Temporal distribution of trauma deaths: Quality of trauma care in a developing country

Background: Examination of the epidemiology and timing of trauma deaths has been deemed a useful method to evaluate the quality of trauma care. Objective: The purpose of this study was to evaluate the quality of trauma care in a regional trauma system and in a university hospital in Brazil by comparing the timing of deaths in the studied prehospital and in-hospital settings to those published for trauma systems in other areas. Methods: We analyzed the National Health Minister`s System of Deaths Information for the prehospital mortality and we retrospectively collected the demographics, timelines, and trauma severity scores of all in-hospital patients who died after admission through the Emergency Unit of Hospital das Clinicas de Ribeirao Preto between 2000 and 2001. Results. During the study period, there were 787 trauma fatalities in the city: 448 (56.9%) died in the prehospital setting and 339 (43.1%) died after being admitted to a medical facility. In 2 years, 238 trauma deaths occurred in the studied hospital, and we found a complete clinical set of data for 224 of these patients. The majority of deaths in the prehospital setting were caused by penetrating injuries (66.7%), whereas in-hospital mortality was mainly because of blunt traumas (59.1%). The largest number of in-hospital deaths occurred beyond 72 hours of stay (107 patients-47%). Conclusions: The region studied showed some deficiencies in prehospital and in-hospitals settings, in particular in the critical care and short-term follow-up of trauma patients when compared with the literature. Particularly, the late mortality may be related to training and human resources deficiency. Based on the timeline of trauma deaths, we can suggest that the studied region needs improvements in the prehospital trauma system and in hospital critical care.

Epidemiologic aspects and clinical outcome of fungal keratitis in southeastern Brazil

PURPOSE. Fungal keratitis (FK) is a sight-threatening disease, more prevalent in developing regions. The present retrospective study was conducted in order to evaluate the epidemiologic and clinical aspects and the progression of FK in patients treated at two ophthalmologic reference centers in Southeast Brazil. METHODS. The charts of patients with infectious keratitis treated between 2000 and 2004 were reviewed. For the 66 cases of FK confirmed by microbiological analysis, data related to patient, disease, and therapeutic approaches were obtained. RESULTS. Mean patient age was 40.7 +/- 16 years. Fifty-three were men and 13 were women. Ocular trauma occurred in 40% of cases (27). Previous medications taken by the patients were quinolone in 72.5% and antimycotics in 30%. Visual acuity (VA) at presentation was >0.3 in 16% and <0.1 in 74.5%. Penetrant keratoplasty was performed in 38% and evisceration in 15%. The causing agents were Fusarium sp in 67%, Aspergillus sp in 10.5%, and Candida sp in 10%. Medication alone resolved 39% of cases within a mean period of 24.5 +/- 12 days. Final VA was >0.3 in 28%, and <0.1 in 63%. CONCLUSIONS. Fungal keratitis presented as a disease with severe complications, predominantly among young males, and was mostly caused by filamentous fungi. The present information permits the establishment of preventive strategies. Reducing the time between onset and treatment and using more accessible specific medication would reverse the negative prognosis. (Eur J Ophthalmol 2009; 19: 355-61)

Glaucoma and Keratoprosthesis Surgery Role of Adjunctive Cyclophotocoagulation

Purpose: To evaluate the efficacy and safety of diode laser transscleral cyclophotocoagulation (DLTSC) to control intraocular pressure (IOP) in keratoprosthesis patients with uncontrolled glaucoma. Patients and Methods: Between 1993 and 2007, 18 eyes of 18 patients underwent DLTSC, either before (n = 3), during (n = I), or after (n = 14) keratoprosthesis surgery. Keratoprosthesis type 1 was used in 72%. All but one of these patients received an Ahmed Glaucoma Valve, either with or after the keratoprosthesis placement. Best-corrected visual acuity, IOP (assessed by digital palpation), number of medications, and complications were recorded preoperatively, at day 7, at 1, 3, and 6 months then every 6 months postoperatively. Results: Mean follow-tip was 26.6 +/- 19.6 months (mean +/- SD) and mean age was 50.1 +/- 15.6 years. Glaucoma was identified in 1 I eyes before keratoprosthesis surgery and in 7 eyes after. Mean postoperative IOP was significantly reduced at 6, 12, 24, 36, and 48 months after DLTSC. DLTSC was repeated in 6 eyes. At final visit, mean best-corrected visual acuity was not decreased and there were no statistically significant differences in the number of glaucoma medications. Two patients had complications after DLTSC: a conjunctival dehiscence and a fungal endophthalmitis. Conclusions: DLTSC has beneficial long-term effects in the control of IOP and can be considered in the management of keratoprosthesis patients with refractory glaucoma.

Regeneration of the Corneal Epithelium after Debridement of its Central Region: An Autoradiographic Study on Rabbits

Purpose: To investigate the proliferative behavior of the corneal and limbal epithelia after debridement on the central region of the rabbit cornea. Methods: After scraping a circular epithelial area, 5 mm in diameter, in the center of the cornea, (3)H-thymidine ((3)H-TdR) was injected intravitreally, and the rabbits killed from 1 to 49 days afterward. The cornea, together with the adjacent conjunctiva, was processed for autoradiography. Results: The regenerating epithelium at the center of the cornea exhibited high frequencies of labeled nuclei when compared to controls. The mitotic indexes for the limbus were comparable in experimental and control eyes. The unique basal stratum of the limbal epithelium exhibited quick proliferation and vertical migration in all eyes. Cells that remained labeled for four weeks or more were observed throughout the corneal epithelium, including its basal stratum, and this did not depend on epithelial damage. Conclusion: Corneal epithelium wounds are healed by sliding and proliferation of cells surrounding the epithelial gap without any evidence for the participation of the limbal epithelium. Daughter cells labeled with (3)H-TdR were visualized in all layers of the corneal epithelium up to 7 weeks after the DNA precursor injection. However, at this long interval, the only labeled cells in the limbus were in the suprabasal layers.

Oleic acid modulation of the immune response in wound healing: A new approach for skin repair

Injury triggers inflammatory responses and tissue repair. Several treatments are currently in use to accelerate healing: however, more efficient formulations are still needed for specific injuries. Since unsaturated fatty acids modulate immune responses, we aimed to evaluate their therapeutic effects on wound healing. Skin wounds were induced in BALB/c mice and treated for 5 days with n-3, n-9 fatty acids or vehicle (control). n-9 treated mice presented smaller wounds than control and n-3 at 120 h post-surgery (p.s.). Collagen III mRNA,TIMP1 and MMP9 were significantly elevated in n-9 group compared to n-3 or vehicle at 120 h p.s. Among the inflammatory mediators studied we found that IL-10, TNF-alpha and IL-17 were also higher in n-9 treated group compared to n-3 or vehicle at 120 h p.s. Interestingly, COX2 had decreased expression on wound tissue treated with n-9. Inflammatory infiltrate analysis revealed diminished frequency of CD4(+), CD8(+) and CD11b(+) cells in n-9 wounds at 24 and 120 h p.s., which was not related to cell death, since in vitro apoptosis experiments did not show any cell damage after fatty acids administration. These results suggested that unsaturated fatty acids, specifically n-9, modulate the inflammation in the wound and enhance reparative response in vivo. n-9 may be a useful tool in the treatment of cutaneous wounds. (C) 2010 Elsevier GmbH. All rights reserved.

Clinical study of cryosurgery efficacy in the treatment of skin and subcutaneous tumors in dogs and cats

Objective-To evaluate the efficacy of cryosurgery for treatment of skin and subcutaneous tumors in dogs and cats. Study Design-Prospective study. Animals-Dogs (n = 20), cats (10). Methods-Cutaneous or subcutaneous tumors were treated by liquid nitrogen cryosurgical spray (1 cm from target tissue at 90 degrees until a 5-mm halo of frozen tissue was achieved) for 15-60 seconds. Malignant lesions had 3 freeze-thaw cycles benign tumors, 2 cycles. The second or third freeze cycle was performed after complete thaw of the preceding freeze. Wounds healed by second intention. Follow-up was weekly for 1 month and then twice monthly until wounds healed, and final outcome was determined by telephone interview of owners. Results-Tumor size ranged from 0.3 to 11 cm, diameter with 28 (60%) being 0.3-1 cm; 8 (17%) 1.1-3cm, and 11 (23%) >3.4cm. Complications included edema, erythema and for extremity lesions, pain and lameness. Treated lesions (n = 47) had an overall remission of 98% (mean follow-up.. 345 +/- 172.02 days [range, 150-750 days]). One malignant peripheral nerve sheath tumor recurred 7 months after cryosurgical treatment. Conclusion-Cryo surgery is an efficient method for treatment of skin and subcutaneous tumors in dogs and cats. Clinical Relevance-Cryosurgical ablation is an effective means of treating small cutaneous or subcutaneous tumors in dogs and cats, especially in older animals where wound closure or cosmetic outcome might limit surgical excision alone. (C) Copyright 2008 by The American College of Veterinary Surgeons.

Mast cell concentration in the wound healing process of incisions made by different instruments

The aim of this study was to compare the concentration of mast cells (MCs) in the healing process of incisions. Thirty rats were submitted to six linear incisions each, performed in the dorsal skin by carbon dioxide (CO(2)) and diode lasers, electrocautery and conventional scalpel. The animals were euthanized at intervals of 0 h, 24 h, 48 h, 72 h, 7 days and 14 days after the incisions had been made. Histological sections were obtained and stained with toluidine blue for identification of MCs, which were manually counted by conventional microscopy in 20 microscopic fields in the border of the incision, near the granulation tissue, or in the area of new collagen formation, depending on intervals. The concentration of MCs was significantly higher in the wounds made by scalpel than in those made by other techniques at 48 h and 72 h. After 72 h the number of MCs was also significantly higher after electrocautery than after incisions made by 4 W CO(2) laser. On days 7 and 14, there was no significant difference in the MC count among the different types of incisions. In summary, the MC concentration varied after different surgical incisions at early phases of wound healing. At the end of the healing process, however, there were similar MC concentrations around the incisions, suggesting that, in standard incisions in the surgical techniques studied, the wound healing process ultimately occurred in a similar pattern.

Different air-water spray regulations affect the healing of Er,Cr:YSGG laser incisions

Surgeries performed with high-intensity laser devices may be improved with accurate protocols, including the air-water spray regulation. Thus, this study sought to investigate the healing process of wounds made on the dorsum of rat tongues using an Er,Cr:YSGG laser device with different air-water spray regulations. The incisions were made on the dorsum of Wistar rat tongues using an Er,Cr:YSGG laser with three different air-water spray regulations (100/0%, 50/50%, 11/7%). Scalpel incisions functioned as controls. The sacrifices occurred between 0 and 14 days after surgery. Morphological, histological, and immunohistochemical (fibronectin and type III collagen) analysis of the wounds were performed. The air-water spray regulation influenced wound healing and the inflammatory response, especially in the earlier stages. Incisions performed using the 100/0% air/water spray regulation had the worst results, expressing a greater amount of fibronectin and type III collagen. The 50/50% air/water spray regulation brought in a non-clear surgical field and poor laser interaction with the tissue. The 11/7% air/water spray regulation showed the best clinical results and less pronounced histological events. According to the results encountered, the air-water spray should be regulated to improve surgery.

The role of surface sealants in the roughness of composites after a simulated toothbrushing test

Objectives: To evaluate the influence of two surface sealants (BisCover/Single Bond) and three application techniques (unsealed/conventional/co-polymerization) on the roughness of two composites (Filtek Z250/Z350) after the toothbrushing test. Methods: Seventy-two rectangular specimens (5 mm x 10 mm x 3 mm) were fabricated and assigned into 12 groups (n = 6). Each sample was subjected to three random roughness readings at baseline, after 100,000 (intermediate), and 200,000 (final) toothbrushing strokes. Roughness (R) at each stage was obtained by the arithmetic mean of the reading of each specimen. Sealant removal was qualitatively examined (optical microscope) and classified into scores (0-3). Data were analyzed by Student`s paired t-test, two-way ANOVA/Tukey`s test, and by Wilcoxon, Kruskal-Wallis and Miller`s test (alpha = 0.05). Results: Z250 groups at baseline did not differ statistically from each other. Unsealed Z350 at baseline had lower R values. All the unsealed groups presented gradual decrease in R from baseline to final brushing. From baseline to the inter-mediate stage, Z250 co-polymerized groups presented a significant reduction in R (score 3). Conventionally sealed groups had no significant changes in R (scores 2-0.8). From baseline to the intermediate stage, the conventionally sealed Z350 Single Bond group had an increase in R (score 1.5). In the final stage, all the conventionally sealed groups presented a reduction in R (scores 0.7-0). Co-polymerized Single Bond groups had a significant reduction in R (scores 2.5-2.7), and co-polymerized BisCover groups an increase in R (scores 2.8-3). Conclusions: At any brushing stage, sealed composites presented superior performance when compared with unsealed composites. (C) 2009 Elsevier Ltd. All rights reserved.

Fatigue and damage accumulation of veneer porcelain pressed on Y-TZP

Objectives: This study compared the reliability and fracture patterns of zirconia cores veneered with pressable porcelain submitted to either axial or off-axis sliding contact fatigue. Methods: Forty-two Y-TZP plates (12 mm x 12 mm x 0.5 mm) veneered with pressable porcelain (12 mm x 12 mm x 1.2 mm) and adhesively luted to water aged composite resin blocks (12 mm x 12 mm x 4 mm) were stored in water at least 7 days prior to testing. Profiles for step-stress fatigue (ratio 3:2:1) were determined from single load to fracture tests (n = 3). Fatigue loading was delivered on specimen either on axial (n = 18) or off-axis 30 degrees angulation (n = 18) to simulate posterior tooth cusp inclination creating a 0.7 mm slide. Single load and fatigue tests utilized a 6.25 mm diameter WC indenter. Specimens were inspected by means of polarized-light microscope and SEM. Use level probability Weibull curves were plotted with 2-sided 90% confidence bounds (CB) and reliability for missions of 50,000 cycles at 200 N (90% CB) were calculated. Results: The calculated Weibull Beta was 3.34 and 2.47 for axial and off-axis groups, respectively, indicating that fatigue accelerated failure in both loading modes. The reliability data for a mission of 50,000 cycles at 200 N load with 90% CB indicates no difference between loading groups. Deep penetrating cone cracks reaching the core-veneer interface were observed in both groups. Partial cones due to the sliding component were observed along with the cone cracking for the off-axis group. No Y-TZP core fractures were observed. Conclusions: Reliability was not significantly different between axial and off-axis mouth-motion fatigued pressed over Y-TZP cores, but incorporation of sliding resulted in more aggressive damage on the veneer. (C) 2009 Elsevier Ltd. All rights reserved.

Effects of Green Tea Use on Wound Healing

Green tea, a product from Camellia sinensis, consists of over 200 componentes. The most known are the catechins, ou polyphenolic compounds, or flavonoids, but it contains also polysacharide conjugates, amino acids, caffeine and vitamins. Studies have suggested that the regular consumption of green tea reduces the risk of cancer, protecting agains initial events and progression of the disease, may act as antioxidant, has bactericidal properties, and that green tea consumption may be an adjuvant in the treatment of diabetes mellitus, hypertension and hypercholesterolemia. Our experimental study was carried out with male Wistar rats, separated in two groups, experimental and control. The animals in control group were given water ad libitum, and the animals in the experimental group received green tea instead of water. After 2 weeks of experimental period, all the animals, suffered surgical wounds on the dorsum. The animals were sacrificed on I, 3 and 7 days after surgery. Skin samples were used for light microscopy evaluation. Our results allowed us to observe that the experimental group (green tea drinking) presented accelerated epithelial neformation on day 3 after surgery, when epithelial neoformation is in the initial phases. The surgical areas presented 48.20% X 27.32% epithelial neoformation for green tea group and their controls respectivelly at this time. The results of the present study, along with other information about green tea in the literature, strongly suggests that regular use of green tea may be beneficial in surgery situations, when fast epithelial neoformation is desirable.

Geophysical investigation using resistivity and GPR methods: a case study of a lubricant oil waste disposal area in the city of Ribeiro Preto, So Paulo, Brazil

Geophysics has been shown to be effective in identifying areas contaminated by waste disposal, contributing to the greater efficiency of soundings programs and the installation of monitoring wells. In the study area, four trenches were constructed with a total volume of about 25,000 m(3). They were almost totally filled with re-refined lubricating oil waste for approximately 25 years. No protection liners were used in the bottoms and laterals of the disposal trenches. The purpose of this work is to evaluate the potential of the resistivity and ground penetrating radar (GPR) methods in characterizing the contamination of this lubricant oil waste disposal area in Ribeiro Preto, SP, situated on the geological domain of the basalt spills of the Serra Geral Formation and the sandstones of the Botucatu Formation. Geophysical results were shown in 2D profiles. The geophysical methods used enabled the identification of geophysical anomalies, which characterized the contamination produced by the trenches filled with lubricant oil waste. Conductive anomalies (smaller than 185 Omega m) immediately below the trenches suggest the action of bacteria in the hydrocarbons, as has been observed in several sites contaminated by hydrocarbons in previously reported cases in the literature. It was also possible to define the geometry of the trenches, as evidenced by the GPR method. Direct sampling (chemical analysis of the soil and the water in the monitoring well) confirmed the contamination. In the soil analysis, low concentrations of several polycyclic aromatic hydrocarbons (PAHs) were found, mainly naphthalene and phenanthrene. In the water samples, an analysis verified contamination of the groundwater by lead (Pb). The geophysical methods used in the investigation provided an excellent tool for environmental characterization in this study of a lubricant oil waste disposal area, and could be applied in the study of similar areas.

Comparing detection and location performance of perpendicular and parallel broadside GPR antenna orientations

GPR (Ground Penetrating Radar) results are shown for perpendicular broadside and parallel broadside antenna orientations. Performance in detection and localization of concrete tubes and steel tanks is compared as a function of acquisition configuration. The comparison is done using 100 MHz and 200 MHz center frequency antennas. All tubes and tanks are buried at the geophysical test site of IAG/USP in Sao Paulo city, Brazil. The results show that the long steel pipe with a 38-mm diameter was well detected with the perpendicular broadside configuration. The concrete tubes were better detected with the parallel broadside configuration, clearly showing hyperbolic diffraction events from all targets up to 2-m depth. Steel tanks were detected with the two configurations. However, the parallel broadside configuration was generated to a much lesser extent an apparent hyperbolic reflection corresponding to constructive interference of diffraction hyperbolas of adjacent targets placed at the same depth. Vertical concrete tubes and steel tanks were better contained with parallel broadside antennas, where the apexes of the diffraction hyperbolas better corresponded to the horizontal location of the buried target disposition. The two configurations provide details about buried targets emphasizing how GPR multi-component configurations have the potential to improve the subsurface image quality as well as to discriminate different buried targets. It is judged that they hold some applicability in geotechnical and geoscientific studies. (C) 2009 Elsevier B.V. All rights reserved.

Effect of oleic and linoleic acids on the inflammatory phase of wound healing in rats

Inflammation is a crucial step for the wound healing process. The effect of linoleic and oleic acids on the inflammatory response of the skin during the healing process and on the release of pro-inflammatory cytokines by rat neutrophils in vitro was investigated. A wound in the dorsal surface of adult rats was performed and fatty acids were then topically administered. Both oleic and linoleic acids increased the wound healing tissue mass. The total protein and DNA contents of the wounds were increased by the treatment with linoleic acid. The treatments with oleic and linoleic acids did not affect vascular permeability. However, the number of neutrophils in the wounded area and air pouches was increased and the thickness of the necrotic cell layer edge around the wound was decreased. A dose-dependent increase in vascular endothelial growth factor-alpha (VEGF-alpha) and interleukin-1 beta (IL-1 beta) by neutrophils incubated in the presence of oleic and linoleic acid was observed. Oleic acid was able to stimulate also the production of cytokine-induced neutrophil chemoattractant in inflammation 2 alphalbeta (CINC-2 alpha/beta). This pro-inflammatory effect of oleic and linoleic acids may speed up the wound healing process. Copyright (c) 2007 John Wiley & Sons, Ltd.

Immune Evasion of Leptospira Species by Acquisition of Human Complement Regulator C4BP

Leptospirosis is a spirochetal zoonotic disease of global distribution with a high incidence in tropical regions. In the last 15 years it has been recognized as an important emerging infectious disease due to the occurrence of large outbreaks in warm-climate countries and, occasionally, in temperate regions. Pathogenic leptospires efficiently colonize target organs after penetrating the host. Their invasiveness is attributed to the ability to multiply in blood, adhere to host cells, and penetrate into tissues. Therefore, they must be able to evade the innate host defense. The main purpose of the present study was to evaluate how several Leptospira strains evade the protective function of the complement system. The serum resistance of six Leptospira strains was analyzed. We demonstrate that the pathogenic strain isolated from infected hamsters avoids serum bactericidal activity more efficiently than the culture-attenuated or the nonpathogenic Leptospira strains. Moreover, both the alternative and the classical pathways of complement seem to be responsible for the killing of leptospires. Serum-resistant and serum-intermediate strains are able to bind C4BP, whereas the serum-sensitive strain Patoc I is not. Surface-bound C4BP promotes factor I-mediated cleavage of C4b. Accordingly, we found that pathogenic strains displayed reduced deposition of the late complement components C5 to C9 upon exposure to serum. We conclude that binding of C4BP contributes to leptospiral serum resistance against host complement.