Epidemiology of severe trauma.

Major injury is the sixth leading cause of death worldwide. Among those under 35 years of age, it is the leading cause of death and disability. Traffic accidents alone are the main cause, fundamentally in low- and middle-income countries. Patients over 65 years of age are an increasingly affected group. For similar levels of injury, these patients have twice the mortality rate of young individuals, due to the existence of important comorbidities and associated treatments, and are more likely to die of medical complications late during hospital admission. No worldwide, standardized definitions exist for documenting, reporting and comparing data on severely injured trauma patients. The most common trauma scores are the Abbreviated Injury Scale (AIS), the Injury Severity Score (ISS) and the Trauma and Injury severity Score (TRISS). Documenting the burden of injury also requires evaluation of the impact of post-trauma impairments, disabilities and handicaps. Trauma epidemiology helps define health service and research priorities, contributes to identify disadvantaged groups, and also facilitates the elaboration of comparable measures for outcome predictions.

[Epidemiological profile of late mortality in severe polytraumatisms]. / Perfil epidemiológico de la mortalidad tardía de los politraumatismos graves.

OBJECTIVE: A study is made of the epidemiology, chronogramand causes of late mortality in traumatized patients. DESIGN: A prospective, observational cohort study of adult trauma patients was carried out. SETTINGS: Province of Guipúzcoa (Basque Country, Spain). Intensive care unit of a tertiary hospital. PATIENTS: Patients with severe trauma (Injury Severity Score > 15), admitted to the ICU from January 1995 to December 2009, with late death (> 7 days). VARIABLES: Epidemiological, laboratory test, hemodynamic and transfusional data were collected. Severity scores: Abbreviated Injury Scale (AIS) and ISS. RESULTS: Patients: 2003; ISS: 24.3±14.2. Total deaths: 405 (20%). Late mortality (>7 days): 102 (25.2%) patients, 9 years older and with a lower (18 points) ISS score than the patients who died early (48 hours). Most frequent injuries: AIS-Head-Cervical spine ≥ 4 (52%); AIS-Abdomen ≥ 4 (19.6%); AIS-Chest ≥ 4 (11.7%); AIS-Extremities ≥ 4 (4.9%). Causes of death: 1) brain death (14.7%); 2) multiorgan failure (67.6%), in two injury contexts: a) severe brain trauma in the vegetative state and high spinal cord injuries with tetraplegia (35.3%); and b) non-neurological injuries (32.3%) with a high prevalence of hypovolemic shock, multiple transfusion and coagulopathy; 3) miscellaneous (10.7%): post-resuscitation anoxic-ischemic encephalopathy, pulmonary embolism and massive stroke; 4) non-evaluable (7%). CONCLUSIONS: Age, severity and type of injuries have an influence upon the time distribution and causality of late mortality. Brain death remains predominant, with multiorgan failure as the most frequent cause. This knowledge should contribute to the identification of problems, and to better organization of the structural and educational resources, thereby reducing the likely factors leading to death from trauma.

Early mortality in spontaneous supratentorial intracerebral haemorrhage.

BACKGROUND: Spontaneous supratentorial intracerebral haemorrhage is a severe, frequent, and poorly understood condition. Despite the publication of 12 randomised controlled trials on this subject, the role of surgery remains controversial and no treatment has proved to be effective. We report on a ten year prospective cohort study based on a defined population treated with or without surgery and their outcome in terms of early survival. METHODS: Population based, ten year prospective observational study directed to patients consecutively admitted to the Intensive Care Unit (ICU) in a tertiary centre with spontaneous supratentorial intracerebral haemorrhage. Patients were distributed in five groups according to the Glasgow Coma Score (GCS) at admission. Haemorrhages were classified as deep-seated or superficial. All patient received standard medical care, and additionally surgery if it was found indicated by the duty neurosurgeon. Primary endpoint was early mortality defined as dead occurred by any cause during the admission in the ICU. FINDINGS: During the ten year period, 1.485 patients were admitted to our centre with primary intracerebral haemorrhage. Of these, 376 were admitted to the intensive care unit and 285 sustained supratentorial haemorrhages. Low GCS was strong predictor of early mortality. Despite the larger size of haematomas in patients undergoing surgical evacuation, surgery was associated with lower early mortality in all GCS subgroups. Maximal benefit was observed in patient with admission GCS of 4-8. Superficial haematomas were operated on more often, and were associated with lower mortality rate than deep-seated cases. CONCLUSIONS: Our findings suggest that craniotomy for haematoma evacuation may reduce early mortality in patients with primary supratentorial intracerebral haemorrhage. Surgery seems specially useful in patients with admission GCS between 4 and 8, and in those with superficial haemorrhages.

[Ambulatory treatment of psychiatric diseases among the deaf in Denmark]. / Ambulant behandling of psykiatriske lidelser blandt døve i Danmark.

An account has been prepared describing the psychiatric treatment of preverbally deaf adults in Denmark during the period 01.01.1986 to 31.12.1991, as well as an analysis of these patients with regard to demographic and psychiatric characteristics. During this period 1231 outpatient treatments were recorded, pertaining to 168 patients. A total of 1.9-2.8% of the deaf adult population received specialised psychiatric treatment per year, either under hospitalization or as out-patients. The most dominant psychiatric diagnoses were functional psychoses (21%), serious personality disorders (25%) and affect reactions (15%). The educational levels and occupational circumstances og these patients were of a much lower standard than those of deaf adults in general. During the course of the investigation period a restructuring has taken place at the National Institution for the Deaf which has enabled a significant reduction in the duration of hospitalization in the Department of Psychiatry for the Deaf. The Institution for the Deaf now permanently accommodates 55 of the previously mentioned 168 out-patients (33%). This reorganisation has resulted in changes in the methods of treatment in the Department of Psychiatry for the Deaf towards hospitalizations of shorter duration for the treatment of acute exacerbations of serious psychiatric disorders as well as of forensic psychiatric patients.

Cross-reaction of lupus anti-dsDNA antibodies with protein translation factor EF-2.

This report elucidates a new cross-reactive intracellular target of anti-dsDNA antibodies. Previous experiments have demonstrated that some anti-dsDNA antibodies penetrate cells grown in tissue culture and all inhibit in vitro translation. Data implicate a cross-reactive antigen directly involved in protein synthesis: elongation factor-2 (EF-2). EF-2 was identified by N-terminal sequencing of a band identified with an antibody to the ribosomal protein S1 from Leuconostoc lactis in Western blot assay. Anti-DNA antibodies bind directly to purified EF-2 from bovine liver in dot blot assays. Anti-dsDNA antibodies were shown to inhibit in vitro translation. This inhibiting effect of anti-dsDNA antibodies was partially restored by EF-2 and abrogated by dsDNA, suggesting this cross-reactive specificity. These data demonstrate a cross-reaction between anti-dsDNA antibodies and EF-2 which may lead to cellular dysfunction, as evidenced by inhibition of protein synthesis, and provide a direct pathogenic role for cell penetrating anti-dsDNA antibodies.

Characterization of immunorelated peptides to porcidin P1.

Porcidin P1, an antimicrobial peptide purified from the granules of porcine polymorphonuclear neutrophils (PMN) using ultrafiltration and reverse phase high performance liquid chromatography (RP-HPLC), was covalently conjugated to BSA and used to generate monospecific polyclonal ascites. Antibodies raised against porcidin P1 were covalently coupled to an Affi-gel Hz affinity column and used for immunoaffinity chromatography of peptides from porcine PMN cell extract. Eleven immunorelated peptides were eluted from the column from neutrophil cell extracts and purified to homogeneity by HPLC. The molecular weights of the immunorelated peptides were determined by mass spectral analysis and ranged in size from 1.91 to 10.65 kDa. Of the 11 immunorelated peptides which were bound to the affinity column, only six peptides were recognized by the anti-porcidin antibodies after HPLC purification. Three immunoreactive peptides displayed potent antibacterial activity towards Staphylococcus aureus and Escherichia coli, reducing viability by as much as 99.9% (> 3 log reduction in CFU) when 5 mu g/mL of each purified peptide was used. The polyclonal monospecific antibodies also reacted with proteins from ovine and human PMN, illustrating possible structural relationships between small antibacterial peptides from the different species.

Antibacterial proteins from porcine polymorphonuclear neutrophils.

Antibacterial peptides were purified from porcine neutrophil granules collected from healthy pigs. Granule proteins, extracted with 0.2 mol/L sodium acetate were subjected to ion-exchange chromatography and five peaks (designated A to E) were detected. Individual porcine neutrophil granule proteins were shown to inhibit the growth of target organisms Escherichia coli and Staphylococcus aureus. The antimicrobial activity was shown to be concentration and time dependent. Peak D showed strong antimicrobial activity against S. aureus and peak C (with a greater number of eluted proteins) was shown to be active against both S. aureus and E. coli. One of the peptides was purified further by reverse-phase HPLC from peak fraction C. The MW of this peptide was approximately 5500 Da as determined by SDS-PAGE and mass spectral analysis and was active against both E. coli and S. aureus in vitro sustaining a > 90% decrease, respectively, in CFU after a 2 h exposure with 50 micrograms of this peptide. Amino acid analysis showed the peptide was rich in aspartate/aspartic acid, glutamine/glutamic acid, proline, arginine and threonine. The antimicrobial activity of this peptide and other novel proteins in porcine neutrophilic granules demonstrates the probable role of these proteins and peptides in host defence of porcine neutrophils against bacterial infection.

Spontaneous rupture of the liver in amyloidosis.

Hepatic rupture is an unusual complication of hepatic amyloidosis. We report the case of a 59-yr-old man with a subcapsular hematoma of the liver with hepatic rupture secondary to amyloidosis. The patient died during the surgery. The etiology, pathology, diagnosis, and treatment of this complication are discussed. Previously reported cases of subcapsular hematoma of the liver secondary to amyloidosis are reviewed. This knowledge and an awareness of the possible diagnosis will help to decrease the high mortality rate associated with this complication.