those without associated risk factors should be analyzed for errors that may be preventable.

Alcohol Clin Exp Res. 2012 Feb 6;
Plebani JG, Ray LA, Morean ME, Corbin WR, Mackillop J, Amlung M, King AC

BACKGROUND: Human laboratory studies have a long and rich history in the field of alcoholism. Human laboratory studies have allowed for advances in alcohol research in a variety of ways, including elucidating neurobehavioral mechanisms of risk, identifying phenotypically distinct subtypes of alcohol users, investigating the candidate genes underlying experimental phenotypes for alcoholism, and testing mechanisms of action of alcoholism pharmacotherapies on clinically relevant translational phenotypes, such as persons exhibiting positive-like alcohol effects or alcohol craving. Importantly, the field of human laboratory studies in addiction has progressed rapidly over the past decade and has built upon earlier findings of alcohol's neuropharmacological effects to advancing translational research on alcoholism etiology and treatment. METHODS AND RESULTS: To that end, the new generation of human laboratory studies has focused on applying new methodologies, further refining alcoholism phenotypes, and translating these findings to studies of alcoholism genetics, medication development, and pharmacogenetics. The combination of experimental laboratory approaches with the recent developments in neuroscience and pharmacology has been particularly fruitful in furthering our understanding of the impact of individual differences in alcoholism risk and in treatment response. CONCLUSIONS: This review of the literature focuses on human laboratory studies of subjective intoxication, alcohol craving, anxiety, and behavioral economics. Each section discusses opportunities for phenotype refinement under laboratory conditions, as well as its application to translational science of alcoholism. A summary and recommendations for future research are also provided.

Br J Nutr. 2012 Jan 31; 1-8
Rejitha S, Prathibha P, Indira M

Sida cordifolia Linn. (Malvaceae) is a plant used in folk medicine for the treatment of the inflammation of oral mucosa, asthmatic bronchitis, nasal congestion and rheumatism. We studied the hepatoprotective activity of 50 % ethanolic extract of S. cordifolia Linn. against alcohol intoxication. The duration of the experiment was 90 d. The substantially elevated levels of toxicity markers such as alanine aminotransferase, aspartate aminotransferase and γ-glutamyl transferase due to the alcohol treatment were significantly lowered in the extract-treated groups. The activity of antioxidant enzymes and glutathione content, which was lowered due to alcohol toxicity, was increased to a near-normal level in the co-administered group. Lipid peroxidation products, protein carbonyls, total collagen and hydroxyproline, which were increased in the alcohol-treated group, were reduced in the co-administered group. The mRNA levels of cytochrome P450 2E1, NF-κB, TNF-α and transforming growth factor-β1 were found to be increased in the alcohol-treated rats, and their expressions were found to be decreased in the co-administered group. These observations were reinforced by histopathological analysis. Thus, the present study clearly indicates that 50 % ethanolic extract of the roots of S. cordifolia Linn. has a potent hepatoprotective action against alcohol-induced toxicity, which was mediated by lowering oxidative stress and by down-regulating the transcription factors.

Eksp Klin Farmakol. 2011; 74(10): 43-5

The modeling of chronic alcohol intoxication for 30 days in rats leads to an increase in the level of free metabolites of nitrogen oxide and NO-synthase with simultaneous decrease in the levels of L-arginine, catalase, and superoxide dismutase. The subsequent 14-day treatment with neuropeptide cerebroprotectors cerebrocurin, cortexin, and cerebrolysin led to normalization of the parameters of nitrogen oxide system. The maximum therapeutic activity was shown by cerebrocurin, which can be recommended for inclusion as component of alcoholic encephalopathy treatment.

Rev Med Chir Soc Med Nat Iasi. 2011 Oct-Dec; 115(4): 1080-4
Puha G, Hurjui J, Lupuşoru CE, Sorodoc L

The depressing effects on the nervous central system (NCS) induced by benzodiazepines and ethanol are similar. The complications are rare in the benzodiazepine poisoning, but are a lot more frequent in association with other depressing drugs for the NCS (especially alcohol).We analyzed retrospectively patients with benzodiazepine poisoning admitted in the Internal Medicine Clinic - Toxicology during 2003 - 2009.The study attempted a complex evaluation of the consequences of acute and chronic alcoholism on the evolution of acute benzodiazepinepoisoning and the description of the clinic evolution and paraclinical particularities of the patients under investigation.343 patients with benzodiazepine poisoning were admitted, 150 were tested through measurement of alcohol level, leading to values between 1 - 415 mg/dl. Chronic alcoholism in personal pathological antecedents of the patients determined a relative risk of intoxication 1.46 times higher. The hospitalization period varied from 1 to 8 days for patients with chronic alcoholism and from 1 to 14 days for patients with acute alcoholism, a statistically important difference.During the period under investigation, from the total of patients admitted for acute benzodiazepine poisoning, 2 deaths were registered. Of the two deaths, one patient showed ethanol coingestion.

Nihon Arukoru Yakubutsu Igakkai Zasshi. 2011 Oct; 46(5): 436-45
Shibayama M, Cho T, Ino A

We investigated the drunken patients visiting the emergency department (ED) to determine their negative influence on emergency medical system in our community. One hundred seven (1.2%) of 8,812 referred patients, including children, was suspected of drinking by the medical stuffs in the ED on the basis of the interview, smell of alcohol on breath, pre-hospital information, and so on. Objective analysis of drinking, such as blood alcohol concentration measurement, was not performed. Both the mean age and the median of the patients were 45 years old. The number of male was 4 times higher than female. Three fourths visited ED during the period from the evening to early morning, when it tends to be confused in ED. Eighty percents were delivered by ambulance service. Over 90% visited ED within 12 hours after drinking. Half of them were classified as moderate or more severe alcohol intoxication level on visiting ED. The medical practice was significantly disturbed by some patients, who were restless, violent, or uncooperative with the medical stuffs. Seven patients attempted suicides during drinking before visiting ED. Two thirds of the patients were diagnosed as mild, and left ED after simple medical treatment. Only 6.5% were indicated to admission and the urgent operations were performed on three patients. The CAGE was obtained from 55 patients, and half of them were positive to two or more questions, indicating suffering from alcohol disorder. Half of the patients drank over 60g of alcohol in one day, and 61% drank in four or more days in one week. Result of the investigation of the drunken patients visiting ED reveals negative influence on emergency medical system.

J Anal Toxicol. 2012 Jan; 36(1): 69-73
Maskell PD, De Paoli G, Seetohul LN, Pounder DJ

Meptazinol (Meptid(®)) is an analgesic drug that is used to treat mild to moderate pain including postoperative pain, obstetrical pain, and the pain of renal colic. This case reports a death due to the combined effects of meptazinol and alcohol in a man with significant heart disease and alcoholic liver disease. A 57-year-old male was found unresponsive in his bed at home with empty blister packets of meptazinol around him. A general drug screen detected the presence of meptazinol, and caffeine and metabolites, in cardiac blood. Analysis, both quantitative (HPLC-DAD) and qualitative (HPLC-DAD, LC-MS), of meptazinol was carried out. Meptazinol was found at the following concentrations: 15.5 mg/L in unpreserved femoral blood; 18.6 mg/L in preserved (fluoride-oxalate) femoral blood; 52.1 mg/L in unpreserved cardiac blood; 16.8 mg/L in preserved vitreous; 61.7 mg/L in unpreserved urine; and 9.8 g/L in stomach contents. Ethanol, analyzed by headspace GC-FID, was present in preserved (fluoride-oxalate) femoral venous blood, urine, and vitreous at concentrations of 232 mg/100 mL, 297 mg/100 mL, and 192 mg/100 mL, respectively. Death was attributed to meptazinol and ethanol toxicity, with atherosclerotic coronary artery disease as a contributing factor.

Neurol Clin. 2012 Feb; 30(1): 277-84
Goforth HW, Fernandez F

Neurologic effects of acute drug intoxication are varied. This article discusses the acute neurologic effects of certain drugs as well as associated treatments and guidelines to management.

Conscious Cogn. 2012 Jan 26;
Jarosz AF, Colflesh GJ, Wiley J

That alcohol provides a benefit to creative processes has long been assumed by popular culture, but to date has not been tested. The current experiment tested the effects of moderate alcohol intoxication on a common creative problem solving task, the Remote Associates Test (RAT). Individuals were brought to a blood alcohol content of approximately .075, and, after reaching peak intoxication, completed a battery of RAT items. Intoxicated individuals solved more RAT items, in less time, and were more likely to perceive their solutions as the result of a sudden insight. Results are interpreted from an attentional control perspective.

Traffic Inj Prev. 2012 Jan; 13(1): 31-42
Dupont RL, Voas RB, Walsh JM, Shea C, Talpins SK, Neil MM

Objective: Triggered by the new federal commitment announced by the Office of National Drug Control Policy (ONCDP) to encourage states to enact drugged driving per se laws, this article reviews the reasons to establish such laws and the issues that may arise when trying to enforce them. Methods: A review of the state of drunk driving per se laws and their implications for drugged driving is presented, with a review of impaired driving enforcement procedures and drug testing technology. Results: Currently, enforcement of drugged driving laws is an adjunct to the enforcement of laws regarding alcohol impairment. Drivers are apprehended when showing signs of alcohol intoxication and only in the relatively few cases where the blood alcohol concentration of the arrested driver does not account for the observed behavior is the possibility of drug impairment pursued. In most states, the term impaired driving covers both alcohol and drug impairment; thus, driver conviction records may not distinguish between the two different sources of impairment. As a result, enforcement statistics do not reflect the prevalence of drugged driving. Conclusions: Based on the analysis presented, this article recommends a number of steps that can be taken to evaluate current drugged driving enforcement procedures and to move toward the enactment of drug per se laws.

J Forensic Sci. 2012 Jan 23;
Petersen TH, Williams T, Nuwayhid N, Harruff R

  Isopropanol (IPA) detected in deaths because of diabetic ketoacidosis (DKA) or alcoholic ketoacidosis (AKA) may cause concern for IPA poisoning. This study addressed this concern in a 15-year retrospective review of 260 deaths in which concentrations of acetone and IPA, as well as their ratios, were compared in DKA (175 cases), AKA (79 cases), and IPA intoxication (six cases). The results demonstrated the frequency of detecting IPA in ketoacidosis when there was no evidence of IPA ingestion. IPA was detectable in 77% of DKA cases with quantifiable concentrations averaging 15.1 ± 13.0 mg/dL; 52% of AKA cases with quantifiable concentrations averaging 18.5 ± 22.1 mg/dL; and in cases of IPA intoxication, averaging 326 ± 260 mg/dL. There was weak correlation of IPA production with postmortem interval in DKA only (r = -0.48). Although IPA concentrations were much higher with ingestion, potentially toxic concentrations were achievable in DKA without known ingestion.

Aust N Z J Public Health. 2012 Feb; 36(1): 55-60
Lyne M, Galloway A

Objective: To assess the implementation and effectiveness of strategies and actions to eliminate and/or reduce alcohol-related problems at large sports and entertainment events in New Zealand. Methods: We conducted site visits and monitoring observations at venues before, during and after a variety of large events between March 2009 and November 2010. Thirteen events were attended at nine different venues. Events included rugby, rugby league and cricket matches, motor racing, rowing, horse racing, an outdoor music festival, and food and wine festivals. Results: Most large events appeared to pass with few or no alcohol-related problems. The exceptions were one of the horse-race meetings, a rugby league match and one food and wine festival. Common contexts at events where alcohol-related problems were seen included: inadequate alcohol control and management by security staff; the ability to purchase four alcoholic drinks (rather than two) at a time; inexperienced bar staff untrained in responsible alcohol service; no or little promotion of low and non-alcoholic drinks; and a lack of monitoring and enforcement of the law on intoxication. Conclusions: An important approach to prevent and reduce alcohol-related problems at large spots and entertainment events is the use of specific alcohol-control strategies. The management of alcohol consumption is a major part of event management that must be planned with harm-minimisation strategies well in advance of the event itself. Implications: If strategies and actions are not properly implemented to manage the sale and supply of alcohol at large events, there is significant risk of alcohol-related problems and harm resulting from them.

Aust N Z J Public Health. 2012 Feb; 36(1): 33-40
Rowe S, Wiggers J, Kingsland M, Nicholas C, Wolfenden L

Objective: To describe, based on routinely recorded police data, the prevalence and characteristics of alcohol consumption among people involved in violence and disorder incidents in non-metropolitan New South Wales (NSW). Methods: A descriptive analysis was conducted of people involved in violence and disorder incidents over 24 months (2003-05) across 21 non-metropolitan police commands. The prevalence of alcohol involvement was reported as: the annual population rate of people involved in incidents who had consumed alcohol; the proportion of people involved in such incidents who had consumed alcohol; and the proportion of such people who were intoxicated. Variation in alcohol involvement was described by: geographic area; day of week; time of day; and location alcohol was last consumed. Results: Annually, one in 118 people in the population consumed alcohol prior to involvement in a violence incident, and one in 476 people did so prior to a disorder incident. At least 71% of such people were intoxicated. Late Saturday evening was the peak time for alcohol involvement. Prior drinking in private residences and licensed premises was associated with violence and disorder incidents (respectively). The prevalence of alcohol consumption rose with increased geographic remoteness. All characteristics displayed geographic variation. Conclusions: The high prevalence of alcohol consumption, particularly intoxication, in violence and disorder incidents represents a significant public health issue for non-metropolitan NSW. Implications: Geographic variability in the prevalence and characteristics of alcohol-related crime suggests a need for locally targeted, yet evidence-based, interventions to reduce such harm.

J Chromatogr B Analyt Technol Biomed Life Sci. 2012 Jan 23;
Liu L, Ma Y, Chen X, Xiong X, Shi S

Puerariae lobata flower (Willdenow) has a long history used to treat alcoholic intoxication in China, which contains a series of isoflavones as its chief pharmacologically active constituents. In this study, bovine serum albumin (BSA) functionalized iron oxide magnetic nanoparticles (Fe(3)O(4) MNPs) coupled with high performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) were used to screen and identify active compounds from ethanolic extract of P. lobata flower. Thirteen active isoflavones were screened and identified as glycitin (1), tectoridin (2), daidzin (3), 3'-methoxy daidzin (4), ononin (5), 3'-hydroxyl daidzein (6), tectorigenin (7), biochanin A (8), prunetin (9), genistein (10), 3'-methoxy daidzein (11), irisolidone (12) and 5,7-dihydroxy-3',4'-methylenedioxyisoflavone (13), while compounds 4, 6, 9, 11 and 13 were identified from this plant for the first time. Furthermore, the activity of each bound ligand was evaluated on-line. The results indicated that the binding affinities of compounds with BSA were highly dependent on chemical structures and the methoxylation and hydroxylation on B-ring could improve the activity. The effective method could be widely applied for rapid screening and identification of active compounds from complex mixtures.

J Psychopharmacol. 2012 Jan 24;
Fernie G, Christiansen P, Cole JC, Rose AK, Field M

Alcohol intoxication is known to influence attentional biases for alcohol-related cues and alcohol-seeking behaviour. It is unknown if heavier drinkers are more or less sensitive to these effects of alcohol, or whether the effects of alcohol on attentional bias are associated with subsequent alcohol-seeking behaviour. In the present study, 55 social drinkers were administered either 0.4 g/kg alcohol or placebo in a repeated measures, double-blind experimental design. Participants completed a visual probe task with eye movement monitoring (to measure attentional bias) and a bogus taste test (to measure alcohol-seeking) in both alcohol and placebo sessions. Heavy drinkers showed an attentional bias for alcohol cues that was unaffected by alcohol, whereas in moderate drinkers attentional bias was present after alcohol administration, but was absent after placebo. All participants voluntarily consumed more beer during the taste test after administration of alcohol compared with placebo. The effects of alcohol on attentional bias were unrelated to the effects of alcohol on beer consumption. Results are consistent with the development of tolerance, rather than sensitization, to the acute effects of alcohol on attentional biases in heavy drinkers. However, alcohol-induced increases in attentional bias were not related to the effects of alcohol on the motivation to drink.

Arkh Patol. 2011 Sep-Oct; 73(5): 27-30

The comparative histologic, morphometric and immunohistochemical investigation of a right ventricular myocardium from 3 groups of patients has been carried out. The first group has included 12 patients with an arrythmogenic right ventricular dysplasia (ARVD) confirmed by an endomyocardial biopsy. The second group has consisted of 7 healthy people died a violent death. The third group has included 7 patients with a chronic alcoholism died from an acute alcoholic intoxication. The patients with ARVD and a chronic alcoholism have had an evident adiposis, a moderate fibrosis, and muscle atrophy with only 65% of cardiac hystiocytes. The patients with a chronic alcoholism have had only dystonia of intramural arteries. The cardiac hystiocytes of patients with ARVD have infected by enteroviruses (100%), parvoviruses B19 (58%), adenoviruses (25%), and hepatitis virus C (16%). 83% of observations have had a mixed viral infections.

PLoS One. 2012; 7(1): e30448
Dada L, Gonzalez AR, Urich D, Soberanes S, Manghi TS, Chiarella SE, Chandel NS, Budinger GR, Mutlu GM

Alcohol intake increases the risk of acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) and is associated with poor outcomes in patients who develop these syndromes. No specific therapies are currently available to treat or decrease the risk of ARDS in patients with alcoholism. We have recently shown increased levels of lung adenosine inhibit alveolar fluid clearance, an important predictor of outcome in patients with ARDS. We hypothesized that alcohol might worsen lung injury by increasing lung adenosine levels, resulting in impaired active Na(+) transport in the lung.We treated wild-type mice with alcohol administered i.p. to achieve blood alcohol levels associated with moderate to severe intoxication and measured the rate of alveolar fluid clearance and Na,K-ATPase expression in peripheral lung tissue and assessed the effect of alcohol on survival during exposure to hyperoxia. We used primary rat alveolar type II cells to investigate the mechanisms by which alcohol regulates alveolar Na(+) transport.Exposure to alcohol reduced alveolar fluid clearance, downregulated Na,K-ATPase in the lung tissue and worsened hyperoxia-induced lung injury. Alcohol caused an increase in BAL fluid adenosine levels. A similar increase in lung adenosine levels was observed after exposure to hyperoxia. In primary rat alveolar type II cells alcohol and adenosine decreased the abundance of the Na,K-ATPase at the basolateral membrane via a mechanism that required activation of the AMPK.Alcohol decreases alveolar fluid clearance and impairs survival from acute lung injury. Alcohol induced increases in lung adenosine levels may be responsible for reduction in alveolar fluid clearance and associated worsening of lung injury.

Drug Alcohol Rev. 2012 Jan 20;
Santos S, Brugal MT, Barrio G, Castellano Y, Domingo-Salvany A, Espelt A, Bravo MJ, DE LA Fuente L,

Introduction and Aims. Although, in the laboratory, most acute adverse effects of cocaine are dose-dependent and alcohol potentiates some of these effects, there are few observational studies, and scarce awareness that the risk of acute cocaine intoxication (ACI) can increase as the amounts of cocaine and alcohol consumed increase. Our objectives were to assess if the risk of ACI increases with the level cocaine use, both in chronic and binge use; and also to determine whether it increases when a cocaine binge is combined with binge drinking or with regular excessive drinking. Design and Methods. Hypotheses were evaluated using logistic regression and case-crossover analyses in a sample of 720 young regular cocaine users who did not regularly use heroin, recruited at drug scenes in 2004-2006. All data on ACI, predictor and confounding variables were obtained through a computer-assisted personal interview. Results. The annual prevalence of ACI was 21%. In the last year 10.3% of the participants reported cocaine binges (≥0.5 g in 4 h). ACI risk increased considerably in the 4 h following a cocaine binge (odds ratio = 34.6; 95% confidence interval 11.5-170.8). Also, it increased with increases in the average level of cocaine used over a long period and when users regularly drank excessively. Finally, the results suggest that the high risk of ACI associated with cocaine binge may increase even more when combined with binge drinking. Discussion and Conclusions. Awareness of the dose-dependent effect of cocaine on ACI risk, as well as the possible synergistic effect of alcohol, ought to be incorporated into preventive and care strategies.[Santos S, Brugal MT, Barrio G, Castellano Y, Domingo-Salvany A, Espelt A, Bravo MJ, de la Fuente L, the ITINERE Project Group. Assessing the effect of patterns of cocaine and alcohol use on the risk of adverse acute cocaine intoxication. Drug Alcohol Rev 2012].

Emerg Med J. 2012 Jan 20;
Barrow A, Ndikum J, Harris T

ObjectiveTo determine the frequency with which a CT head is performed in patients presenting more than 4 h after minor head injury and the clinical features that predict an abnormal scan.DesignObservational cohort study.SettingEmergency department (ED) of the Royal London Hospital, London, UK.Participants500 patients presenting to the ED of the Royal London Hospital.MethodsChart review of all patients with minor head injury presenting more than 4 h from insult to the ED between December 2007 and May 2009. Inclusion criteria were: age over 16 years, Glasgow coma scale (GCS) 14 or 15 on first assessment, over 4 h post-injury. Exclusion criteria were: age under 16 years, GCS 13 and less, injuries limited to the face with no risk of intracranial injury; presentation less than 4 h after injury.Results497 patients were identified: 147 patients had CT head; 11 had intracranial injuries on CT. Loss of consciousness (p=0.0005), potential coagulopathy (p=0.0015), injuries above the clavicles (p=0.0150), open/depressed skull fracture (p=0.0221), alcohol/drug intoxication (p=0.0406) and focal neurology (p=0.0562) were predictors of positive CT scan. Five patients (1% of sample, 45% of patients with abnormal CT) required a neurosurgical procedure. Two (18.2%) self-discharged and four (36.4%) were followed up as outpatients. One patient (0.09%) died as a result of intracranial injury.DiscussionPatients with minor head injury who present over 4 h post-insult exhibit a similar risk of intracranial pathology to those presenting within 4 h. The risk factors previously identified to predict intracranial injury are similar in this study.