Risultati per: Riabilitazione dopo un trauma traumatico

Annals of Internal Medicine, Ahead of Print.

Occasionally, newspapers report positive stories of animal species believed to be extinct, only to be discovered alive and repopulating their habitats. In this issue of JAMA, Albert and colleagues assessed the role of sigh breaths in ventilated trauma patients at risk of acute respiratory distress syndrome. Though sighs did not result in a significant improvement in the primary outcome, they were well-tolerated and were associated with an improvement in some clinical outcomes. The sigh, believed to be extinct, is back. In 1976, Fairley declared that, “The mechanical ventilation sigh is a Dodo” (the dodo is an extinct flightless bird). Despite this statement, sighs survived in the clinical practice of several centers and were the subject of substantial clinical research. Importantly, they also remained a viable option in various commercial ventilators.

This randomized clinical trial compares the efficacy of sighs in addition to usual care vs usual care alone in improving clinical outcomes among trauma patients receiving mechanical ventilation and are at risk for developing acute respiratory distress syndrome.

Purpose
Patient-reported outcome measures (PROMs) are useful for trauma registries interested in monitoring patient outcomes and trauma care quality. PROMs had not previously been collected by the New Zealand Trauma Registry (NZTR). More than 2500 New Zealanders are admitted to hospital for major trauma annually. The Trauma Outcomes Project (TOP) collected PROMs postinjury from three of New Zealand’s (NZ’s) major trauma regions. This cohort profile paper aims to provide a thorough description of preinjury and 6 month postinjury characteristics of the TOP cohort, including specifically for Māori (Indigenous population in Aotearoa me Te Waipounamu/NZ).

Participants
Between July 2019 and June 2020, 2533 NZ trauma patients were admitted to one of 22 hospitals nationwide for major trauma and included on the NZTR. TOP invited trauma patients (aged ≥16 years) to be interviewed from three regions; one region (Midlands) declined to participate. Interviews included questions about health-related quality of life, disability, injury recovery, healthcare access and household income adequacy.

Findings to date
TOP recruited 870 participants, including 119 Māori. At 6 months postinjury, most (85%) reported that the injury still affected them, 88% reported problems with≥1 of five EQ-5D-5L dimensions (eg, 75% reported problems with pain or discomfort, 71% reported problems with usual activities and 52% reported problems with mobility). Considerable disability (World Health Organization Disability Assessment Schedule, WHODAS II, score ≥10) was reported by 45% of participants. The prevalence of disability among Māori participants was 53%; for non-Māori it was 44%. Over a quarter of participants (28%) reported trouble accessing healthcare services for their injury. Participation in paid work decreased from 63% preinjury to 45% 6 months postinjury.

Future plans
The 12 and 24 month postinjury data collection has recently been completed; analyses of 12 month outcomes are underway. There is potential for longer-term follow-up interviews with the existing cohort in future. TOP findings are intended to inform the National Trauma Network’s quality improvement processes. TOP will identify key aspects that aid in improving postinjury outcomes for people experiencing serious injury, including importantly for Māori.

Annals of Internal Medicine, Volume 176, Issue 11, Page 1561-1562, November 2023.

Annals of Internal Medicine, Volume 176, Issue 11, Page 1561-1562, November 2023.

Objective
Bangladesh is currently undergoing an epidemic of road traffic crashes (RTCs). In addition to morbidity and mortality, the economic loss from RTC as per cent of gross domestic product is comparatively higher than in countries with similar socioeconomic conditions. However, trauma care remained poorly developed as a specialty and service delivery mechanism. This study aimed to examine the current situation of in-hospital trauma care after RTCs to inform the design of a comprehensive service for Bangladesh.

Design, setting and participants
This qualitative study attempted to elicit stakeholders’ perceptions and experiences of managing RTCs through in-depth interviews and focus group discussions. Three districts and Dhaka city were selected based on the frequency of occurrence of RTCs. Fifteen in-depth interviews and 5 focus group discussions were conducted with 38 RTC patients, their relatives and community members in the catchment areas of 11 facilities managing trauma patients. Key informant interviews were conducted with 21 service providers and 17 key stakeholders/policy-makers.

Results
Hospital-based trauma care was generally poor in primary and secondary-level facilities. There was no triage area or triage protocol in the emergency rooms, no trained staff for trauma care, no dedicated RTC patient register and scarce life-saving equipment. Only in Dhaka-based tertiary hospitals was trauma care prioritised. These hospitals follow Advanced Trauma Life Support guidelines and maintain an RTC logbook. Emergency diagnostic services were not always available in the hospitals. Most RTC patients were males; the female participants were additionally vulnerable to physical and mental trauma. Affected people avoided taking legal action considering it a lengthy, complicated and ultimately ineffective process.

Conclusion
The trauma care services currently available in the studied health facilities are very rudimentary and without the necessary human and financial resources. This needs urgent attention from policymakers, programmers and practitioners to reduce morbidity and mortality from the current epidemic of RTCs in Bangladesh.

New England Journal of Medicine, Volume 389, Issue 20, November 2023.

Introduction
Hypocalcaemia forms part of the ‘diamond of death’ in major trauma, alongside hypothermia, acidosis and coagulopathy. In adults, admission hypocalcaemia prior to transfusion is associated with increased mortality, increased blood transfusion requirements and coagulopathy. Data on paediatric major trauma patients are limited. This systematic review and meta-analysis aims to describe and synthesise the available evidence relevant to paediatric trauma, admission hypocalcaemia and outcome.

Methods and analysis
The Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines will be used to construct this review. A planned literature search for articles in the English language will be conducted from inception to the date of searches using MEDLINE on the EBSCO platform, CINAHL on the EBSCO platform and Embase on the Ovid platform. The grey literature will also be searched. Both title and abstract screening and full-text screening will be done by two reviewers, with an adjudicating third reviewer. Heterogeneity will be assessed using the I2 test, and the risk of bias will be assessed using the ROBINS-I tool. A meta-analysis will be undertaken using ratio measures (OR) and mean differences for measures of effect. When possible, the estimate of effect will be presented along with a CI and a p value.

Ethical review and dissemination
Ethical review is not required, as no original data will be collected. Results will be disseminated through peer-reviewed publications and at academic conferences.

PROSPERO registration number
CRD42023425172.

Objectives
To design, develop, deliver and assess a training initiative on haemorrhage control for emergency medical services (EMS) staff in Ukraine, in an active wartime setting.

Design
Using the Medical Research Council framework for complex interventions, a training programme was designed and developed in a collaboration between Irish and Ukrainian colleagues and delivered by experienced prehospital clinicians/educators. Feedback was gathered from participants.

Setting
The Russian invasion of Ukraine has caused large numbers of trauma patients with limited access to advanced prehospital emergency care. Ukrainian authorities requested support in delivering such care.

Participants
Ukrainian EMS nominated clinical staff as trainees, in partnership with an educational institution in Kyiv.

Intervention
One day provider and train-the-trainer courses were developed and delivered, focused on early delivery of tranexamic acid (TXA), using intraosseous access (IO) in victims of wartime trauma.

Outcome measures
Safe organisation and delivery of courses, assessed knowledge and skills competence and self-reported satisfaction and pre/post confidence/competence.

Results
Two provider and one train-the-trainer courses and four equipment supply exercises were delivered for 89 EMS staff (doctors, nurses, paramedics); none had prior experience of IO or prehospital delivery of TXA. All participants were assessed as competent as providers and/or trainers. High levels of satisfaction and significantly improved self-assessed confidence and competence were reported.

Conclusion
Rapid design and delivery of a training programme focused on an identified need for advanced care of trauma patients in a wartime setting has been possible. Training and immediate access to appropriate equipment was demonstrated. Evidence of frequency of use and safe, effective interventions has not been collected; such data are important for evaluation but difficult to collect in this setting. A high level of demand for this training now exists.

Circulation, Volume 148, Issue Suppl_1, Page A14586-A14586, November 6, 2023. Introduction:Childhood trauma is associated with a greater risk of developing hypertension in adulthood. Black individuals develop hypertension at younger ages, have more aggressive hypertension, and are more likely to experience childhood trauma compared to White individuals. Yet, the impact of childhood trauma on vascular stiffness in Black individuals remains less clarified; thus, we examined the association between childhood trauma and arterial stiffness in Black individuals.Hypothesis:Childhood trauma exposure will be associated with vascular dysfunction and this association may differ by sex.Methods:Childhood trauma exposure and vascular function were assessed in a cohort of healthy Black participants without known CVD [n=404] from a large metropolitan city. Childhood trauma was assessed using the Early Trauma Inventory short form [ETISR-SF] consisting of four-physical, sexual, emotional, and general-domains, with higher scores indicative of higher traumatic life events assessed before age 18 years. Outcomes of central augmentation index [CAIx] and carotid femoral pulse wave velocity [CfPWV] were measured as indices of wave reflections and arterial stiffness using applanation tonometry [Sphygmocor Inc.], and central pulse pressure [CPP] was calculated as the difference between the aortic systolic and diastolic blood pressures. Relationships between ETISR-SF and outcomes were assessed using multivariate-adjusted and sex-stratified linear regression models.Results:Mean age of the cohort was 53(SD=10.3), 61% women. Cumulative childhood trauma was associated with CAIxβ=0.33%, 95%CI: 0.04,0.62 and CPPβ=0.24mmHg, 95%CI:0.04,0.45, but not CfPWVβ=-0.02m/s, 95%CI:-0.07,0.02 after adjusting for demographic, BMI, BP, lipids, glucose, clinical history, health behaviors, and depression. Significant traumaxSex interactions were identified for CAIxP=0.01and CPPP=0.02. Among women, childhood trauma was associated with higher CAIxβ=0.32%, 95%CI: 0.04, 0.60 and CPPβ=0.19 mmHG, 95%CI: -0.02, 0.41, but not in men.Conclusion:Exposure to childhood trauma is associated with measures of arterial stiffness in Black women, noting the detrimental effects of childhood trauma on future CVD risk in Black women.

Circulation, Volume 148, Issue Suppl_1, Page A374-A374, November 6, 2023. Introduction:Identifying patients with major trauma in prehospital settings by Field Triage Scheme (FTS) is of paramount importance. The goal of the FTS was set with a sensitivity (Sn) of 95% and specificity (Sp) of 50% to identify patients with major trauma, although many studies showed it unachievable. A simplified FTS (sFTS) may offer a more rapid prehospital triage of patients. However, evidence of its accuracy remains unclear.Hypothesis:We examined the performance of identifying patients with major trauma by triage tools of sFTS, modified sFTS, and adding shock index (SI) in different age groups.Methods:We conducted a multinational retrospective cohort study involving a total of 51,622 adult trauma patients in the studied countries from 2016 to 2020, using data from the Pan-Asia Trauma Outcomes Study. We tested (1) sFTS comprising only physiological and anatomical criteria, (2) modified sFTS defined by fine-tuning the physiological criteria of GCS score < 15, respiratory rate

Circulation, Volume 148, Issue Suppl_1, Page A237-A237, November 6, 2023. Introduction:Previous studies have reported that hospital arrival during nighttime was associated with worse outcomes in critically ill pediatric patients. However, this “nighttime effect” in pediatric patients with severe trauma has not yet been well-investigated.Hypothesis:We hypothesized that hospital arrival during nighttime is associated with higher mortality rates in pediatric patients with severe trauma.Methods:We conducted a nationwide retrospective cohort study in Japan from 2004 to 2019 using the Japan Trauma Data Bank, a nationwide trauma registry. Patients who were aged 15 were included. Patients with cardiac arrest on hospital arrival were excluded. Hospital arrival was categorized into daytime (from 8:00 am to 4:59 pm) arrival and nighttime (from 5:00 pm to 7:59 am) arrival. The main outcome was the in-hospital mortality rate, and the secondary outcome was the emergency department (ED) mortality rate. As a main analysis, an inverse probability of treatment weighting (IPTW) analysis was performed using propensity scores to adjust for confounders such as age, sex, type of injury, transport time, vital signs, and ISS. In addition, we conducted 1) a subgroup analysis in patients who underwent operation (OP) or interventional radiology (IR) during hospitalization and 2) sensitivity analysis using a multilevel mixed-effects logistic regression model.Results:In total, 6,574 pediatric patients with severe trauma were included, and the overall in-hospital mortality rate was 6.5%. The IPTW analysis showed that compared with daytime arrivals, nighttime arrivals were associated with significantly higher in-hospital mortality (odds ratio [OR], 1.41; 95% confidence interval [CI], 1.09-1.83;P= 0.010) and ED mortality rates (OR, 2.42; 95% CI, 1.07-5.45;P= 0.034) in the entire cohort but not in the subgroup who underwent OP or IR during hospitalization. The sensitivity analysis consistently supported the results of the main analysis.Conclusions:Hospital arrival during nighttime was associated with a higher in-hospital mortality rate in pediatric patients with severe trauma. Further investigations are needed to elucidate the reasons for this “nighttime effect.”

Circulation, Volume 148, Issue Suppl_1, Page A372-A372, November 6, 2023. Introduction:Previous studies showed that the prognosis for severe trauma patients is better after transport to trauma centers compared to non-trauma centers. However, the benefit from transport to trauma centers may differ according to age group. This study aimed to evaluate the age-dependent effect of trauma center transport on survival outcomes among severe trauma patients.Methods:A cross-sectional study using the Korean national emergency medical service (EMS) based on Severe Trauma Registry in 2018-2019 was conducted. EMS-treated trauma patients whose injury severity score was above or equal to 16, and who were not out-of-hospital cardiac arrest or death on arrival were included. Patients were classified into 3 groups: pediatrics (age 65). The primary outcome was in-hospital mortality. Multivariable logistic regression analysis was conducted to evaluate the effect of trauma center transport on outcome after adjusting age, sex, comorbidity, mechanism of injury, Revised Trauma Score, and Injury Severity Score. All analysis was stratified according to the age group, and subgroup analysis for traumatic brain injury was also conducted.Results:Overall, a total of 10,511 patients were included in the study, and the number of patients in each age group was 488 in pediatrics, 6,812 in working age, and 3,211 in elderly, respectively. The adjusted odds ratio (95% confidence interval [CI]) of trauma center transport on in-hospital mortality were 0.76 (95% CI, 0.43-1.32) in pediatrics, 0.78 (95% CI, 0.68-0.90) in working age, 0.71(95% CI, 0.60-0.85) in elderly, respectively. In the subgroup analysis of traumatic brain injury, the benefit from trauma center transport was observed only in elderly group.Conclusion:We found the age-dependent effect of trauma center transport in severe trauma patients. There was no beneficial effect of trauma center transport in pediatric group. Further research is warranted to evaluate and develop the response system for pediatric severe trauma patients in Korea.

Le donne di mezza età a rischio maggiore aterosclerosi carotidea

Objectives
To estimate the level of anhedonia among adolescents and explore the association between anhedonia and childhood trauma (CT).

Design
A stratified random cluster sample of adolescents participated in a survey, which included three questionnaires: Snaith-Pamilton Pleasure Scale, Childhood Trauma Questionnaire and Patient Health Questionnaire-9.

Setting
The study was conducted in 60 classes in 10 primary, middle and high schools in five economically developed cities along the Southeast Coast of China from April to October 2022.

Participants
One thousand seven hundred and forty-five adolescents with ages ranging from 9 to 18 years participated in the study.

Primary and secondary outcomes
The primary outcome was the level of anhedonia, CT and depression among adolescents. The association between anhedonia and CT was determined.

Results
The mean scores of anhedonia, CT and depression were 24.88 (6.18), 36.75 (8.87) and 4.46 (5.36), respectively. Anhedonia scores of boys (24.24±6.12) and girls (25.62±6.16) were different (t=–4.69, p