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.

Management of a permanent tooth after trauma to deciduous predecessor: an evaluation by cone-beam computed tomography

Impaction of permanent teeth represents a clinical challenge with regard to diagnosis, treatment plan, and prognosis. There is a close relationship between deciduous teeth and permanent teeth germ, and any injury in the deciduous dentition may influence the permanent teeth eruption. The extent of the damage caused to the permanent teeth germ depends on the patient age at the time of injury, type of trauma, severity, and direction of the impact. Conventional radiographic images are frequently used for diagnosis; however, recent developments in three-dimensional (3D) imaging systems have enabled dentistry to visualize structural changes effectively, with better contrast and more details, close to the reality. The cone-beam computed tomography (CBCT) has been used in the diagnosis and treatment plan of these impacted teeth. The purpose of the present case report is to describe a successful conservative management of a retained permanent maxillary lateral incisor with delayed root development after a trauma through the deciduous predecessor in a 9 year-old patient. After clinical and radiographic examination, a CBCT examination of the maxilla was requested to complement the diagnosis, providing an accurate 3D position of the retained tooth and its relationship to adjacent structures. The proposed treatment plan was the surgical exposure and orthodontic traction of the retained tooth. The lateral incisor spontaneously erupted after 6 months. Therefore, this case report suggests that permanent teeth with incomplete root formation have a great potential for spontaneous eruption because no tooth malposition or mechanical obstacles are observed.

Comparative analysis between identified injuries of victims of fall from height and other mechanisms of closed trauma

OBJECTIVE:to identify predictors of death in blunt trauma patients sustaining pelvic fractures and, posteriorly, compare them to a previously reported series from the same center.METHOD: Retrospective analysis of trauma registry data, including blunt trauma patients older than 14 y.o. sustaining pelvic fractures admitted from 2008 to 2010. Patients were assigned into group 1 (dead) or 2 (survivors). We used Student's t, qui square and Fisher's tests for statistical analysis, considering p<0.05 as significant. Posteriorly, we compared predictors of death between both periods.RESULTS: Seventy-nine cases were included. Mean RTS, ISS and TRISS were, respectively, 6.44 + 2.22, 28.0 + 15.2 e 0.74 + 0.33. Nineteen patients died (24,0%). Main cause of death was hemorrhage (42,1%). Group 1 was characterized by (p<0.05) lower systolic blood pressure and Glasgow coma scale means on admission, higher heart rate, head AIS, extremity AIS and ISS means, as well as, higher frequency of severe head injuries and complex pelvic fractures. Comparing both periods, we notice that the anatomic and physiologic severity of injury increased (RTS and ISS means). Furthermore, there was a decrease in the impact of associated thoracic and abdominal injuries on the prognosis and an association of lethality with the presence of complex pelvic fractures.CONCLUSION: There were significant changes in the predictors of death between these two periods. The impact of thoracic and abdominal associated injures decreased while the importance of severe retroperitoneal hemorrhage increased. There was also an increase in trauma severity, which accounted for high lethality.

Avaliação da gravidade do trauma em condutores de motocicleta vítimas de acidentes de trânsito no Rio Grande do Norte

Descriptive exploratory study, prospective, with quantitative approach, performed on the Monsenhor Walfredo Gurgel Hospital Complex (MWGHC), in Natal/RN, aiming to identify injuries by body area and wound severity on drivers who suffered motorcycle accidents, evaluate the severity of injuries and trauma on these drivers and identify the existence of association between wound and trauma severity and some of the accident s characteristics. The population comprised 371 motorcycle drivers, with data collected between October and December 2007. We used as instruments the Abberviated Injury Scale (AIS), Injury Severity Score (ISS) and the Glasgow Coma Scale (GCE1). The results show that, concerning characterization, there was a predominance of the male gender (88.4%), aged between 18 and 24 years (39.90%), originating from the Natal metropolitan region (55.79%), with fundamental-level instruction (51.48%), catholic (75.78%), married (47.98%). 23.18% work on commerce-related activities and 75.20% have income of up to 2 minimum wages. As for the accident s characteristics, the predominant shift was the afternoon (46.36%), received up to one hour after the event (50.67%), transported by countryside ambulances colleagues and relatives (51.21%), 25.34% had the accident on Sunday; 53.91% suffered falls and vehicle rolls; among the collisions there was a predominance of the motorcycle-automoblie type (28.03%); 52,6% were licensed and among these 50.76% had up to one year of license; 65.50% declared not having suffered previous accidents; 65.77% declared waring helmets in the time of the accident; 57.41% said not to have used drugs, and among those who used, alcohol was the most consumed (98.10%). The lowest score evaluated by GCS1 (3 to 8) was linked to drivers who suffered accidents on Saturday (10.3%), those who were not wearing helmets (14.29%) and the victims of motorcycle-pedestrian/animal crashes (13.33%). The body areas most affected had AIS between 1 and 3 (95.76%) and were: external surface (39.90%) and head/neck (33.20%). As for trauma severity, the highest scores (ISS>25) belonged to those who consumed alcohol (30.73%), suffered falls or vehicle rolls (48.9%) and those attended to 3 hours or longer after the accident (50%). We conclude that for motorcycle drivers who suffered accidents, age, gender, weekday, type of accident, use of drugs and the absence of helmet use signal both to the risk of occurrence of these events, as well as for the greater severity of injuries and trauma.

Caracterização do acidente de trânsito e gravidade do trauma: um estudo em vítimas de um hospital de emergência de Natal

Descriptive exploratory study, with quantitative approach and prospective data performed on the Monsenhor Walfredo Gurgel Hospital Complex (MWGH), in Natal/RN, aiming to classify the type of motor vehicle involved in the accident, the public roadway s user quality and the more frequent injuries; to evaluate the severity of trauma in traffic accident victims; characterized the severity of the injuries and the trauma, and the type of motor vehicle involved. The population comprises 605 traffic accident victims, with data collected between October and December 2007. We used as a support for the evaluation of severity of injuries and trauma the Glasgow Coma Scale (GCSl), the Condensed Abbreviated Injury Scale (CAIS) and the Injury Severity Score (ISS). The results show that 82.8% of the victims were male; 78.4% were aged 18 to 38; the victims originating from the State s Countryside prevailed (43.1%); 24.3% of the population had completed middle-level instruction; 23.1% worked on commerce and auxiliary activities; most (79.4%) was catholic; 48.8% were married/consensual union; 76.2% earned up to two monthly minimum wages; Sunday was the day with the most accidents (25.1%); 47.4% were attended to in under an hour after the event; the motorcycle on its own was responsible for 53.2% of the accidents; 42.3% were attended to by the SAMU; 61.8% were victims of crashes; over half (53.4%) used individual protection equipment (IPE); 49.4% were helmets and 4.0% the seatbelt; 61.3% were motorcycle drivers; 43.3% of the accidents took place in the afternoon shift; from 395 drivers, 55.2% were licensed, and 50.7% among those had been licensed for 1 to 5 years; 90.7% of the victims had GCS1 between 13 and 15 points at the time of evaluation; the body area most affected was the external surface (35.9%); 38.8% of the injuries were light or moderate (AIS=1 and AIS=2); 83.2% had light trauma (ISS between 1 and 15 points). In face of the results, we can conclude that there is a risk for the elevation of injury severity and trauma resulting from traffic accidents, when these events are related to certain variables such as gender, age, weekday, the interval between the accident and the first care, ingestion of drugs, type of accident, the public roadway s user quality, the use of IPE, day shift, body regions and the type of motor vehicle involved in the accident

Depression and disease severity in patients with premature acute coronary syndrome

OBJECTIVES The association between depression and cardiovascular disease severity in younger patients has not been assessed, and sex differences are unknown. We assessed whether major depression and depressive symptoms were associated with worse cardiovascular disease severity in patients with premature acute coronary syndrome, and we assessed sex differences in these relationships. METHODS We enrolled 1023 patients (aged ≤ 55 years) hospitalized with acute coronary syndrome from 26 centers in Canada, the United States, and Switzerland, through the GENdEr and Sex determInantS of cardiovascular disease: From bench to beyond-Premature Acute Coronary Syndrome study. Left ventricular ejection fraction, Killip class, cardiac troponin I, and Global Registry of Acute Coronary Events score data were collected through chart review. RESULTS The sample comprised 248 patients with major depression and 302 women. In univariate analyses, major depression was associated with a lower likelihood of having an abnormal left ventricular ejection fraction (odds ratio, 0.70; 95% confidence interval, 0.51-0.97; P = .03) and lower troponin I levels (estimate, -4.04; 95% confidence interval, -8.01 to -0.06; P = .05). After adjustment for sociodemographic and clinical characteristics, neither major depression nor depressive symptoms were associated with disease severity indices, and there were no sex differences. CONCLUSION The increased risk of adverse events in depressed patients with premature acute coronary syndrome is not explained by disease severity.

Impact of a program for the prevention of traffic accidents in a Southern Brazilian city: a model for implementation in a developing country

Background: Traffic accidents constitute the main cause of death in the first decades of life. Traumatic brain injury is the event most responsible for the severity of these accidents. The SBN started an educational program for the prevention of traffic accidents, adapted from the American model ""Think First"" to the Brazilian environment, since 1995, with special effort devoted to the prevention of TBI by using seat belts and motorcycle helmets. The objective of the present study was to set up a traffic accident prevention program based on the adapted Think First and to evaluate its impact by comparing epidemiological variables before and after the beginning of the program. Methods: The program was executed in Maringa city, from September 2004 to August 2005, with educational actions targeting the entire population, especially teenagers and young adults. The program was implemented by building a network of information facilitators and multipliers inside the organized civil society, with widespread population dissemination. To measure the impact of the program, a specific software was developed for the storage and processing of the epidemiological variables. Results: The results showed a reduction of trauma severity due to traffic accidents after the execution of the program, mainly TBI. Conclusions: The adapted Think First was systematically implemented and its impact measured for the first time in Brazil, revealing the usefulness of the program for reducing trauma and TBI severity in traffic accidents through public education and representing a standardized model of implementation in a developing country. (C) 2009 Elsevier Inc. All rights reserved.

Plasma von Willebrand factor as a predictor of survival in pulmonary arterial hypertension associated with congenital heart disease

Biomarkers have been identified for pulmonary arterial hypertension, but are less well defined for specific etiologies such as congenital heart disease-associated pulmonary arterial hypertension (CHDPAH). We measured plasma levels of eight microvascular dysfunction markers in CHDPAH, and tested for associations with survival. A cohort of 46 inoperable CHDPAH patients (age 15.0 to 60.2 years, median 33.5 years, female:male 29:17) was prospectively followed for 0.7 to 4.0 years (median 3.6 years). Plasma levels of von Willebrand factor antigen (VWF:Ag), tissue plasminogen activator (t-PA) and its inhibitor (PAI-1), P-selectin, reactive C-protein, tumor necrosis factor alpha, and interleukin-6 and -10 were measured at baseline, and at 30, 90, and 180 days in all subjects. Levels of six of the eight proteins were significantly increased in patients versus controls (13 to 106% increase, P < 0.003). Interleukin-10 level was 2.06 times normal (P = 0.0003; Th2 cytokine response). Increased levels of four proteins (t-PA, PAI-1, P-selectin, and interleukin-6) correlated with disease severity indices (P < 0.05). Seven patients died during follow-up. An average VWF:Ag (mean of four determinations) above the level corresponding to the 95th percentile of controls (139 U/dL) was independently associated with a high risk of death (hazard ratio = 6.56, 95%CI = 1.46 to 29.4, P = 0.014). Thus, in CHDPAH, microvascular dysfunction appears to involve Th2 inflammatory response. Of the biomarkers studied, plasma vWF:Ag was independently associated with survival.

The XWS open access catalogue of extreme European windstorms from 1979 to 2012

The XWS (eXtreme WindStorms) catalogue consists of storm tracks and model-generated maximum 3 s wind-gust footprints for 50 of the most extreme winter windstorms to hit Europe in the period 1979–2012. The catalogue is intended to be a valuable resource for both academia and industries such as (re)insurance, for example allowing users to characterise extreme European storms, and validate climate and catastrophe models. Several storm severity indices were investigated to find which could best represent a list of known high-loss (severe) storms. The best-performing index was Sft, which is a combination of storm area calculated from the storm footprint and maximum 925 hPa wind speed from the storm track. All the listed severe storms are included in the catalogue, and the remaining ones were selected using Sft. A comparison of the model footprint to station observations revealed that storms were generally well represented, although for some storms the highest gusts were underestimated. Possible reasons for this underestimation include the model failing to simulate strong enough pressure gradients and not representing convective gusts. A new recalibration method was developed to estimate the true distribution of gusts at each grid point and correct for this underestimation. The recalibration model allows for storm-to-storm variation which is essential given that different storms have different degrees of model bias. The catalogue is available at www.europeanwindstorms.org.

Occurrence of severe and moderate traumatic brain injury in patients attended in a Brazilian teaching hospital - Epidemiology and dosage of alcoholemy

This study aimed at observing aspects of epidemiology in order to investigate the use of alcohol in patients older than 18 with severe and moderate traumatic brain injury, which were attended in the Clinics Hospital of the University of Uberlandia. Positive alcoholemy was found in 39.3% of the patients. of the 33 positive exams alcoholemy was found higher than 60 mg/dL in 28 (84.6%). There was not significant relation between alcoholemy levels and trauma severity. The major prevalence occurred on Saturdays nights. The most frequent types of external causes were transportation accidents (64.74) followed by accidental falls (17.27%) and physical aggression (16.55%). 93.9% of the patients with positive alcoholemy were men aged 20-29. 24.2% of the ones with positive alcoholemy died yet no significant difference was found in the study of the ones with negative alcoholemy (n=51) (p=0.93); RR= 0.9; IC95%=0.40-2.08.

The role of drinking restraint in alcohol dependence: validation of the temptation and restraint inventory in an alcohol dependent sample

Objective: The Temptation and Restraint Inventory (TRI) is commonly used to measure drinking restraint in relation to problem drinking behavior. However, as yet the TRI has not been validated in a clinical group with alcohol dependence. Method: Male (n = 111) and female (n = 57) inpatients with DSM-IV diagnosed alcohol dependence completed the TRI and measures of problem drinking severity, including the Alcohol Dependence Scale and the quantity, frequency and week total of alcohol consumed. Results: The factor structure of the TRI was replicated in the alcohol dependent sample. Cognitive Emotional Preoccupation (CEP), one of the two higher order factors of the TRI, demonstrated sound predictive power toward all dependence severity indices. The other higher order factor, Cognitive Behavioral Control (CBC), was related to frequency of drinking. There was limited support for the CEP/CBC interactional model of drinking restraint. Conclusions: Although the construct validity of the TRI was sound, the measure appears more useful in understanding the development, maintenance and severity of alcohol-related problems in nondependent drinkers. The TRI may show promise in detecting either continuous drinking or heavy episodic type dependent drinkers.

Indices and Implications of Emotional Underarousal for Persons with a History of Head Trauma

We examined the role of altered emotional functioning across the spectrum of injury severity (mild head injury [MHI], moderate/severe traumatic brain injury [TBI]), its implications for social behaviours, and the effect of modifying arousal and its relation to cognitive performance. In the first study (N = 230), students with self-reported MHI endorsed engaging in socially unacceptable and erratic behaviours significantly more often than did those with no MHI. We did not find significant differences between the groups in the measure of emotional intelligence (EI); however, for students who reported a MHI, scores on the EI measure significantly predicted reports of socially unacceptable behaviours such that lower scores predicted poorer social functioning, accounting for approximately 20% of the variance. Also, the experience of postconcussive symptoms was found to be significantly greater for students with MHI relative to their peers. In the second study (N = 85), we further examined emotional underarousal in terms of physiological (i.e., electrodermal activation [EDA]) and self-reported responsivity to emotionally-evocative picture stimuli. Although the valence ratings of the stimuli did not differ between students with and without MHI as we had expected, we found evidence of reduced and/or indiscriminate emotional responding to the stimuli for those with MHI which mimics that observed in other studies for persons with moderate/severe TBI. We also found that emotional underarousal followed a gradient of injury severity despite reporting a pattern of experiencing more life stressors. In the third study (N = 81), we replicated our findings of emotional underarousal for those with head trauma and also uniquely explored neuroendocrine aspects (salivary cortisol; cortisol awakening response [CAR]) and autonomic indices (EDA) of emotional dysregulation in terms of stress responsivity across the spectrum of injury severity (MHI [n = 32], moderate/severe TBI [n = 9], and age and education matched controls [n = 40]). Although the manipulation was effective in modifying arousal state in terms of autonomic and self-reported indices, we did not support our hypothesis that increased arousal would be related to improved performance on cognitive measures for those with prior injury. To our knowledge, this is the only study to examine the CAR with this population. Repeated measure analysis revealed that, upon awakening, students with no reported head trauma illustrated the typical CAR increase 45 minutes after waking, whereas, students who had a history of either mild head trauma or moderate/severe TBI demonstrated a blunted CAR. Thus, across the three studies we have provided evidence of emotional underarousal, its potential implications for social interactions, and also have identified potentially useful indices of dysregulated stress responsivity regardless of injury severity.

Desempenho dos ajustes do Trauma and Injury Severity Score (TRISS): revisão integrativa

RESUMO Objetivo identificar estudos que realizaram ajustes na equação do Trauma and InjurySeverity Score (TRISS) e compararam a capacidade discriminatória da equação modificada com a original. Método Revisão integrativa de pesquisas publicadas entre 1990 e 2014 nas bases de dados LILACS, MEDLINE, PubMed e SciELO utilizando-se a palavra TRISS. Resultados foram incluídos 32 estudos na revisão. Dos 67 ajustes de equações do TRISS identificados, 35 (52,2%) resultaram em melhora na acurácia do índice para predizer a probabilidade de sobrevida de vítimas de trauma. Ajustes dos coeficientes do TRISS à população de estudo foram frequentes, mas nem sempre melhoraram a capacidade preditiva dos modelos analisados. A substituição de variáveis fisiológicas do Revised Trauma Score (RTS) e modificações do Injury Severity Score (ISS) na equação original tiveram desempenho variado. A mudança na forma de inclusão da idade na equação, assim como a inserção do gênero, comorbidades e mecanismo do trauma apresentaram tendência de melhora do desempenho do TRISS. Conclusão Diferentes propostas de ajustes no TRISS foram identificadas nesta revisão e indicaram, principalmente, fragilidades do RTS no modelo original e necessidade de alteração da forma de inclusão da idade na equação para melhora da capacidade preditiva do índice.

Association of biomarkers of lipid modification with functional and morphological indices of coronary stenosis severity in stable coronary artery disease.

Biomarkers of blood lipid modification and oxidative stress have been associated with increased cardiovascular morbidity. We sought to determine whether these biomarkers were related to functional indices of stenosis severity among patients with stable coronary artery disease. We studied 197 consecutive patients with stable coronary artery disease due to single vessel disease. Fractional flow reserve (FFR) ≤ 0.80 was assessed as index of a functionally significant lesion. Serum levels of secretory phospholipase A2 (sPLA2) activity, secretory phospholipase A2 type IIA (sPLA2-IIA), myeloperoxydase (MPO), lipoprotein-associated phospholipase A2 (Lp-PLA2), and oxidized low-density lipoprotein (OxLDL) were assessed using commercially available assays. Patients with FFR > 0.8 had higher sPLA2 activity, sPLA2 IIA, and OxLDL levels than patients with FFR ≤ 0.8 (21.25 [16.03-27.28] vs 25.85 [20.58-34.63] U/mL, p < 0.001, 2.0 [1.5-3.4] vs 2.6 [2.0-3.4] ng/mL, p < 0.01; and 53.0 [36.0-71.0] vs 64.5 [50-89.25], p < 0.001 respectively). Patients with FFR > 0.80 had similar Lp-PLA2 and MPO levels versus those with FFR ≤ 0.8. sPLA2 activity, sPLA2 IIA significantly increased area under the curve over baseline characteristics to predict FFR ≤ 0.8 (0.67 to 0.77 (95 % confidence interval [CI]: 0.69-0.85) p < 0.01 and 0.67 to 0.77 (95 % CI: 0.69-0.84) p < 0.01, respectively). Serum sPLA2 activity as well as sPLA2-IIA level is related to functional characteristics of coronary stenoses in patients with stable coronary artery disease.