Outcomes of traumatic brain injury: the prognostic accuracy of various scores and models.

INTRODUCTION: Traumatic Brain Injury (TBI) is a worldwide health problem, and is a pathology that causes significant mortality and disability in Latin America. Different scores and prognostic models have been developed in order to predict the neurological outcomes of patients. We aimed to test the prognostic accuracy of the Marshall CT classification system, the Rotterdam CT scoring system, and the IMPACT and CRASH models, in predicting 6-month mortality and 6-month unfavourable outcomes in a cohort of trauma patients with TBI in a university hospital in Colombia. METHODS: We analysed 309 patients with significant TBI who were treated in a regional trauma centre in Colombia over a two year period. Bivariate and multivariate analyses were undertaken. The discriminatory power of each model, as well as its accuracy and precision, were assessed by logistic regression and AUC. Shapiro Wilks, chi2 and Wilcoxon test were used to compare the actual outcomes in the cohort against the predicted outcomes. RESULTS: The median age was 32 years, and 77.67% were male. All four prognostic models showed good accuracy in predicting outcomes. The IMPACT model had the greatest accuracy in predicting an unfavourable outcome (AUC 0.864; 95% CI 0.819 - 0.909) and in predicting mortality (AUC 0.902; 95% CI 0.862 - 0.943) in patients with TBI. CONCLUSION: All four prognostic models are applicable to eligible TBI patients in Colombia. The IMPACT model was shown to be more accurate than the other prognostic models, and had a higher sensitivity in predicting 6-month mortality and 6-month unfavourable outcomes in patients with TBI in a university hospital in Colombia.

Damage control of civilian penetrating brain injuries in environments of low neuro-monitoring resources.

INTRODUCTION: Gunshot wounds to the head are more common in military settings. Recently, a damage control (DC) approach for the management of these lesions has been used in combat areas. The aim of this study was to evaluate the results of civilian patients with penetrating gunshot wounds to the head, managed with a strategy of early cranial decompression (ECD) as a DC procedure in a university hospital with few resources for intensive care unit (ICU) neuro-monitoring in Colombia. MATERIALS AND METHODS: Fifty-four patients were operated according to the DC strategy (<12 h after injury), over a 4-year period. Variables were analysed and results were evaluated according to the Glasgow Outcome Scale (GOS) at 12 months post injury; a dichotomous variable was established as 'favourable' (GOS 4-5) or 'unfavourable' (GOS 1-3). A univariate analysis was performed using a χ(2) test. RESULTS: Forty (74.1%) of the patients survived and 36 (90%) of them had favourable GOS. Factors associated with adverse outcomes were: Injury Severity Score (ISS) greater than 25, bi-hemispheric involvement, intra-cerebral haematoma on the first CT, closed basal cisterns and non-reactive pupils in the emergency room. CONCLUSION: DC for neurotrauma with ECD is an option to improve survival and favourable neurological outcomes 12 months after injury in patients with penetrating traumatic brain injury treated in a university hospital with few resources for ICU neuro-monitoring.

Hepatic and Mesenteric Vasculitis as Presenting Manifestation of Mixed Cryoglobulinemia Related to Chronic Hepatitis C Virus Infection in a Female Patient.

Approximately 80% of patients with hepatitis C virus infection develop chronic liver disease as cirrhosis, and 40% develop autoimmune complications as mixed cryoglobulinemia (MC). Gastrointestinal involvement in MC is rare, and even more so is hepatic involvement. We report a case of an 87-year-old woman with a 10-year history of blood transfusion-acquired hepatitis C virus infection, without treatment. She consulted the emergency department for diffuse abdominal pain, associated with vomiting. After 2 weeks of hospitalization in the intensive care unit, a diagnosis of MC was made; cirrhosis and secondary mesenteric and hepatic vasculitis were confirmed by a diagnostic laparoscopy. Unfortunately the condition of the patient worsened with sepsis and resulted in death in the fourth week from admission. This case highlights the importance of having in mind gastrointestinal tract vasculitis as a medical cause of abdominal pain in patients with chronic hepatitis C virus infection and using data laboratory tests, images, and histopathologic studies to aid with the diagnosis.

First trimester sonographic diagnosis of orofacial defects. Review of literature.

Ultrasound has been used since the 1950s as a useful tool for the screening of several pregnancy abnormalities. The National Institute for Excellence in Health and Care (NICE) guidelines for prenatal control recommend its routine use between 12 and 20 weeks of gestational age, given that during the first trimester, a series of very frequent markers that determine a high risk of fetal anomalies can be evaluated. Among these markers, the most frequently studied are: increased nuchal translucency, the absence of nasal bones, increased tricuspid regurgitation, and altered flow in the venous duct. There is also a new ultrasound technique consisting of the evaluation of the retronasal triangle view, which captures the coronal plane of the face in which the primary palate and the frontal process of the maxillary are simultaneously visualized, presenting high sensitivity and specificity for malformations such as oropalatine clefts, malformations of the nasal bones, and micrognathia. The purpose of this article is to make a comprehensive review of first trimester sonographic diagnosis of orofacial defects.

External Validation of the Rotterdam Computed Tomography Score in the Prediction of Mortality in Severe Traumatic Brain Injury.

INTRODUCTION: Traumatic brain injury (TBI) is a public health problem. It is a pathology that causes significant mortality and disability in Colombia. Different calculators and prognostic models have been developed to predict the neurological outcomes of these patients. The Rotterdam computed tomography (CT) score was developed for prognostic purposes in TBI. We aimed to examine the accuracy of the prognostic discrimination and prediction of mortality of the Rotterdam CT score in a cohort of trauma patients with severe TBI in a university hospital in Colombia. MATERIALS AND METHODS: We analyzed 127 patients with severe TBI treated in a regional trauma center in Colombia over a 2-year period. Bivariate and multivariate analyses were used. The discriminatory power of the score, its accuracy, and precision were assessed by logistic regression and as the area under the receiver operating characteristic curve. Shapiro-Wilk, Chi-square, and Wilcoxon tests were used to compare the real outcomes in the cohort against the predicted outcomes. RESULTS: The median age of the patient cohort was 33 years, and 84.25% were male. The median injury severity score was 25, the median Glasgow Coma Scale motor score was 3, the basal cisterns were closed in 46.46% of the patients, and a midline shift of >5 mm was seen in 50.39%. The 6-month mortality was 29.13%, and the Rotterdam CT score predicted a mortality of 26% (P < 0.0001) (area under the curve: 0.825; 95% confidence interval: 0.745-0.903). CONCLUSIONS: The Rotterdam CT score predicted mortality at 6 months in patients with severe head trauma in a university hospital in Colombia. The Rotterdam CT score is useful for predicting early death and the prognosis of patients with TBI.

Predicted Unfavorable Neurologic Outcome Is Overestimated by the Marshall Computed Tomography Score, Corticosteroid Randomization After Significant Head Injury (CRASH), and International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) Models in Patients with Severe Traumatic Brain Injury Managed with Early Decompressive Craniectomy.

INTRODUCTION: Traumatic brain injury (TBI) is of public health interest and produces significant mortality and disability in Colombia. Calculators and prognostic models have been developed to establish neurologic outcomes. We tested prognostic models (the Marshall computed tomography [CT] score, International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT), and Corticosteroid Randomization After Significant Head Injury) for 14-day mortality, 6-month mortality, and 6-month outcome in patients with TBI at a university hospital in Colombia. METHODS: A 127-patient cohort with TBI was treated in a regional trauma center in Colombia over 2 years and bivariate and multivariate analyses were used. Discriminatory power of the models, their accuracy, and precision was assessed by both logistic regression and area under the receiver operating characteristic curve (AUC). Shapiro-Wilk, χ2, and Wilcoxon test were used to compare real outcomes in the cohort against predicted outcomes. RESULTS: The group's median age was 33 years, and 84.25% were male. The injury severity score median was 25, and median Glasgow Coma Scale motor score was 3. Six-month mortality was 29.13%. Six-month unfavorable outcome was 37%. Mortality prediction by Marshall CT score was 52.8%, P = 0.104 (AUC 0.585; 95% confidence interval [CI] 0 0.489-0.681), the mortality prediction by CRASH prognosis calculator was 59.9%, P < 0.001 (AUC 0.706; 95% CI 0.590-0.821), and the unfavorable outcome prediction by IMPACT was 77%, P < 0.048 (AUC 0.670; 95% CI 0.575-0.763). CONCLUSIONS: In a university hospital in Colombia, the Marshall CT score, IMPACT, and Corticosteroid Randomization After Significant Head Injury models overestimated the adverse neurologic outcome in patients with severe head trauma.

Results of early cranial decompression as an initial approach for damage control therapy in severe traumatic brain injury in a hospital with limited resources.

INTRODUCTION: Severe traumatic brain injury (sTBI) is a disease that generates significant mortality and disability in Latin America, and specifically in Colombia. The purpose of this study was to evaluate the 12-month clinical outcome in patients with sTBI managed with an early cranial decompression (ECD) as the main procedure for damage control (DC) therapy, performed in a University Hospital in Colombia over a 4-year period. MATERIALS AND METHODS: A database of 106 patients who received the ECD procedure, and were managed according to the strategy for DC in neurotrauma, was analyzed. Variables were evaluated, and the patient outcome was determined according to the Glasgow Outcome Score (GOS) at 12 months postinjury. This was used to generate a dichotomous variable with "favorable" (GOS of 4 or 5) or "unfavorable" (GOS of 1-3) outcomes; analysis of variance was performed with the Chi-square, Wilcoxon-Mann-Whitney and Fisher tests. RESULTS: An overall survival rate of 74.6% was observed for the procedure, At 12 months postsurgery, a favorable clinical outcome (GOS 4-5) was found in 70 patients (66.1%), Unfavorable outcomes in patients were associated with the following factors: Closed trauma, an Injury Severity Score >16, obliterated basal cisterns, subdural hematoma as the main injury seen on the admission computed tomography, and nonreactive pupils observed in the emergency department. CONCLUSION: Twelve months outcome of patients with sTBI managed with ECD in a neuromonitoring limited resource University Hospital in Colombia shows an important survival rate with favorable clinical outcome measure with GOS.

A standardized trauma care protocol decreased in-hospital mortality of patients with severe traumatic brain injury at a teaching hospital in a middle-income country.

INTRODUCTION: Standardized trauma protocols (STP) have reduced morbidity and in-hospital mortality in mature trauma systems. Most hospitals in low- and middle-income countries (LMICs) have not implemented STPs, often because of financial and logistic limitations. We report the impact of an STP designed for the care of trauma patients in the emergency department (ED) at an LMIC hospital on patients with severe traumatic brain injury (STBI). METHODS: We developed an STP based on generally accepted best practices and damage control resuscitation for a level I trauma centre in Colombia. Without a pre-existing trauma registry, we adapted an administrative electronic database to capture clinical information of adult patients with TBI, a head abbreviated injury score (AIS) ≥3, and who presented ≤12h from injury. Demographics, mechanisms of injury, and injury severity were compared. Primary outcome was in-hospital mortality. Secondary outcomes were Glasgow Coma Score (GCS), length of hospital and ICU stay, and prevalence of ED interventions recommended in the STP. Logistic regression was used to control for potential confounders. RESULTS: The pre-STP group was hospitalized between August 2010 and August 2011, the post-STP group between September 2011 and June 2012. There were 108 patients meeting inclusion criteria, 68 pre-STP implementation and 40 post-STP. The pre- and post-STP groups were similar in age (mean 37.1 vs. 38.6, p=0.644), head AIS (median 4.5 vs. 4.0, p=0.857), Injury Severity Scale (median 25 vs. 25, p=0.757), and initial GCS (median 7 vs. 7, p=0.384). Post-STP in-hospital mortality decreased (38% vs. 18%, p=0.024), and discharge GCS increased (median 10 vs. 14, p=0.034). After controlling for potential confounders, odds of in-hospital mortality post-STP compared to pre-STP were 0.248 (95%CI: 0.074-0.838, p=0.025). Hospital and ICU stay did not significantly change. The use of many ED interventions increased post-STP, including bladder catheterization (49% vs. 73%, p=0.015), hypertonic saline (38% vs. 63%, p=0.014), arterial blood gas draws (25% vs. 43%, p=0.059), and blood transfusions (3% vs. 18%, p=0.008). CONCLUSIONS: An STP in an LMIC decreased in-hospital mortality, increased discharge GCS, and increased use of vital ED interventions for patients with STBI. An STP in an LMIC can be implemented and measured without a pre-existing trauma registry.

Fisiología de la perfusión medular / Physiology of spinal perfusion

Introducción: En las últimas décadas ha aumentado el interés por el estudio de la fisiología de la perfusión a nivel de la médula espinal. Muchos de los tratamientos en pacientes con lesión medular han sido basados en el paralelismo de la dinámica vascular entre el cerebro y la médula. Conocer estos aspectos así como los métodos relacionados con su monitoria resulta favorable para la adecuada intervención del paciente con lesión a nivel medular. Objetivo: Realizar una revisión en la literatura científica de los aspectos más importantes que intervienen en la perfusión de la médula espinal, los mecanismos de autorregulación y su aplicación clínica dentro del estudio de la fisiología medular. Métodos: Con las palabras claves, se realizó una revisión no sistemática en las bases de datos correspondientes a OVID, Medline/PubMed, Science Direct. Resultados y Conclusiones: El papel de la autorregulación es vital en la conservación de la integridad de la médula espinal, realizar un adecuado control de ella así como de otros factores químicos y metabólicos son determinantes en el control del flujo sanguíneo medular y minimiza el riesgo de lesión medular secundaria. Las curvas de autorregulación para el cerebro y la médula espinal son virtualmente idénticas; dentro de un rango de 60-150 mmHg.

Introduction: Over the past decades the interest in the study of the physiology of perfusion at the level of the spinal cord has increased. Many treatments in patients with spinal cord injury have been based on the parallelism of the vascular dynamics between the brain and the spinal. Knowing about these aspects and methods related to their monitoring practice is favorable for a proper intervention of the patient with spinal cord injury. Objective: To do a scientific literature review on the most important aspects involved in spinal cord perfusion, autoregulatory mechanisms and their clinical applications in the study of spinal cord physiology. Methods: Using the keywords, a non-systematic review on the OVID, Medline/PubMed and Science Direct databases, was performed. Results and Conclusion: The role of autoregulation is vital in maintaining the integrity of the spinal cord, an adequate control of it as well as other chemical and metabolic factors are important in the control of medullary blood flow and minimizes the risk of secondary spinal cord injury. The autoregulation curves for the brain and spinal cord are virtually identical, within a range of 60-150 mmHg.

Uso dispositivo diversor de flujo pipeline® para tratamiento endovascular de aneurisma intracraneal distal gigante / Use pipeline® flow diversion device for endovascular treatment of giant distal intracranial aneurysm

El Dispositivo de Embolización Pipeline (PED) fue el primer dispositivo para la desviación de flujo aprobado por la FDA (Food and Drug Administration), el cual se emplea como tratamiento de aneurismas intracraneales. Se presenta el caso de un paciente femenino de 74 años de edad con diagnóstico de aneurisma sacular de la bifurcación de la arteria carótida interna derecha más placa calcificada en el origen de la arteria carótida interna derecha. Se decide terapia endovascular más colocación de PED como método terapéutico

The Pipeline Embolization Device (PED) was the first device for flow diversion approved by the FDA (Food and Drug Administration), which is used as a treatment of intracranial aneurysms. The case arises from a 74-year-old female patient with a diagnosis of a saccular aneurism in the right internal carotid artery bifurcation and a calcified plaque in the origin of the right internal carotid artery. The therapeutic method was decided to be endovascular therapy and PED placement