Avaliação da gravidade do traumatismo crânio-encefálico por índices anatômicos e fisiológicos

Este estudo analisou prospectivamente a gravidade do Traumatismo Crânio-Encefálico (TCE) a partir de índices anatômicos e fisiológicos em pacientes internados em Unidade de Terapia Intensiva. Teve por objetivo caracterizar a população quanto a idade, sexo, tempo de permanência na UTI e causa externa. Caracterizar a gravidade das lesões pela Abbreviated Injury Scale (AIS), do trauma pelo Injury Severity Score (ISS) e do TCE pela Escala de Coma de Glasgow (ECGl), além de verificar a possível associação entre os índices. Os resultados apontam a predominância de adultos jovens e do sexo masculino com causa externa mais freqüente em acidentes de trânsito de veículo a motor e média de permanência na UTI de 6,28 dias. Quanto a gravidade das lesões constatou-se que os pacientes apresentaram lesões graves, que não ameaçam a vida (AIS3) e lesões graves, que ameaçam a vida (AIS4) e que a região corpórea mais atingida foi a cabeça e pescoço. Em relação a gravidade do trauma constatou-se que a maioria dos pacientes obteve ISS 3 16. Pela gravidade do TCE, a maioria dos pacientes apresentou TCE grave ou ECGl de 3 a 8. Através da associação entre os índices analisados por grupos de gravidade constatou-se que há associação estatisticamente significativa entre a ECGl-1 e a AIS da região cabeça, ou seja ECGl 3 a 8 e AIS- cabeça 4 e 5 e ECGl 9 a 12 e AIS- cabeça 2 e 3. Não houve associação estatisticamente significativa entre a ECGl-1 e o ISS, TCE isolado ou TCE associado a outras lesões e o ISS ou a ECGl.

Recuperação das vítimas de traumatismo cranio-encefálico no período de 1 ano após o trauma

Estudo prospectivo longitudinal sobre a recuperação aos 12 meses, de vítimas de traumatismo crânio-encefálico (TCE) de diferentes gravidades, com idade entre 12 e 60 anos. As vítimas foram avaliadas 1 ano após o trauma considerando-se tanto suas limitações funcionais mensuradas pela Escala de Resultados de Glasgow (ERG) em sua versão de oito categorias, como também, o seu retorno à produtividade. Aos 12 meses, 77,2% das vitimas alcançaram a pontuação 0 e 1 na ERG ampliada. Destas, 38,6% obtiveram a pontuação 0, ou seja, recuperação total . Indivíduos incapazes (pontuação > 1) foram 22,8% sendo aqueles com incapacidade moderada (+), ERG2, e grave (+), ERG4, os mais freqüentes. Retorno à produtividade ocorreu em 83,3% das vítimas e destas, 19,4% tinham alterações na ocupação principal.

Predictors of awakening from postanoxic status epilepticus after therapeutic hypothermia.

BACKGROUND: Postanoxic status epilepticus (PSE) is considered a predictor of fatal outcome and therefore not intensively treated; however, some patients have had favorable outcomes. The aim of this study was to identify favorable predictors for awakening beyond vegetative state in PSE. METHODS: We studied six subjects treated with hypothermia improving beyond vegetative state after cerebral anoxia, despite PSE. They were among a cohort of patients treated for anoxic encephalopathy with therapeutic hypothermia in our institution between October 1999 and May 2006 (retrospectively, 3/107 patients) and June 2006 and May 2008 (prospectively, 3/74 patients). PSE was defined by clinical and EEG criteria. Outcome was assessed according to the Glasgow-Pittsburgh Cerebral Performance Categories (CPC). RESULTS: All improving patients had preserved brainstem reflexes, cortical somatosensory evoked potentials, and reactive EEG background during PSE. Half of them had myoclonic PSE, while three had nonconvulsive PSE. In the prospective arm, 3/28 patients with PSE showed this clinical-electrophysiologic profile; all awoke. Treatments consisted of benzodiazepines, various antiepileptic drugs, and propofol. One subject died of pneumonia in a minimally conscious state, one patient returned to baseline (CPC1), three had moderate impairment (CPC2), and one remained dependent (CPC3). Patients with nonconvulsive PSE showed a better prognosis than subjects with myoclonic PSE (p = 0.042). CONCLUSION: Patients with postanoxic status epilepticus and preserved brainstem reactions, somatosensory evoked potentials, and EEG reactivity may have a favorable outcome if their condition is treated as status epilepticus.

Severe traumatic brain injury in a high-income country: an epidemiological study.

This adult cohort determined the incidence and patients' short-term outcomes of severe traumatic brain injury (sTBI) in Switzerland and age-related differences. A prospective cohort study with a follow-up at 14 days was performed. Patients ≥16 years of age sustaining sTBI and admitted to 1 of 11 trauma centers were included. sTBI was defined by an Abbreviated Injury Scale of the head (HAIS) score >3. The centers participated from 6 months to 3 years. The results are presented as percentages, medians, and interquartile ranges (IQRs). Subgroup analyses were performed for patients ≤65 years (younger) and >65 (elderly). sTBI was observed in 921 patients (median age, 55 years; IQR, 33-71); 683 (74.2%) were male. Females were older (median age, 67 years; IQR, 42-80) than males (52; IQR, 31-67; p<0.00001). The estimated incidence was 10.58 per 100,000 inhabitants per year. Blunt trauma was observed in 879 patients (95.4%) and multiple trauma in 283 (30.7%). Median Glasgow Coma Score (GCS) on the scene was 9 (IQR 4-14; 8 in younger, 12 in elderly) and in emergency departments 5 (IQR, 3-14; 3 in younger, 8 in elderly). Trauma mechanisms included the following: 484 patients with falls (52.6%; younger, 242 patients [50.0%]; elderly, 242 [50.0%]), 291 with road traffic accidents (31.6%; younger, 237 patients [81.4%]; elderly, 54 [18.6%]), and 146 with others (15.8%). Mortality was 30.2% (24.5% in younger, 40.9% in elderly). Median GCS at 14 days was 15 (IQR, 14-15) without differences among subgroups. Estimated incidence of sTBI in Switzerland was low, age was high, and mortality considerable. The elderly had higher initial GCS and a higher death rate, but high GCS at 14 days.

Comparação entre instrumentos de mensuração das consequências do trauma crânio-encefálico

O trauma crânio-encefálico (TCE) é considerado a causa mais importante de incapacidades entre jovens e a mais freqüente causa neurológica de morbidade. Em conseqüência, há um crescente interesse em instrumentos para monitorizar a recuperação após sua ocorrência. Nesse contexto, a Escala de Resultados de Glasgow (ERG) e a Disability Rating Scale (DRS) são instrumentos bastante utilizados. A atual investigação tem como objetivo comparar os resultados observados com o uso da DRS, ERG original e ampliada. Para atingir esse propósito, foram avaliadas as conseqüências pós-trauma de 63 vítimas de TCE contuso, com idade entre 12 e 65 anos, em seguimento ambulatorial em um centro de trauma da cidade de São Paulo, entre seis meses e três anos após TCE. A comparação dos resultados permitiu concluir que, embora as três escalas fossem fortemente correlacionadas, a ERG ampliada destacou-se pela sua maior sensibilidade para detectar alterações nas vítimas com melhores condições pós-traumáticas.

Arnau de Montrodon y la catedral de San Carlomagno. Sobre la imagen y el culto al emperador carolingio en Gerona

In 1345, the unique worship of Saint Charlemagne was institutionalized in the cathedral of Gerona. The roots (and for many, the reasons) of this celebration are found in the existence of an old local legend, the well-known testimonies to which go back to the eleventh century. Nevertheless, a lengthy analysis of the facts that marked the life of the cathedral during the long permanence Amau de Montrodon had there—first in quality of canon (1297-1335) and later as bishop (1333-1348)- make it possible for us to verify that the promotion of the cult to San Charlemagne falls within a complex program of ideological and symbolic exaltation of the See of Girona that was designed by this notable and restlessly active ecclesiastic

Kernohan's notch and misdiagnosis of disorders of consciousness.

A 69-year-old man presented with a sudden headache followed by unconsciousness. There was no head injury. The Glasgow Coma Scale (GCS) score was 3/15 and there was a left mydriasis, unreactive to light. The CT-scan showed a left acute subdural haematoma causing a remarkable mass effect. A supratentorial hemispheric craniotomy was performed. Nevertheless, after several weeks at the intensive care unit (ICU), the patient was still unresponsive to external stimuli and did not show any motor activity. A comfort care attitude was decided on with the family and the patient was extubated. However, a few days later, the patient subsequently showed a surprisingly favourable course, with improved wakefulness. Indeed, the GCS score improved, and the treatment plan was modified so that the patient benefited from rehabilitation. The MRI showed a right cerebral peduncle lesion, consistent with a Kernohan-Woltman notch phenomenon (KWNP). Six months later, the patient was able to walk and live quite normally.

Postoperative management of adult central neurosurgical patients: systemic and neuro-monitoring.

Postoperative neurosurgical patients are at risk of developing complications. Systemic and neuro-monitoring are used to identify patients who deteriorate in order to treat the underlying cause and minimize the impact on outcome. Hypotension and hypoxia are likely to be the most frequent insults and can be detected easily with blood pressure monitoring and pulse oximetry. Repeated clinical examination, however, is probably the most important monitor in the postoperative setting. Clinical scores such as the Glasgow Coma Score and the more recently introduced FOUR Score are important tools to standardize the clinical assessment. Intracranial pressure monitoring, cerebral blood flow monitoring, electroencephalography, and brain imaging are often used postoperatively. Despite the numerous publications on this topic only few studies address the impact of postoperative monitoring on outcome. Accordingly, in most patients the decision on which monitors are to be used must be based on the patient's presentation and clinical judgment.

Age over 40 years increases the failure rate of non-operative management of blunt splenic injuries

Objective: Non-operative management (NOM) of blunt splenic injuries (BSI) is nowadays considered the standard treatment. The study aimed to determine the criteria applied for NOM and to identify risk factors for its failure. Methods: Review of all adult patients with BSI treated at the University Hospital Bern, Switzerland, between 2000 and 2008. Results: There were 206 patients (146 men, 70·9%) with a mean age of 38·2 ± 19·1 years and an Injury Severity Score of 30·9 ± 11·6. The American Association for the Surgery of Trauma classification of the splenic injury was: grade I, n=43 (20·9%); grade II, n=52 (25·2%); grade III, n=60 (29·1%); grade IV, n=42 (20·4%) and grade V, n=9 (4·4%). 47 patients (22·8%) required immediate surgery. Five or more units of red cell transfusions (P<0·001), Glasgow Coma Scale<11 (P=0·009) and age ≥55 years (P=0·038) were associated with primary operative management (OM). 159 patients (77·2%) qualified for NOM, which was successful in 89·9% (143/159). The overall splenic salvage rate was 69·4% (143/206). Multivariate analysis found age ≥40 years to be the only factor independently related to the failure of NOM (P=0·001). Conclusion: Advanced age is associated with an increased failure rate ofNOM in patients with BSI.

Fatores associados ao óbito de motociclistas nas ocorrências de trânsito

Para identificar fatores associados ao óbito em motociclistas envolvidos em ocorrências de trânsito, em Maringá-PR, foi realizado estudo retrospectivo incluindo os motociclistas envolvidos em acidentes no ano de 2004. As fontes de dados foram os registros da Polícia Militar, do SIATE e do Instituto Médico Legal. Foram realizadas análises bivariadas e regressão logística binária. Identificaram-se 2.362 motociclistas nos Boletins de Ocorrência e, destes, 1.743 tinham registros nos Relatórios de Atendimento do Socorrista. As vítimas fatais diferiram das demais quanto à faixa etária, ao local de residência, ao tempo de habilitação e as suas condições fisiológicas na cena da ocorrência. No modelo final permaneceram as seguintes variáveis: Escala de Coma de Glasgow (ECGl), Revised Trauma Score (RTS), pulso e saturação de O2 no sangue. As condições fisiológicas das vítimas na cena do acidente se destacaram no modelo final e a ECGl superou o RTS na associação com óbito.

Keskeisten kädentaitojen osaaminen perustason sairaankuljetuksessa

Keskeisten kädentaitojen osaaminen perustason sairaankuljetuksessa. Osa 1: osaamista arvioivan mittarin kehittäminen. Osa II: osaamista arvioivan mittarin luotettavuus ja käyttökelpoisuus. - Opinnäytetyö liittyy Keski-Uudenmaan pelastuslaitoksen ja Helsingin ammattikorkeakoulu Stadian yhteiseen KUOSCE-hankkeeseen. Opinnäytetyön tarkoitus oli kuvata perustason sairaankuljetuksessa tarvittavaa kädentaitojen osaamista ja kehittää luotettava ja käyttökelpoinen arviointimittari perustason sairaankuljetuksessa tarvittavan kädentaitojen osaamisen tutkimiseen. Kehitettyä mittaria tullaan myös hyödyntämään Helsingin ammattikorkeakoulun ensihoidon koulutuksessa. Mittari luotiin OSCE -menetelmää apuna käyttäen ja se muotoiltiin teoriaosan kanssa yhteneväiseksi. Teoriaosasta kerättiin taulukkomalliseen mittariin väittämiä joihin sopivat kyllä- ja ei-vastaukset. Arvioitaviksi kädentaidoiksi valikoituivat hengitysteiden turvaaminen tajuttomalta potilaalta, hengityksen arviointi tajuissaan olevalta ilman apuvälineitä sekä stetoskoopin ja pulssioksimetrin avulla, hengityksen tukeminen maski-paljeventilaatiolla ja nieluputken käyttö. Verenkierron osalta arvioidaan verenpaineen mittausta manuaalisella aneroidimittarilla ja pulssin tunnustelua. Tajunnantason arviossa mitataan, kuinka perustason sairaankuljettajat osaavat käyttää Glasgow Coma Scalea ja tehdä karkean neurologisen arvion. Lisäksi arvioidaan verensokerin mittaustaitoa. Mittaria pilotoitiin pienellä testiryhmällä ja tulosten avulla mittaria kehitettiin loogisempaan muotoon. Korjaustöiden tuloksena saatiin aikaan paranneltu mittari, joka teoriassa on luotettava ja toimiva. Mittarin kehittämistä jatketaan keväällä 2007 opinnäytetyön toisessa osassa, jolloin on tarkoitus suorittaa testausta pienellä ryhmällä Keski-Uudenmaan Pelastuslaitoksen palomies-sairaankuljettajia. Seuraavat ensihoitajaopiskelijaryhmät jatkavat KUOSCE-hanketta käyttämällä valmista mittaria laajempaan testaukseen. Osa 2: Osaamista arvioivan mittarin luotettavuus ja käyttökelpoisuus: Tämä opinnäytetyö on osa Keski-Uudenmaan pelastuslaitoksen ja Helsingin ammattikorkeakoulu Stadian yhteistä KUOSCE-hanketta. Hankkeen päämääränä on hankkia OSCE-menetelmää apuna käyttäen tutkittua tietoa Keski-Uudenmaan pelastuslaitoksen perustason sairaankuljetuksen osaamistasosta sekä yleisestä koulutustarpeesta. Tietoa käytetään apuna suunnitellessa ja kohdennettaessa täydennyskoulutusta niille ensihoidon osaamisen alueille, joista löytyy eniten koulutustarvetta. Ensimmäisen opinnäytetyömme aiheena oli ”Keskeisten kädentaitojen osaaminen perustason sairaankuljetuksessa - osaamista arvioivan mittarin kehittäminen”, jossa kehitimme 10 itsenäisesti toimivaa mittaria. Kehitystyössä käytettiin apuna tutkittua kansainvälistä sekä kotimaista tutkimustietoa sekä työelämässä toimivien ensihoitajien sekä palomies-sairaankuljettajien osaamista ja ammattitaitoa. Kehitettyjä mittareita modifioitiin asiantuntijaryhmässä ja kuvaamme tässä työssä millaisia muutoksia modifioituihin mittareihin tehtiin. Tässä opinnäytetyömme toisessa osassa arvioimme myös kehitettyjen ja modifioitujen mittareiden luotettavuutta ja käyttökelpoisuutta. Näiden ominaisuuksien arvioimiseksi suoritettiin modifioitujen mittareiden pilotointi Keski-Uudenmaan pelastuslaitoksen palomies-sairaankuljettajilla (n=14). Pilotoinnin tuloksia ja pilotoinnista saatuja havaintoja tullaan käyttämään apuna mittarien kehittämisessä edelleen luotettavammaksi. Työssä selvitämme sitä, miten mittareiden pilotointi tapahtui, miten se sujui ja mitä havaintoja saimme pilotoinnista. Työmme tarkoituksena on saada tuotettua mahdollisimman luotettavaa ja käyttökelpoista informaatiota mittareiden toimivuudesta. Tätä informaatiota voidaan käyttää hyväksi tulevaisuudessa mittareita edelleen kehitettäessä ja niitä käytettäessä. Tulevaisuuden mittareiden käyttäjät voivat näin huomioida mittareiden vahvuudet sekä heikkoudet objektiivista testausta järjestäessään.

Investigating barriers in HIV-testing oncology patients. The IBITOP study: phase I.

BACKGROUND: Since the advent of combined antiretroviral therapy (ART), the incidence of non-AIDS-defining cancers (non-ADCs) among HIV-positive patients is rising. We previously described HIV testing rates of <5% in our oncology centre, against a local HIV prevalence of 0.4% (1). We have since worked with the Service of Oncology to identify, how HIV testing can be optimized, we have conducted a study on investigating barriers in HIV-testing oncology patients (IBITOP) among treating oncologists and their patients. METHODS: After an initial two-month pilot study to examine feasibility (2), we conducted the first phase of the IBITOP study between 1st July and 31st October 2013. Patients of unknown HIV status, newly diagnosed with solid-organ non-AIDS-defining cancer, and treated at Lausanne University Hospital were invited to participate. Patients were offered HIV testing as a part of their initial oncology work-up. Oncologist testing proposals and patient acceptance were the primary endpoints. RESULTS: Of 235 patients with a new oncology diagnosis, 10 were excluded (7 with ADCs and 3 of known HIV-positive status). Mean age was 62 years; 48% were men and 71% were Swiss. Of 225 patients, 75 (33%) were offered HIV testing. Of these, 56 (75%) accepted, of whom 52 (93%) were tested. A further ten patients were tested (without documentation of being offered a test), which gave a total testing rate of 28% (62/225). Among the 19 patients who declined testing, reasons cited included self-perceived absence of HIV risk, previous testing and palliative care. Of the 140 patients not offered HIV testing and not tested, reasons were documented for 35 (25%), the most common being previous testing and follow-up elsewhere. None of the 62 patients HIV tested had a reactive test. CONCLUSIONS: In this study, one third of patients seen were offered testing and the HIV testing rate was fivefold higher than that of previously observed in this service. Most patients accepted testing when offered. As HIV-positive status impacts on the medical management of cancer patients, we recommend that HIV screening should be performed in settings, where HIV prevalence is >0.1%. Phase II of the IBITOP study is now underway to explore barriers to HIV screening among oncologists and patients following the updated national HIV testing guidelines which recommend testing in non-ADC patients undergoing chemotherapy.

'Aquí es redacten i s'esculpeixen inscripcions': aproximació al corpus epigràfic de la ciutat de Girona

El text que es presenta a continuació: ‘Aquí s'esculpeixen inscripcions’. Aproximació al Corpus epigràfic de la ciutat de Girona, forma part d'un projecte d'investigació i anàlisi molt més ampli del que aquí es pot mostrar. Aquest té com a objectiu principal l'estudi dels signes i símbols escrits de la ciutat de Girona. És a dir, l'estudi de l'ús públic que es fa de l'escriptura, entenent l'escriptura com una eina que fa perdurable un determinat missatge i que pretén arribar a un gran nombre de persones

Intracranial hypertension: what additional information can be derived from ICP waveform after head injury?

OBJECTIVE: Although intracranial hypertension is one of the important prognostic factors after head injury, increased intracranial pressure (ICP) may also be observed in patients with favourable outcome. We have studied whether the value of ICP monitoring can be augmented by indices describing cerebrovascular pressure-reactivity and pressure-volume compensatory reserve derived from ICP and arterial blood pressure (ABP) waveforms. METHOD: 96 patients with intracranial hypertension were studied retrospectively: 57 with fatal outcome and 39 with favourable outcome. ABP and ICP waveforms were recorded. Indices of cerebrovascular reactivity (PRx) and cerebrospinal compensatory reserve (RAP) were calculated as moving correlation coefficients between slow waves of ABP and ICP, and between slow waves of ICP pulse amplitude and mean ICP, respectively. The magnitude of 'slow waves' was derived using ICP low-pass spectral filtration. RESULTS: The most significant difference was found in the magnitude of slow waves that was persistently higher in patients with a favourable outcome (p<0.00004). In patients who died ICP was significantly higher (p<0.0001) and cerebrovascular pressure-reactivity (described by PRx) was compromised (p<0.024). In the same patients, pressure-volume compensatory reserve showed a gradual deterioration over time with a sudden drop of RAP when ICP started to rise, suggesting an overlapping disruption of the vasomotor response. CONCLUSION: Indices derived from ICP waveform analysis can be helpful for the interpretation of progressive intracranial hypertension in patients after brain trauma.