Search PubMed⌕ Search

Biomedical subjects

E J DeMaria

Publications and source records attributed to E J DeMaria.

At least 55 records · Page 3Linked to original sources
PubMed1993

Interleukin-1 receptor antagonist improves survival and preserves organ adenosine-5'-triphosphate after hemorrhagic shock.

BACKGROUND: This study was designed to determine the role of interleukin-1 (IL-1) in hemorrhagic shock death. METHODS: Pentobarbital anesthetized C3H/HeN mice (n = 59) were prepared with a femoral arterial catheter and were randomized to treatment with an IL-1 receptor antagonist (IL-1ra, 10 mg/kg, n = 29) or an equal volume of phosphate-buffered saline solution (vehicle, n = 30) by subcutaneous bolus injection at 15 minutes before hemorrhage and again at 120 minutes. Continuous posthemorrhage delivery of IL-1ra or vehicle was performed in each group (1.5 mg IL-1ra in 30 microliters/day) through a subcutaneous osmotic pump. Rapid hemorrhage of 4 ml/100 gm weight was followed by normal saline resuscitation of 12 ml/100 gm 60 minutes later. RESULTS: Survival analysis by Wilcoxon rank sum analysis revealed a significantly improved 5-day survival in IL-1ra-treated mice (n = 15, 20%) as compared with vehicle-treated mice (n = 14, 6%, p < 0.001). To determine a possible mechanism of this survival advantage, the remaining mice in each treatment group were killed at 30 minutes to obtain blood and tissue samples from the heart, liver, and kidney for measurement of adenosine-5'-triphosphate (ATP). No difference in hematocrit, circulating neutrophils, or levels of glucose, lactate, or tumor necrosis factor was identified between groups to explain the improved outcome. IL-1ra prevented hemorrhage-induced ATP depletion observed in vital organs of vehicle-treated mice. CONCLUSIONS: The data implicate IL-1 in shock-induced ATP depletion and suggest IL-1ra may improve hemorrhagic shock survival by preventing ATP depletion in vital organs.

Adenosine Triphosphate↗
PubMed1993

Evaluation and treatment of the elderly trauma victim.

This article examined issues in the care of the injured elderly patient. Past studies have documented variable potential for functional recovery in survivors of serious trauma in the elderly population, and trauma care for this subgroup uses health care resources at an exaggerated rate. Excessive health care costs arise from increased postinjury morbidity and mortality in the elderly population; factors that predict mortality include injury severity, advanced age, and complications. Recent work has focused on the frequency of preventable complications, particularly critical care management errors, in trauma patients of all ages. It appears that the impact of preventable complications on mortality may be greatest in the geriatric trauma victim. Current recommendations for care of these patients include aggressive treatment of all injuries according to standard trauma practice. Routine ICU admission with a low threshold for the institution of invasive monitoring to guide therapy is recommended for all geriatric trauma victims with moderate to more serious injury. The development of specialized management approaches for care of the injured elderly patient will result from ongoing study of this population, as research efforts provide more information about the physiologic and metabolic responses to injury in the elderly population.

Accidents, Traffic↗
PubMed1992

Coronary vasomotor dysfunction following hemorrhagic shock.

Myocardial dysfunction and subendocardial ischemia have been described during hemorrhagic shock, but technical limitations have precluded the in vitro examination of coronary reactivity following hemorrhage. We tested the hypothesis that in vitro coronary artery contraction and relaxation are impaired by hemorrhagic shock (HS). HS was produced in awake rats (n = 6) 24 hr after surgery for arterial cannulation, by bleeding to a mean arterial pressure of 50 mm Hg for 2 hr followed by reinfusion of shed blood. Using a small vessel myograph, reactivity of coronary arterial ring segments from three groups of rats not undergoing HS were compared to coronaries harvested from rats after HS (Group 4). The three nonshock treatments included normal rats without pretreatment (Group 1), rats undergoing prior surgical cannulation alone (Group 2), and rats undergoing prior surgical cannulation followed by nonhypotensive hemorrhage (Group 3). Responses to 125 mM potassium (KCl) and to 10(-6) M serotonin (STN) determined smooth muscle contraction. Acetylcholine administration determined endothelium-mediated smooth muscle relaxation, whereas acetylcholine plus nitroprusside combined determined maximum smooth muscle relaxation. Rats following HS demonstrated impaired coronary arterial smooth muscle contraction to KCl when compared to normal rats, but the response to STN did not differ among groups. Maximum smooth muscle relaxation was significantly lower in rats following HS as compared to rats in Groups 1 and 2. Endothelium-dependent relaxation was significantly impaired when compared to each of the three nonshock groups. Thus, in coronary arteries isolated from neurohumoral influences, HS was associated with diminished smooth muscle contraction and relaxation as well as impaired endothelium-mediated relaxation.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1992

Blunt colonic injury--a multicenter review.

During the past decade there has been a shift in the management of injuries of the colon to primary repair without a protective diverting colostomy. Unfortunately, reports concerning this practice contain relatively few patients with blunt trauma and it is unclear whether the principles established for penetrating injury should be applied in the setting of blunt colon injury. A retrospective review of 54,361 major blunt trauma patients admitted to nine regional trauma centers from January 1, 1986, through December 31, 1990, was conducted. Statistical analysis of the data collected regarding 286 (0.5%) of these patients who suffered colonic injury revealed: (1) injury to the colon is found in more than 10% of patients undergoing laparotomy following blunt trauma; (2) available diagnostic modalities are unreliable in detecting isolated colonic pathology; (3) primary repair of full-thickness injuries or resection and anastomosis may be safely performed without diversion; (4) gross fecal contamination is the strongest contraindication to primary repair. Further, delay of surgery, shock, and the timing of antibiotic administration were not associated with significantly increased morbidity.

Abbreviated Injury Scale↗
PubMed1992

Preventable complications and death from multiple organ failure among geriatric trauma victims.

We reviewed 374 consecutive trauma patients over age 65 years to determine (1) if the emergency room Trauma Score (TS) could predict mortality, thereby improving ICU triage, and (2) the frequency of preventable complications in patients who died (n = 31). Fifty-two percent of deaths (n = 16) occurred in patients with TS = 15 or 16. Multiple organ failure/sepsis (MOF/S) was the most common cause of death overall (42%) and was also the most frequent cause of death in patients with a TS = 15-16 (63%). Nonsurvivors in the TS = 15-16 subgroup were older (80.9 +/- 2.0 vs. 74.9 +/- 0.5 years, p less than 0.02) and had greater ISSs (15.8 +/- 3.7 vs. 8.0 +/- 0.4, p = 0.001) than survivors. Patients with a TS less than 15 suffered high overall mortality (45%). Preventable complications contributed to mortality in 32% of all deaths and in 62% of MOF/S deaths. Aggressive care to prevent avoidable complications may improve survival in elderly trauma victims.

Age Factors↗
PubMed1991

Management of patients with indeterminate diagnostic peritoneal lavage results following blunt trauma.

The management of blunt trauma victims with indeterminate diagnostic peritoneal lavage (DPL) findings remains controversial. We reviewed 1,196 patients undergoing DPL to identify patients with indeterminate DPL (red cell counts of 20,000 to 99,999 rbc/mm3). Only 4% (48%) had indeterminate DPL results. Repeat DPL (R-DPL) was performed in 31 patients. Six repeat DPLs produced positive results (greater than 100,000 rbc/mm3), 15 produced indeterminate results, and 10 produced negative results (less than 20,000 rbc/mm3). A review of the nine laparotomies performed in this group revealed only two operations that were therapeutic. Twelve patients had abdominal CT scans following indeterminate DPL. Six patients had negative CT scans and were successfully managed without operation. The findings were positive on six other CT scans. Four patients with positive CT scans, including two splenic injuries, one liver injury, and one renal laceration, were managed successfully without surgery. The remaining two patients with positive CT scans underwent laparotomy. The first had a renovascular injury diagnosed from the CT scan after negative findings on repeat DPL. The second had a minor splenic injury diagnosed from the CT scan. A subsequent repeat DPL produced a positive result prompting a nontherapeutic operation. Eleven patients were observed without repeat DPL or CT scanning. Of these, four eventually underwent laparotomy on the basis of clinical suspicion alone. Only one of these patients required therapeutic intervention at the time of laparotomy. Intra-abdominal injury was common in patients with indeterminate DPL results, however, only four (8%) of the patients required a therapeutic operation. Both negative repeat DPL results or negative findings on CT scans predicted successful nonoperative management.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗
PubMed1991

Trauma care for the elderly?

The enormous consumption of health-care resources by bluntly injured elderly patients can be justified if their outcome after trauma is good. In this series, 89% of injured elderly patients ultimately returned to their homes, either independent of (57%) or dependent on (32%) outside help. Factors contributing to increased mortality in such patients included age, injury severity, and the presence or absence of cardiac and septic complications. A Geriatric Trauma Survival Score (GTSS) was devised that predicted the likelihood of mortality in these patients. Finally, study of reimbursement indicated that Medicare does not adequately reimburse hospitals for the enormous cost of providing elderly trauma care.

Aged↗
PubMed1990

Continuous measurement of atrial volume with an impedance catheter during positive pressure ventilation and volume expansion.

Right atrial volume (RAV) and other hemodynamic parameters were measured in ten anesthetized swine with an impedance catheter in the right atrium during ventilation and increasing levels of positive end-expiratory pressure (PEEP) to determine the effects of PEEP on right atrial dynamics. RAV and cardiac output (CO) decreased progressively during ventilation with 5, 10 and 15 centimeters of water PEEP, whereas central venous pressure and pulmonary capillary wedge pressure increased. Despite this decrease in RAV, atrial ejection fraction increased significantly and active atrial output (AAO equals stroke volume times heart rate) was maintained. Thus, the decrease in CO resulted from a decrease in the passive component of ventricular filling. Compensatory increases in AAO helped to minimize the fall in CO in some swine (r = 0.73, p less than 0.01). Peripheral adenocorticotropin (ACTH) increased from 14.0 +/- 4.5 picograms per milliliter at zero centimeters of water PEEP to 46.8 +/- 18.3 picograms per milliliter at 10 centimeters of water PEEP (p less than 0.05). Volume expansion that restored CO to control levels despite PEEP led to a significant increase in RAV and in passive ventricular filling, as well as a decrease in ACTH to 11.2 +/- 1.5 picograms per milliliter (p less than 0.05). Changes in the ACTH levels correlated with changes in the RAV (r = 0.58, p less than 0.05), but did not correlate with changes in CO, arterial pressure or central venous pressure. The data herein suggest that the decrease in CO with PEEP results from decreased venous return, RAV and passive ventricular filling, whereas a compensatory increase in right atrial contractility helps to maintain CO. Ventilation with PEEP stimulates hormonal secretion that can be terminated by adequate volume expansion.

Adrenocorticotropic Hormone↗
PubMed1989

Behavioral and hormonal influence on blood volume restitution after hemorrhage in swine.

Hemorrhage of 14 ml.kg-1.5 min-1 was done in two groups of chronically prepared, splenectomized Yorkshire pigs that were conditioned behaviorally to lie in a Panepinto sling. In group 1 the conditioning included early use of active restraint. It was done before the preparative surgery and on postoperative day 3 before the experiment on day 4. In group 2 the use of active restraint was minimized during conditioning that was extended to postoperative days 4 and 5 before the experiment on day 6. Before hemorrhage, core temperature and plasma catecholamines, cortisol, adrenocorticotropin, vasopressin, and renin were greater in group 1 than in group 2; but blood volume, hematocrit, and body weight were identical. Peak hormonal concentrations were greater or more sustained during the 1st h after hemorrhage in group 1 than in group 2. Restitution of blood volume was greater in group 1 than in group 2 at 4 and 7 h. Greater total peripheral resistance at 2 h after hemorrhage and greater restitution of plasma protein by 7 h in group 1 contributed to its accelerated volume restoration. Comparison of arterial pressure and of right atrial volume (conductance catheter) between groups suggested that a greater response of arterial or right atrial stretch receptors in group 1 could not account for the results. We suggest that the method and duration of behavioral conditioning and the time for recovery from surgery are important determinants of the hemodynamic and hormonal responses to hemorrhage and their subsequent influence on the restitution of blood volume.

Adrenocorticotropic Hormone↗
PubMed1989

Atrial peptide release after hemorrhage in unanesthetized swine.

Hemorrhage of 14 ml/kg in 5 min was done in two groups of chronically prepared, splenectomized Yorkshire pigs. Group 1 was studied on post-operative day 4 and was conditioned behaviorally with "active restraint", whereas group 2 was studied on postoperative day 6 and was conditioned with behavioral "shaping." The peak decrease in blood volume occurred by 0.25 h after hemorrhage in both groups. However, plasma atrial natriuretic factor (ANF) as measured by radioimmunoassay did not decrease significantly until 2 h in group 1 and 0.5 h in group 2 even though the recovery of blood volume was significantly more rapid in group 1 than in group 2. The responses of ANF differed significantly between groups, suggesting that ANF release after hemorrhage is influenced by prior handling and the time for recovery from surgery. In both groups, some pigs showed increases in ANF during the 1st h after hemorrhage, and changes in ANF were unrelated to decreases in central venous pressure or absolute right atrial volume determined with a conductance catheter. In contrast, changes in ANF after hemorrhage correlated positively with several variables including atrial rate and changes in vasopressin. Multiple regression suggested that the effect of reduced atrial volume on ANF release was opposed by these latter variables or related factors. Furthermore, known actions of ANF do not appear to account for the observed hemodynamic and hormonal responses to hemorrhage.

Animals↗
PubMed1989

Potentiated cortisol response to paired hemorrhage: role of angiotensin and vasopressin.

Potentiated adrenocorticotropin (ACTH) and cortisol responses occur after the second of two small hemorrhages (hems) spaced 24 h apart in the dog. To test whether increased responses of other hormones might be associated with this effect, we examined plasma renin activity (PRA), angiotensin II (ANG II), and vasopressin after paired 10% hem (H1 and H2) spaced 5 h apart in chronically prepared conscious dogs. Cortisol secretion increased after each hem, and the response to H2 was larger (P less than 0.05; H1 peak at 6.8 +/- 1.3 micrograms/min vs. H2 peak at 18.3 +/- 5.3 micrograms/min). ACTH did not change after H1 but increased after H2, and the H2 response was larger (P less than 0.01). Vasopressin increased after each hem, and the H2 response was larger (P less than 0.01). The time courses of ACTH and vasopressin responses were similar after H2 (significant increases by 8 min). PRA and ANG II increased by 4 min after each hem, and although the difference was small the early PRA and ANG II responses were greater after H2. Blood volume and hem volume did not differ between hems. Hemodynamic responses to the hems were not different. We conclude that, although the PRA and ANG II respond rapidly enough after hem to influence pituitary responses, the slightly greater responses of these factors to H2 are not responsible for greatly increased pituitary-adrenal responses to H2. On the other hand, the markedly potentiated vasopressin response to H2, which parallels that of ACTH, suggests that vasopressin may mediate the increased ACTH responses to H2.

Adrenocorticotropic Hormone↗
PubMed1989

Aldosterone secretion following non-hypotensive hemorrhage is potentiated by prior blood loss.

Aldosterone is a major regulator of fluid and electrolyte balance after hemorrhage and is released from the adrenal cortex by the action of adrenocorticotropin (ACTH) and angiotensin II (AII). Past work has shown that the hemorrhage-induced release of ACTH and cortisol is potentiated by prior hemorrhage. We therefore studied the response of adrenal aldosterone secretion to repeated hemorrhage and its control by ACTH and AII. Six awake dogs with chronic lumboadrenal vein catheters were bled 10% of measured blood volume (H1) with reinfusion at 30 minutes. The hemorrhage was repeated 5 hours later (H2). Adrenal presentation rates for AII (AII-PR) and ACTH (ACTH-PR) were calculated for each sample. Control hormonal and hemodynamic parameters before each hemorrhage were not different; hemodynamic responses to H1 and H2 did not differ. Aldosterone secretion increased significantly after each hemorrhage. The increase in aldosterone secretion after H1 was associated with an early increase in AII-PR and late increase in ACTH-PR. Aldosterone secretion following H2 was greater than that following H1 and was associated with early and larger responses of AII-PR and ACTH-PR. Aldosterone secretion following H1 correlated with the AII-PR (r = 0.75; p less than 0.001), but not with the ACTH-PR. In contrast, aldosterone secretion following H2 correlated with both the AII-PR (r = 0.54; p less than 0.01) and ACTH-PR (r = 0.71; p less than 0.001) and multiple regression analysis showed a highly significant relation with both AII and ACTH (r = 0.81; p less than 0.001). The data suggest that aldosterone secretion after initial small hemorrhage occurs as a result of increased AII, whereas both AII and ACTH may contribute to the larger aldosterone secretory response to H2. Since major trauma commonly involves at least two insults separated in time (e.g., injury followed by surgery), potentiated responses of aldosterone and other pituitary-adrenal hormones (ACTH, vasopressin, and cortisol) may have important implications for the control of fluid and electrolyte balance and metabolism in injured patients.

Adrenal Glands↗
PubMed1988

Do DRG payments adequately reimburse the costs of trauma care in geriatric patients?

The records of 82 consecutive trauma patients over age 65 years were reviewed to determine the costs of trauma care as well as the projected DRG reimbursement in the seriously injured elderly. During the period of study, 636 additional trauma patients under the age of 65 were admitted. For all trauma victims, hospital costs exceeded projected reimbursement by $2.55 million ($98,000 per month). In the elderly population, mean hospital costs dramatically exceeded mean projected reimbursement in patients over the age of 80 ($18,197 +/- 3,682 vs. $7,069 +/- 700; p less than 0.001), in patients with severe overall injury ($18,992 +/- 3,540 vs. $8,508 +/- 643; p less than 0.001), and in patients with more than one complication ($25,504 +/- 3,959 vs. $7,247 +/- 626; p less than 0.001). Hospital costs were also increased in elderly patients discharged to a nursing home ($22,811 +/- 3,664) primarily as a result of prolonged hospital stay in older patients with more severe injury and with more frequent complications. The daily cost for trauma care in elderly patients who died was a staggering $1,735 +/- 366, reflecting the aggressive care given these patients. In the elderly trauma population, the number of complications was the only factor that correlated with hospital costs (r = 0.63; p less than 0.001). There was no significant correlation between hospital costs and projected DRG reimbursement, suggesting that the current DRG system is a very poor predictor of actual costs for trauma care in this population. The data suggest that the present DRG system grossly underestimates hospital costs in patients more than 65 years old with severe injury and with complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1987

Potentiated hormonal responses in a model of traumatic injury.

Although major trauma often involves repeated insults, few studies have examined the endocrine response to repeated injury. In earlier work, we described potentiated responses of circulating adrenocorticotropin (ACTH) and adrenal secretion of cortisol, epinephrine, and norepinephrine to the second of two small hemorrhages separated by 24 hr. To investigate the response of other hormones to repeated hemorrhage and to examine possible hormonal interactions in a shorter, more clinically relevant time frame, we placed chronic adrenal vein cannulas in eight splenectomized, trained dogs. Each animal was bled 10% of measured blood volume with reinfusion of shed blood at 30 min. The hemorrhage was repeated 5 hr later. Initial hemorrhage led to a small but significant increase in adrenal cortisol secretion and circulating ACTH, vasopressin (AVP), angiotensin II (AII), and plasma renin activity (PRA). Although a 5-hr time interval between stimuli is commonly thought to lead to cortisol feedback, the circulating ACTH and adrenal cortisol secretory responses to the second hemorrhage were exaggerated in comparison to their initial responses. Similarly, the AVP response to the second hemorrhage was also increased. In contrast, the responses of PRA and AII to the second hemorrhage were not greater than their responses to the initial hemorrhage. No differences in measured blood volume before each hemorrhage or in the heart rate and arterial pressure responses to hemorrhage were observed that could explain the potentiated hormonal responses. Thus, potentiated responses of cortisol, ACTH, and AVP, but not of PRA and AII, were observed in a model of trauma that emphasizes repeated injury in a clinically relevant time frame.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenal Glands↗
PubMed1987

Survival after trauma in geriatric patients.

In contrast to other studies, a recent report from the authors' institution has shown a good prognosis for functional recovery in geriatric patients that survive trauma. Because most survivors regained their pre-injury function, the authors examined factors related to nonsurvival in this population of 82 consecutive blunt trauma victims older than the age of 65. Seventeen patients died (21%). Compared with survivors, nonsurvivors were older, had more severe overall injury, and had more severe head and neck trauma but did not differ in severity of trauma that did not involve the head and neck, number of body regions injured, mechanism of injury, or incidence of surgery after injury. Nonsurvivors experienced more frequent complications (82% vs. 33%, p less than 0.05), including a higher incidence of cardiac complications (53% vs. 15%, p less than 0.05) and ventilator dependence for 5 or more days (41% vs. 14%, p less than 0.05). Mortality rates were increased in patients who were 80 years of age or older compared with those ages 65-79 (46% vs. 10%, p less than 0.01), despite injury of similar severity. More frequent complications may contribute to an increased mortality rate in the older group, including an increased incidence of prolonged mechanical ventilation (36% vs. 12%, p less than 0.025), cardiac complications (54% vs. 10%, p less than 0.01), and pneumonia (36% vs. 16%, p less than 0.06). Severely injured patients (Injury Severity Score [ISS] greater than or equal to 25) older than 80 years old had a mortality rate of 80%, and the survivors required permanent nursing home care. Discriminant analysis yielded a reliable method of differentiating survivors from nonsurvivors based on age, ISS, and the presence of cardiac and septic complications. To assess the accuracy of the discriminant function, 61 consecutive patients admitted during 1985 were reviewed prospectively. Discriminant scoring predicted outcome correctly in 92% of these patients. A Geriatric Trauma Survival Score (GTSS) based on the discriminant function was calculated for each of the 143 patients studied and was highly correlated with mortality rate (r = 0.99, p less than 0.001). Thus, the GTSS may serve as a valuable tool for evaluating death in geriatric trauma victims. Furthermore, because complications are potentially avoidable and contribute to increased mortality rates, routine aggressive care for geriatric patients with moderate overall injury is indicated.

Aged↗
PubMed1987

Aggressive trauma care benefits the elderly.

Few past studies have examined the long-term functional outcome of geriatric patients who survive trauma. To evaluate factors that determine the long-term potential for recovery in this population, we studied 63 survivors of blunt trauma over age 65 years between 9 and 38 months after hospital discharge. The overall level of injury was moderate, with a mean Injury Severity Score of 15.8 +/- 1.1. Thirty-nine patients (62%) had two or more body regions injured. Forty-five patients (71%) had pre-existing cardiopulmonary disease. Surgery was required in half of the patients, one third experienced complications, and nine (14%) required ventilatory support for 5 or more days. Only two patients did not live independently before trauma. Immediately after discharge, 21 patients (33%) were independent, 23 (37%) were dependent but living at home, and 19 (30%) required nursing-home care (NH). NH patients were older, more severely injured, had more severe head and neck trauma, and required surgery more frequently after trauma than patients discharged directly home. Twelve of the 19 NH patients (63%) returned home 3.1 +/- 0.9 months after discharge, and 13 of the 23 dependent patients (57%) became independent. Ultimately, 56 patients (89%) returned home after trauma. These patients were younger, had a shorter hospital stay, and experienced fewer complications than patients who required permanent NH care. Among 12 patients 80 years old and over, eight patients eventually returned home. Overall, 38 patients (57%) returned to independent living after trauma. Aggressive support of the elderly trauma victim appears justified, since few patients require permanent NH care and the majority return to independent living after trauma.

Activities of Daily Living↗
PubMed1985

Septic complications of corticosteroid administration after central nervous system trauma.

The records of 197 consecutive multiple trauma patients were reviewed to define the infectious complications of corticosteroids used to treat brain and spinal cord injury. An injury severity score (ISS) and a central nervous system (CNS) injury score were determined for each patient. Patients with an ISS less than 20 did well with or without steroids and were excluded from further study. All deaths that occurred 5 or more days after injury were caused by sepsis, and all occurred in steroid recipients. Twenty-nine of 61 steroid-treated early survivors developed infectious complications, compared to eight of 55 patients who did not receive steroids (47.5% vs. 14.5%, p less than 0.001). There was no correlation between severity of CNS trauma and infectious complication rate. Steroid-treated patients frequently developed multiple pathogen primary infections and multiple, simultaneous septic foci. Patients treated with steroids more often developed infections caused by Staphylococcus aureus, assorted gram negative rods, anerobic bacteria, or fungi. The study strongly suggests a significant increase in both the incidence and severity of infectious complications occurring in patients treated with corticosteroids for CNS trauma.

Adolescent↗