Investigating feasibility of 2021 WHO protocol for cervical cancer screening in underscreened populations: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC).

BACKGROUND: High-risk human papillomavirus (hrHPV) testing has been recommended by the World Health Organization as the primary screening test in cervical screening programs. The option of self-sampling for this screening method can potentially increase women's participation. Designing screening programs to implement this method among underscreened populations will require contextualized evidence. METHODS: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer (PRESCRIP-TEC) will use a multi-method approach to investigate the feasibility of implementing a cervical cancer screening strategy with hrHPV self-testing as the primary screening test in Bangladesh, India, Slovak Republic and Uganda. The primary outcomes of study include uptake and coverage of the screening program and adherence to follow-up. These outcomes will be evaluated through a pre-post quasi-experimental study design. Secondary objectives of the study include the analysis of client-related factors and health system factors related to cervical cancer screening, a validation study of an artificial intelligence decision support system and an economic evaluation of the screening strategy. DISCUSSION: PRESCRIP-TEC aims to provide evidence regarding hrHPV self-testing and the World Health Organization's recommendations for cervical cancer screening in a variety of settings, targeting vulnerable groups. The main quantitative findings of the project related to the impact on uptake and coverage of screening will be complemented by qualitative analyses of various determinants of successful implementation of screening. The study will also provide decision-makers with insights into economic aspects of implementing hrHPV self-testing, as well as evaluate the feasibility of using artificial intelligence for task-shifting in visual inspection with acetic acid. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05234112 . Registered 10 February 2022.

Location of traumatic brain injury-related deaths: epidemiological analysis of 11 European countries.

Background: Understanding the factors related to traumatic brain injury (TBI)-related mortality is important in obtaining a complete picture of the predictors and burden of injury-related deaths. Objective: To analyze deaths due to TBI occurring inside versus outside hospitals. Methods: Data were obtained by requests to the representatives of national statistical offices and health administration institutions for one reported calendar year (2014 or the nearest available year). Results: A total of 4513 cases of TBI-related deaths were identified. Of these, 2045 (45%) occurred outside and 2468 (55%) in hospitals. The pooled out-of-hospital age-adjusted mortality rate was 5.5 (95% CI = 4.8-6.3), and in-hospital age-adjusted rate was 6.6 (95% CI = 5.2-7.9) per 100 000 people. Outside (25%) or inside (53%) hospitals, the most common cause of TBI-related deaths was falls. The age group of 15-24 years and traffic-related, suicide-related, and violence-related mechanisms were the most significant factors associated with deaths occurring outside hospitals. Conclusions: The results of this study may be of use in planning and allocation of public health resources, and identification of the situations most commonly associated with fatalities in different locations.

Years of life lost due to traumatic brain injury in Europe: A cross-sectional analysis of 16 countries.

INTRODUCTION: Traumatic brain injuries (TBIs) are a major public health, medical, and societal challenge globally. They present a substantial burden to victims, their families, and the society as a whole. Although indicators such as incidence or death rates provide insight into the occurrence and outcome of TBIs in various populations, they fail to quantify the full extent of their public health and societal impact. Measures such as years of life lost (YLLs), which quantifies the number of years of life lost because the person dies prematurely due to a disease or injury, should be employed to better quantify the population impact. The aim of this study was to provide an in-depth analysis of the burden of deaths due to TBI by calculating TBI-specific YLLs in 16 European countries, analyzing their main causes and demographic patterns, using data extracted from death certificates under unified guidelines and collected in a standardized manner. METHODS AND FINDINGS: A population-wide, cross-sectional epidemiological study was conducted in 16 European countries to estimate TBI YLLs for the year 2013. The data used for all analyses in this study were acquired from the statistical office of the European Union (Eurostat). A specifically tailored dataset of micro-level data was provided that listed the external cause of death (International Classification of Diseases-10th Revision [ICD-10] codes V01-Y98), the specific nature of injury (ICD-10 codes S00-T98), the age at death, and sex for each death. Overall number of TBI YLLs, crude and age-standardized TBI YLL rates, and TBI YLLs per case were calculated stratified for country, sex, and age. Pooled analyses were performed in order to estimate summary age-standardized rates of TBI YLLs. In order to evaluate the relative importance of TBI in the context of all injuries, proportions of TBI YLLs out of overall injury YLLs were calculated. The total number of TBI YLLs was estimated by extrapolating the pooled crude rate of TBI YLLs in the 16 analyzed countries to the total population of the 28 member states of the EU (EU-28). We found that a total of 17,049 TBI deaths occurred in 2013 in the 16 analyzed countries. These translated into a total of 374,636 YLLs. The pooled age-standardized rate of YLLs per 100,000 people per year was 259.1 (95% CI: 205.8 to 312.3) overall, 427.5 (95% CI: 290.0 to 564.9) in males, and 105.4 (95% CI: 89.1 to 121.6) in females. Males contributed substantially more to TBI YLLs than females (282,870 YLLs, 76% of all TBI YLLs), which translated into a rate ratio of 3.24 (95% CI: 3.22 to 3.27). Each TBI death was on average associated with 24.3 (95% CI: 22.0 to 26.6) YLLs overall, 25.6 (95% CI: 23.4 to 27.8) in males and 20.9 (17.9 to 24.0) in females. Falls and traffic crashes were the most common external causes of TBI YLLs. TBI contributed on average 41% (44% in males and 34% in females) to overall injury YLLs. Extrapolating our findings, about 1.3 million YLLs were attributable to TBI in the EU-28 in 2013 overall, 1.1 million in males and 271,000 in females. This study is based on administratively collected data from 16 countries, and despite the efforts to harmonize them to the greatest possible extent, there may be differences in coding practices or reporting between countries. If present, these would be inherited into our findings without our ability to control for them. The extrapolation of the pooled rates from the 16 countries to the EU-28 should be interpreted with caution. CONCLUSIONS: Our study showed that TBI-related deaths and YLLs have a substantial impact at the individual and population level in Europe and present an important societal and economic burden that must not be overlooked. We provide information valuable for policy-makers, enabling them to evaluate and plan preventive activities and resource allocation, and to formulate and implement strategic decisions. In addition, our results can serve as a basis for analyzing the overall burden of TBI in the population.

Severity, Causes and Outcomes of Traumatic Brain Injuries Occurring at Different Locations: Implications for Prevention and Public Health.

AIM: Traumatic brain injuries (TBI) are a major public health problem. Although they are well studied, information on some aspects, such as the place of occurrence, is limited. The aim of this study was to describe the patterns of severity, causes and outcomes of TBI occurring at different locations and to identify the primary populations at risk of suffering TBI at each of the analysed locations. METHODS: 1,818 patients with TBI admitted to hospitals in Austria, Slovakia, Croatia, Bosnia, and Macedonia were analysed. Primary populations at risk, injury severity and extent along with short/long-term outcomes were analysed for TBI at each location. RESULTS: The highest mean age (57.9 years, p<0.001) was observed in injuries at home. The distribution of injury causes across the group was significantly different (p<0.001), with falls (39%) and traffic accidents (30%) being predominant. TBI occurring on roads or highways were the most severe (mean ISS=32.5, p<0.001; mean GCS=7.8, p<0.001). Injuries at home had the worst outcome (50% mortality, p<0.001 and 70% unfavourable outcome, p<0.001) whereas TBI at sport facilities or outdoors had the best outcome (24% mortality, 44% unfavourable outcome). When adjusted for age and severity, TBI occurring at home had the highest odds of mortality (OR=3.12, 95% CI=1.86-5.25) and unfavourable outcome (OR=2.51, 95% CI=1.54-4.08), compared to sports facility and outdoors as a reference. CONCLUSIONS: TBI at different locations display distinctive patterns as to causes, severity, outcome and populations at risk. Location is therefore a relevant epidemiological aspect of TBI and we advocate its inclusion in future studies. Definitions of primary populations at risk at different locations could help in targeted public health actions.

Traumatic brain injuries caused by traffic accidents in five European countries: outcome and public health consequences.

BACKGROUND: Road traffic accidents (RTAs) have been identified by public health organizations as being of major global concern. Traumatic brain injuries (TBIs) are among the most severe injuries and are in a large part caused by RTA. The objective of this article is to analyse the severity and outcome of TBI caused by RTA in different types of road users in five European countries. METHODS: The demographic, severity and outcome measures of 683 individuals with RTA-related TBI from Austria, Slovakia, Bosnia, Croatia and Macedonia were analysed. Five types of road users (car drivers, car passengers, motorcyclists, bicyclists and pedestrians) were compared using univariate and multivariate statistical methods. Short-term outcome [intensive care unit (ICU) survival] and last available long-term outcome of patients were analysed. RESULTS: In our data set, 44% of TBI were traffic related. The median age of patients was 32.5 years, being the lowest (25 years) in car passengers. The most severe and extensive injuries were reported in pedestrians. Pedestrians had the lowest rate of ICU survival (60%) and favourable long-term outcome (46%). Drivers had the highest ICU survival (73%) and car passengers had the best long-term outcome (59% favourable). No differences in the outcome were found between countries with different economy levels. CONCLUSION: TBI are significantly associated with RTA and thus, tackling them together could be more effective. The population at highest risk of RTA-related TBI are young males (in our sample median age: 32.5 years). Pedestrians have the most severe TBI with the worst outcome. Both groups should be a priority for public health action.

Trends in age-adjusted coronary heart disease mortality rates in Slovakia between 1993 and 2009.

Cardiovascular diseases (CVD) and especially coronary heart disease (CHD) are the main causes of death in the Slovak Republic (SR). The aim of this study is to explore trends in age-adjusted coronary heart disease mortality rates in the whole Slovak population and in the population of working age between the years 1993 and 2009. A related indicator - potential years of life lost (PYLL) due to CHD--was calculated in the same period for males and females. Crude CHD mortality rates were age-adjusted using European standard population. The joinpoint Poisson regression was performed in order to find out the annual percentage change in trends. The age-adjusted CHD mortality rates decreased in the Slovak population and also in the population of working age. The change was significant only within the working-age sub-group. We found that partial diagnoses (myocardial infarction and chronic ischaemic heart disease) developed in the mirror-like manner. PYLL per 100,000 decreased during the observed period and the decline was more prominent in males. For further research we recommend to focus on several other issues, namely, to examine the validity of cause of death codes, to examine the development of mortality rates in selected age groups, to find out the cause of differential development of mortality rates in the Slovak Republic in comparison with the Czech Republic and Poland, and to explain the causes of decrease of the age-adjusted CHD mortality rates in younger age groups in Slovakia.

International evidence-based guidelines on hypertension and type 2 diabetes mellitus: A systematic review.

This systematic review provides a high-quality, comprehensive summary of recommendations on hypertension (HT) and type 2 diabetes mellitus (T2DM), accentuating patient blood pressure, HbA1c levels, patterns of drug treatment, management, and screening of these diseases. The overall objective of the review is to support adapting existing clinical practice guidelines in Indonesia, Vietnam, and Myanmar. The database PubMed and the web search engines Google and Google Scholar were searched from October to December 2019 for evidence-based guidelines covering the overall disease management in Europe, the United States of America, and low and middle-income countries (Indonesia, Vietnam, and Myanmar-IVM later on). Nine studies were selected for the review, seven concerning HT and five T2DM. Guidelines in IVM and Europe identified HT as increased blood pressure (BP; ≥140/90 mmHg). IVM guidelines also recommended commencing drug treatment if lifestyle interventions were not successful. Four international HT guidelines recommended monitoring BP every few months, and the other three guidelines gave recommendations based on the patient's current BP levels. All five T2DM guidelines recommended target HbA1c levels below 7%-6.5%, but only IVM guidelines included re-examination every 3-6 months. Metformin was recommended as the first choice of medical treatment, if not contraindicated. Amid the guidelines' recommendations, there were no major variations in the Class of recommendation and Level of evidence (except IVM guidelines where COR and LOE were missing). Revision and completion of IVM guidelines by this grading system would enhance evidence-based and informed decisions in clinical care.

Traumatic brain injury related deaths in residents and non-residents of 30 European countries: a cross-sectional study.

The incidence and mortality of traumatic brain injuries (TBI) among non-residents to countries where they occur remains unknown, warranting epidemiological research. Epidemiological data are key to inform prevention and public health policies related to TBI, as well as to help promote safe travelling practice. The aim of this study was to analyse the epidemiological patterns of TBI-related deaths among residents and non-residents in 30 European countries in 2015 using standardised European level data on causes of death. A large-scale cross-sectional study analysing TBI-related deaths in 30 European countries in 2015 among residents and non-residents to the country of occurrence of the death was conducted. Data from death certificates collected on European level by Eurostat were used to calculate the numbers of TBI-related deaths and estimate crude and age-standardised mortality rates. Rates were stratified by country, sex, age-group and by resident status. External causes of the injury were determined using the provided ICD-10 codes. 40,087 TBI-related deaths were identified; overall about 3% occurred among non-residents with highest proportions in Turkey (11%), Luxembourg (9%) and Cyprus (5%). Taking into account tourism intensity in the countries, Bulgaria, Greece and Austria showed highest rates of TBI-related deaths in non-residents: 0.7,0.5 and 0.5 per million overnight stays, respectively. The pooled age-standardised TBI-related mortality in non-residents was 0.2 (95% CI 0.1-0.3), among residents 10.4 (95% CI 9.4-11.5) per 100,000. In non-residents, TBI-related deaths were shifted to younger populations (86% in < 35 years); in non-residents 78% were 15-64 years old. Falls were predominant among residents (47%), and traffic accidents among non-residents (36%). Male:female ratio was higher among non-residents (3.9), compared to residents (2.1). Extrapolating our findings, we estimate that annually 1022 TBI-related deaths would occur to non-residents in the EU-27 + UK and 1488 in Europe as a continent. We conclude, that the primary populations at risk of TBI-related deaths in European countries differ in several characteristics between residents and non-residents to the country of the occurrence of death, which warrants for different approaches in prevention and safety promotion. Our findings suggest that TBI occurring in European countries among non-residents present a problem worthy of attention from public health and travel medicine professionals and should be further studied.

Co-occurrence of behavioural risk factors for non-communicable diseases among 40-year and above aged community members in three regions of Myanmar.

Background: Risky behaviours such as smoking, alcohol consumption, physical inactivity and inadequate consumption of fruits and vegetables are known contributing factors for non-communicable diseases (NCDs) which account for 74% of global mortality. Such behavioural risk factors co-occur frequently resulting in synergistic action for developing NCD related morbidity and mortality. This study aims to assess the existence of multiple risk behaviours and determine the socio-economic and demographic factors associated with co-occurrence of behavioural risks among Myanmar adult population. Method: Data were collected, in the context of the SUNI-SEA project (Scaling Up NCD interventions in Southeast Asia), from 660 community members aged 40 years and above of both sexes, residing in selected urban and rural areas from Ayeyawaddy, Yangon and Mandalay regions of Myanmar. The co-occurrence of behavioural risk factors was presented as percentage with 95% CI and its determinants were identified by multinomial logistic regression. Results: The co-occurrence of two risk behaviours and three or four risk behaviours were found in 40% (95% CI: 36.2%, 43.9%) and 10.8% (95% CI: 8.5%, 13.4%) respectively. Urban residents, men, participants without formal schooling and unemployed persons were more likely to exhibit co-occurrence of two risk behaviors and three or four risk behaviours. Conclusion: The current study shows high prevalence of co-occurrence of behavioural risk factors among Myanmar adults in the study area. NCD prevention and control programs emphasizing management of behavioural risks should be intensively promoted, particularly directed towards multiple behavioural risk factors, and not focused on individual factors only.

Risky behaviours such as smoking, alcohol consumption, physical inactivity and inadequate consumption of fruits and vegetables are known contributing factors for non-communicable diseases (NCDs) which account for 74% of global mortality. Such behavioural risk factors co-occur frequently resulting in synergistic action for developing NCD related morbidity and mortality. This study aims to assess the existence of multiple risk behaviours and determine the socio-economic and demographic factors associated with co-occurrence of behavioural risks among the Myanmar adult population. Data were collected from 660 community members aged 40 years and above of both sexes, residing in selected urban and rural areas from Ayeyawaddy, Yangon and Mandalay Regions of Myanmar. The current study shows substantial proportion of study adults had co-occurrence of behavioural risk factors (at least two risk factors), contributing to 50.8%. Urban residents, men, participants without formal schooling and unemployed persons were more likely to present co-occurrence of two risk behaviors and three or four risk behaviours, compared with their counterparts. Based on the study findings, the research team highly recommends that NCD prevention and control programs emphasizing management of behavioural risks should be intensively promoted, particularly directed towards multiple behavioural risk factors, and not focused on single risk factor only.

Effects of gender on outcomes after traumatic brain injury.

BACKGROUND: It has been reported that female gender may be an independent risk factor for poor outcome after traumatic brain injury (TBI). The goal of this study was to investigate gender differences in outcome after TBI. METHODS: Between February 2002 and April 2010, 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data on crash, treatment, and outcomes were collected. Data sets from patients who had isolated TBI were selected. Six-month outcomes were classified as "favorable" if Glasgow Outcome Scale scores were 5 or 4 and were classified as "unfavorable" if Glasgow Outcome Scale scores were 3 or less. The Rotterdam score was used to classify computed tomography (CT) findings. Univariate statistics (Fisher's exact test, t test, χ2 test) and logistic regression were used to identify factors associated with hospital mortality and favorable outcome. RESULTS: There were 134 female and 305 male patients. Hospital mortality was 39.6% for females and 32.5% for males (p = 0.16). Rates of unfavorable outcome were 58.7% for females and 53.4% for males (p = 0.09). There were no significant mortality differences between females and males for factors such as age groups, trauma mechanisms, Glasgow Coma Scale scores, lesions on the CT scan, or treatment factors. Logistic regression revealed that gender had no significant influence on mortality of unfavorable outcome. The differences in outcome were due to the higher mean age of females (61.4 vs. 50.4, p < 0.001) and possibly because of small differences in Glasgow Coma Scale scores and in CT scores. CONCLUSIONS: Female gender is not an independent risk factor for in-hospital mortality after TBI.

Severity and outcome of traumatic brain injuries (TBI) with different causes of injury.

INTRODUCTION: Most epidemiological studies and reports have reached a consensus on the leading causes of traumatic brain injury (TBI). Despite the fact that the area of TBI is relatively well studied, reports on differences in severity and outcome of TBI with different causes are lacking. GOAL: This paper analyses the differences in severity and in short- and long-term outcome of TBIs with different causes. METHOD: This study analysed data on 1109 patients with severe TBI by dividing them into three injury-cause groups: 'traffic-related', 'falls' and 'other causes'. Severity and outcome was evaluated using chosen direct and indirect indicators. RESULTS: The most severe trauma occurred in the traffic-related group followed by falls and injuries with other causes. On the other hand, patients with traffic-related TBI had the best outcome. Age improves the outcome in the traffic-related group significantly. However, in the multivariate analysis after adjusting for age (and other important predictors including level of care) the odds for favourable long-term outcome stayed significantly higher in the traffic-related group. CONCLUSIONS: It is concluded that the causes of TBI should be considered by both clinicians and public health professionals as a lead in prognosis of outcome and policy planning.

Care transitions in the first 6months following traumatic brain injury: Lessons from the CENTER-TBI study.

BACKGROUND: No large international studies have investigated care transitions during or after acute hospitalisations for traumatic brain injury (TBI). OBJECTIVES: To characterise various TBI-care pathways and the number of associated transitions during the first 6 months after TBI and to assess the impact of these on functional TBI outcome controlled for demographic and injury-related factors. METHODS: This was a cohort study of patients with TBI admitted to various trauma centres enrolled in the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. Number of transitions and specific care pathways were identified. Multiple logistic regression analyses were used to assess the impact of number of transitions and care pathways on functional outcome at 6 months post-injury as assessed by the Glasgow Outcome Scale-Extended (GOSE). RESULTS: In total, 3133 patients survived the acute TBI-care pathway and had at least one documented in-hospital transition at 6-month follow-up. The median number of transitions was 3 (interquartile range 2-3). The number of transitions did not predict functional outcome at 6 months (odds ratio 1.08, 95% confidence interval 1.09-1.18; P=0.063). A total of 378 different care pathways were identified; 8 were identical for at least 100 patients and characterized as "common pathways". Five of these common care pathways predicted better functional outcomes at 6 months, and the remaining 3 pathways were unrelated to outcome. In both models, increased age, violence as the cause of injury, pre-injury presence of systemic disease, both intracranial and overall injury severity, and regions of Southern/Eastern Europe were associated with unfavourable functional outcomes at 6 months. CONCLUSIONS: A high number of different and complex care pathways was found for patients with TBI, particularly those with severe injuries. This high number and variety of care pathway possibilities indicates a need for standardisation and development of "common data elements for TBI care pathways" for future studies. STUDY REGISTRATION: ClinicalTrials.gov NCT02210221.

Relation of employment status, behavioral and social conditions on individual perception of health in a region of Slovakia: pilot study.

BACKGROUND: The question of the health status of the unemployed in the Slovak Republic is a relatively unexplored area of study, in spite of the fact that the country has experienced one of the most consistently high unemployment rates among the 27 states of the EU. The aim of the pilot study was to identify the health and the other impacts of unemployment on the population in the region of Zvolen. METHODS: two groups of respondents were studied: the long-term unemployed and a control group of the employed. The data was collected using the guided-interview questionnaire procedure. A total of 214 respondents were observed out of which 107 were from the long-term unemployed group and 107 from the control group. There were 83 male (38.8%) and 131 female respondents (61.2%). The average age of the group was 36.0 (CI 95% = 33.8-38.3). RESULTS: Using logistic regression, it was established that the chances of finding a job were 1.08 times greater in cases of a higher level of education (OR = 1.08, CI 95% = 1.04-1.12, P < or = 0,001). It was also established that smoking decreases the chances of finding employment by OR = 0.91 (CI 95% = 0.83-0.98) times (P < or = 0.01). People who are employed consume more alcohol attaining OR = 1.28 (CI 95% = 1.21-1.35) compared to the unemployed (P < or =0.0001). CONCLUSION: The study proved that even with restricted resources it is possible to obtain credible results comparable with those achieved by more complex studies.

Epidemiology, treatment and outcome of patients after severe traumatic brain injury in European regions with different economic status.

BACKGROUND: We hypothesized that the economic status of a region might influence quality of care and outcome of patients with severe brain trauma. METHODS: Between January 2001 and December 2005, 13 centres enrolled patients with severe brain trauma. Data on accident, treatment and outcomes were collected prospectively. The regions were classified as 'high income' (Austria, five centres), 'upper middle income' (UMI) (Croatia, Slovakia, six centres) or 'lower middle income' (LMI) (Bosnia, Macedonia, two centres). Data on epidemiology, treatment and outcomes were compared according to this classification. Quality of care was assessed using a new scoring system. RESULTS: A total of 1172 data sets were analysed. Patients from the wealthier regions were significantly older. Low-level falls and traffic accidents contributed to more than two-third of all cases. Violence-related trauma was significantly more frequent in 'middle income' regions. Treatment quality was significantly different; treatment according to guidelines for brain trauma management was provided most frequently for patients from high-income regions. Compared with expected mortality rates, mortality was 6.5% lower in the 'high-income' centres, 2.4% lower in the 'UMI' centres and 13% higher in the 'LMI' centres. Advanced age, poor neurological status, high trauma severity and poor quality of care were associated with significantly lower odds for survival. CONCLUSIONS: The association between the economic status and outcome of brain trauma patients was due to the quality of care. Successful implementation of guidelines for brain trauma management requires a well-funded health care system.

International evidence-based guidelines on hypertension and type 2 diabetes mellitus: a systematic review

This systematic review provides a high-quality, comprehensive summary of recommendations on hypertension (HT) and type 2 diabetes mellitus (T2DM), accentuating patient blood pressure, HbA1c levels, patterns of drug treatment, management, and screening of these diseases. The overall objective of the review is to support adapting existing clinical practice guidelines in Indonesia, Vietnam, and Myanmar. The database PubMed and the web search engines Google and Google Scholar were searched from October to December 2019 for evidence-based guidelines covering the overall disease management in Europe, the United States of America, and low and middle-income countries (Indonesia, Vietnam, and Myanmar­IVM later on). Nine studies were selected for the review, seven concerning HT and five T2DM. Guidelines in IVM and Europe identified HT as increased blood pressure (BP; ≥140/90 mmHg). IVM guidelines also recommended commencing drug treatment if lifestyle interventions were not successful. Four international HT guidelines recommended monitoring BP every few months, and the other three guidelines gave recommendations based on the patient's current BP levels. All five T2DM guidelines recommended target HbA1c levels below 7%­6.5%, but only IVM guidelines included re-examination every 3­6 months. Metformin was recommended as the first choice of medical treatment, if not contraindicated. Amid the guidelines' recommendations, there were no major variations in the Class of recommendation and Level of evidence (except IVM guidelines where COR and LOE were missing). Revision and completion of IVM guidelines by this grading system would enhance evidence-based and informed decisions in clinical care.

A comparison of European Trauma Registries. The first report from the EuroTARN Group.

UNLABELLED: Trauma management systems have grown in response to regional variations in trauma population, geographical conditions and the provisions of care. National Trauma Registries are being established to improve patient outcomes. However international comparisons could provide the potential to record regional performance, identify and share examples of best practice. To assess whether it was possible to compare data currently being collected by a number of trauma services across Europe, a group was established to develop a common core dataset and to assess the feasibility of collecting anonymised data. METHOD: A series of meetings with European collaborators led to the creation of a group entitled EuroTARN. A website was developed in 2002 and interested parties were invited to submit suggestions for a European dataset using an online version of the Delphi technique. A core dataset was created in 2003 and in 2004 participants were invited to submit a summary of past cases online via the EuroTARN Website. RESULTS: Representatives from 14 countries met and corresponded to create the core dataset. During a trial data collection phase 14 institutions from 11 countries submitted unadjusted mortality data for over 21,500 cases with injury severity Scores of over 15 including information on multiply injured and head injured patients. The results demonstrated that there were observed differences in trauma outcome for similar groups of patients. CONCLUSION: It is possible to collect and collate outcome data from established trauma registries across Europe with minimal additional infrastructure using a web-based system. Initial analysis of the results reveals significant international variations. The network has potential as a source of data for epidemiological and clinical research and for optimal trauma system design across Europe.

Severe traumatic brain injury in Austria IV: intensive care management.

OBJECTIVES: The goal of this paper is to describe the ICU management of severe traumatic brain injury (TBI) in Austria. PATIENTS AND METHODS: Data sets from 415 patients included by 5 Austrian hospitals were available. The analysis focused on complications and outcomes of intensive care, monitoring of intracranial pressure (ICP), efficacy of interventions to control ICP, management of hemodynamics and cerebral perfusion pressure (CPP), ventilation, and effects of hyperglycaemia. RESULTS: Overall ICU mortality was 30.8%; 90-day mortality was 35.7%. Final outcome was favorable in 33%, unfavorable in 51%, and in 16% the final outcome was unknown. An ICP monitoring device was used in 64%; most patients received intraparenchymal sensors (77%). Events associated with mortality > 50% were CPP < 50 mm Hg for > 12 hours/day, ICP > 25 mm Hg for > 12 hours/day, and MAP < 70 mm Hg for > 18 hours/day. The use of ICP monitoring was associated with significantly reduced ICU mortality. Interventions that may have improved the outcome included the use of barbiturates (short-term), hypertonic saline, moderate hyperventilation (33 < pCO2 < 37; p < 0.001 vs. aggressive hyper-and normoventilation), and normothermia. Hyperglycaemia was associated with poor outcome. CONCLUSIONS: Our study showed that ICU management of patients with severe TBI mostly follows international guidelines, and that outcome was comparable to or even better than that reported by other authors. Low CPP was associated with poor outcome, and was more often due to low MAP than to elevated ICP. The use of barbiturates and hypertonic saline was more common than expected. CPP should be maintained > 50 mm Hg, the use of catecholamines, fluid loading, barbiturates (short-term), moderate hyperventilation, hypertonic saline, and insulin may improve outcome after severe TBI.

Severe traumatic brain injury in Austria I: introduction to the study.

OBJECTIVES: The goals of the Austrian Severe Traumatic Brain Injury Study were to investigate the current management of patients with severe traumatic brain injury in Austria and to assess the effects of introducing guidelines for the management of severe traumatic brain injury upon the outcome of these patients. The purpose of this paper is to give a detailed description of the goals, methods, and overall results of the study, and to provide an introduction to a series of papers where the results of the study will be presented and discussed. STUDY DESIGN: The study included patients with severe traumatic brain injury from five centers in Austria. Data on accident, pre-hospital treatment, hospital treatment, and patient status were collected prospectively. Patient data was entered daily for the first 10 days in hospital and then up to a year after discharge from intensive care. All data was entered into an internet-based database. The data was evaluated to describe epidemiology, pre-hospital treatment, medical management, and surgical management; the evaluation also assessed the effects of guideline-based management on traumatic brain injury patients. RESULTS: The data set comprises a total of 492 patient records from the 5 participating hospitals; this data was collected over a 3-year period. Data quality is considered good; the number of missing data items is low. ICU mortality was 31.6%. Final outcome: 23% of the patients had a good recovery, 10% had moderate disabilities, 8% had severe disabilities, 6% were persistent vegetative, and 38% died. Final outcome was unknown in 16% of patients. CONCLUSIONS: This study proved that an internet-based database may be a valuable tool for prospective multicenter studies if many variables have to be collected for a high number of patients. The results of our study provide enough evidence to initiate further research on many aspects of the management of traumatic brain injury patients.

Severe traumatic brain injury in Austria II: epidemiology of hospital admissions.

OBJECTIVES: The goal of this paper is to describe the hospital-based epidemiology of severe TBI in Austria. PATIENTS AND METHODS: Data sets from 492 patients included in the study by 5 Austrian hospitals were available. Age and gender distribution, education, occupation, location of trauma, mechanism of injury, alcohol use, type and severity of injury, associated injuries, length of intensive care unit stay, and intensive care unit outcome were evaluated for each of the 5 centers. RESULTS: The sample represents roughly 13% of all cases with severe TBI which were treated in Austrian hospitals during the study period. Mean age was 48 +/- 21 years, and most patients were male (72%). The most important trauma locations were roads (50%), home (24%), outdoors (10%), and workplace (7%). Transportrelated trauma was the most important mechanism (44%) followed by falls < 3 m (30%), falls > 3 m (11%), and sports injuries (5%). Detailed analysis of transport-related trauma showed that car accidents (45%) were most common, followed by pedestrian (20%), motorbike (19%), and bicycle (16%) accidents. Significant differences between the centers were found for most of the variables analyzed. The severe traumatic brain injury was associated with spinal cord injury in 10%, and with severe multiple trauma in 38% of cases. Intensive care mortality was 31.7%. There were no significant correlations between mechanisms of injury and severity of trauma, nor between mechanisms and ICU outcome. CONCLUSIONS: Epidemiology of severe traumatic brain injuries in Austria is not much different from other industrialized countries. Traffic accidents are responsible for the majority of traumas, stressing the importance of road injury prevention. Attention should also be paid to the specific risks of older people and to prevent injuries at home.

Severe traumatic brain injury in Austria III: prehospital status and treatment.

OBJECTIVES: The goal of this paper is to describe prehospital status and treatment of patients with severe TBI in Austria. PATIENTS AND METHODS: Data sets from 396 patients with severe TBI (Glasgow Coma Scale score < 9) included by 5 Austrian hospitals were available. The analysis focused on incidence and/or degree of severity of typical clinical signs, frequency of use of different management options, and association with outcomes for both. ICU mortality, 90-day mortality, final outcome (favorable = good recovery or moderate disability; unfavorable = severe disability, vegetative state, or death) after 6 or 12 months, and ratio of observed (90-day) to predicted mortality (O/E ratio) are reported for the selected parameters. Chi2 -test, t-test, Fisher's exact test, and logistic regression were used to identify significant (p < 0.05) differences for association with survival and favorable outcome (both coded as 1). RESULTS: The majority of patients were male (72%), mean age was 49 +/- 21 years, mean injury severity score (ISS) was 27 +/- 17, mean first GCS score was 5.6 +/- 2.9, and expected hospital survival was 63 +/- 30%. ICU mortality was 32%, 90-day mortality was 37%, and final outcome was favorable in 35%, unfavorable in 53%, unknown in 12%. We found that age > 60 years, ISS > 50 points, GCS score < 4, bilateral changes in pupil size and reactivity, respiratory rate < 10/min, systolic blood pressure (SBP) < 90 mm Hg, and heart rate < 60/min were associated with significantly higher ICU and 90-day mortality rates, and lower rates of favorable outcome. With regard to prognostic value the GCS motor response score is identical to the full GCS score. Administration of > 1000 ml of fluid and helicopter transport were associated with better outcomes than expected, while endotracheal intubation in the field had neither a positive nor a negative effect on outcomes. Administration of no or < 500 ml of fluids was associated with worse outcomes than expected. Outcomes were better than expected in the few patients (5%) who received hypertonic saline. CONCLUSIONS: Age, ISS, and initial neuro status are the factors most closely associated with outcome. Hypotension must be avoided. Fluids should be given to restore and/or maintain SBP > 110 mm Hg. Helicopter transport should be arranged for more seriously injured patients.