The role of trauma scoring in developing trauma clinical governance in the Defence Medical Services

This paper discusses mathematical models of expressing severity of injury and probability of survival following trauma and their use in establishing clinical governance of a trauma system. There are five sections: (i) Historical overview of scoring systems—anatomical, physiological and combined systems and the advantages and disadvantages of each. (ii) Definitions used in official statistics—definitions of ‘killed in action’ and other categories and the importance of casualty reporting rates and comparison across conflicts and nationalities. (iii) Current scoring systems and clinical governance—clinical governance of the trauma system in the Defence Medical Services (DMS) by using trauma scoring models to analyse injury and clinical patterns. (iv) Unexpected outcomes—unexpected outcomes focus clinical governance tools. Unexpected survivors signify good practice to be promulgated. Unexpected deaths pick up areas of weakness to be addressed. Seventy-five clinically validated unexpected survivors were identified over 2 years during contemporary combat operations. (v) Future developments—can the trauma scoring methods be improved? Trauma scoring systems use linear approaches and have significant weaknesses. Trauma and its treatment is a complex system. Nonlinear methods need to be investigated to determine whether these will produce a better approach to the analysis of the survival from major trauma.     

The harsh life on the 15th century Croatia‐Ottoman Empire military border: Analyzing and identifying the reasons for the massacre in Čepin

Excavation of the historic period cemetery in ?epin, Croatia revealed the presence of a large number of perimortem injuries distributed among males, females, and subadults. Archaeological and historical data suggest these individuals were victims of a raid carried out by Turkish akinji light cavalry in 1441. Comparisons with the frequencies of perimortem trauma in 12 other, temporally congruent skeletal series from the Balkans (n = 2,123 skeletons) support this assumption. The role of the akinji in the Ottoman army was twofold: to supply war captives, and to terrorize and disperse local populations before the advance of regular troops. This article tests the hypothesis that the purpose of the 1441 raid was the latter. To accomplish this, perimortem trauma in the series were analyzed by sex, age, location, and depth of the injury. A total of 82 perimortem injuries were recorded in 12 males, 7 females, and 3 subadults. The demographic profile of the victims suggests that young adults were specifically targeted in the attack. Significant sex differences are noted in the number, distribution, and pattern of perimortem trauma. Females exhibit significantly more perimortem injuries per individual, and per bone affected, than males. The morphology and pattern of perimortem trauma in females is suggestive of gratuitous violence. Cumulatively, analysis of the osteological data suggest that the objective of the 1441 akinji raid was to spread terror and panic in the ?epin area, either as revenge for recent military setbacks, or as part of a long‐term strategy intended to depopulate the area around Osijek. Am J Phys Anthropol, 2010. © 2009 Wiley‐Liss, Inc.     

Spondylolysis in prehistoric human remains from Guam and its possible etiology

This study reports the findings of complete bilateral separation of the neural arch (spondylolysis) in 176 inhumations from the Hyatt Site, Tumon Bay, which is located on the west side of the island of Guam. Skeletons were excavated and analyzed by the Paul H. Rosendahl Inc. (PHRI) team in 1989–1990. The inhumations were associated with the pre-European Latte Period (circa 1,200–1,521 A.D.). This period was characterized by the use of large stone pillars, called latte sets, for the construction of houses. Of the 176 individuals, only 38 adult skeletons had complete spines, and 21% (8/38) of these had evidence of spondylolysis in their lumbar vertebrae, particularly in L-5. The age of the eight individuals range from 30 to 50 years. No children were found with spondylolysis. Of the males 29.4% (5/17) had spondylolysis, as did 14.3% (3/21) of the females. However, the difference between the sexes was not statistically significant. Though the sample is small, it is suggested that the high incidence of lumbar spondylolysis found in these ancient Chamorros was related to lower back traumatic events. The transport of latte stones, involving hyperextension and torque of the lower back, while dragging the stones, probably contributed to the development of microfractures in the spine and subsequent spondylolysis. If this hypothesis is correct, then both males and females appear to have been participants in an organized community labor force. It is predicted that similar frequencies of spondylolysis will be found at other Latte sites. Am J Phys Anthropol 104:393–397, 1997. © 1997 Wiley-Liss, Inc.     

Transfusion-associated microchimerism in traumatic patients

Transfusion-associated microchimerism (TA-MC) is the stable persistence of an allogeneic cell population, resulting from allogeneic blood transfusion (often resulting after trauma). Currently TA-MC is not completely understood, needing further study to reveal its underlying mechanism. This article reviews the immune tolerance mechanism of TA-MC; factors which lead to the appearance of TA-MC; clinical implications of microchimerism; and the latest diagnostic methods of TA-MC.     

数字化外科技术在颌面部外伤修复重建中的应用与展望

近年来,数字化外科技术在颌面部外伤修复重建临床应用中得到不断发展和完善,极大地提高了手术的精确性和可靠性,节约了手术时间。本文主要从术前手术模拟、快速打印3D头模、术中导航、导板制作、个性化修复体及机器人的临床应用等六个方面来阐述数字化外科技术在颌面部骨折修复重建中的应用,总结了各个技术的原理、优缺点及应用现状,回顾了我们单位应用数字化技术提高颌面部外伤修复手术的精确度和可行性以及恢复了患者良好的面型及功能的临床应用经验。同时,本文对未来数字化外科在颌面部骨折修复重建中的应用提出了新的展望,我们认为,结合术前手术模拟、术中导航及术中机器人技术依据术中具体情况自动调整手术方案进行颌面部骨折修复重建的完全自动化智能机器人的实现将是最终的目标。     

Residual energy dispersal fracturing: A newly proposed term for fractures propagating from sharp-force trauma

Objectives

The identification and interpretation of skeletal trauma is an important topic in osteoarchaeology, forensic anthropology and palaeosciences. Trauma analysis is a fast-moving sub-discipline with constantly evolving methodological approaches. This paper describes the process of a particular form of fracturing that propagates specifically from the floor of cut marks and proposes new terminology for this subset of fractures.

Materials and Methods

This terminological gap was identified during the re-examination of remains from a minimum of 52 decapitated individuals (52 post-cranial and 47 cranial remains) found in a mass grave from the 10th–11th century CE on Ridgeway Hill near Weymouth in Dorset (UK) in 2009. Originally analyzed by Oxford Archaeology Ltd., all individuals in this collection were re-appraised using digital technology to test new techniques for this study.

Results

During this investigation, it has become apparent that the length of chop marks can be overestimated during some conventional analysis because the chop transitions into a fracture propagating from the floor of the chop mark.

Discussion

To increase awareness of these fractures, the term residual energy dispersal (RED) fractures is proposed as these are distinct from other radiating fractures arising from sharp-blunt-force trauma. The ability to distinguish RED fractures from others has the potential to contribute to the identification of previously unidentified chop marks and to the interpretation of events surrounding an injury.     

动态监测血清降钙素原对多发伤患者并发脓毒症的诊断价值

目的:探讨动态监测血清降钙素原(PCT)对多发伤合并脓毒症的诊断价值。方法:选取我院重症监护室并发脓毒症的多发伤患者21例(Sepsis组)、无并发脓毒症的多发伤患者20例(非Sepsis组),连续检测患者入院第1、3、5、7 d血清中的PCT含量,并测定C反应蛋白和白细胞计数。结果:Sepsis组血清PCT浓度明显高于非Sepsis组(P<0.01);不同程度脓毒症患者间PCT水平有显著差异,随严重程度升高而升高(P<0.01)。结论:血清PCT对多发伤患者合并脓毒症的诊断具有重要价值,且血清PCT水平与脓毒症的严重程度有关,监测其动态变化有助于预后判断。     

Inflammation in Traumatic Brain Injury: Role of Cytokines and Chemokines

A traumatic injury to the adult mammalian central nervous system (CNS), such as a stab wound lesion, results in reactive astrogliosis and the migration of hematogenous cells into the damaged neural tissue. The roles of cytokines and growth factors released locally by the damaged endogenous cells are recognized in controlling the cellular changes that occur following CNS injury. However, the role of chemokines, a novel class of chemoattractant cytokines, is only recently being studied in regulating inflammatory cell invasion in the injured/diseased CNS (1). The mRNAs for several chemokines have been shown to be upregulated in experimental allergic encephalomyelitis (EAE), an inflammatory demyelinating disease of the CNS, but chemokine expression in traumatic brain injury has not been studied in detail. Astrocytes have been demonstrated to participate in numerous processes that occur following injury to the CNS. In particular, astrocytic expression of cytokines and growth factors in the injured CNS has been well reviewed (2). Recently a few studies have detected the presence of chemokines in astrocytes following traumatic brain injury (3,4). These studies have suggested that chemokines may represent a promising target for future therapy of inflammatory conditions. This review summarizes the events that occur in traumatic brain injury and discusses the roles of resident and non-resident cells in the expression of growth factors, cytokines and chemokines in the injured CNS.     

北京军都山古代居民的颅骨创伤

北京延庆军都山墓地是东周时期玉皇庙文化的代表性墓地。对墓地出土125例个体颅骨创伤的观察表明,军都山男性颅骨创伤的发生率为13.3%,均为生前钝器伤;女性和未成年个体则未发现有颅骨创伤病例。颅骨创伤的发生没有时代变化或墓葬等级间的差异。军都山古代男性居民较高的颅骨创伤率与暴力冲突关系最为密切,是军都山社会关系不稳定性的一种体现,与农牧交错区生态的脆弱性、外来人群流入以及与周边定居农业人群互动等因素所导致的竞争增强有关。     

64层螺旋CT增强扫描在急诊胸部创伤中的初步应用

目的：探讨64层螺旋CT增强扫描在急诊胸部创伤中的诊断价值及临床意义。方法：18例急诊胸部创伤患者均行胸部64层螺旋CT平扫及增强扫描。采用最大密度投影（MIP）、曲面重建（CPR）和容积再现技术（VR）对胸部大血管进行重建、分析。将CT诊断结果与手术、随访复查结果进行比较。结果：18例中,CT平扫显示胸部主要损伤有：肺挫伤10例（55.56%）,血胸及肋骨骨折各9例（50%）,气胸8例（44.44%）,锁骨骨折6例（33.33%）。CT增强扫描诊断心脏大血管损伤7例,其中锁骨下动脉假性动脉瘤3例,胸主动脉假性动脉瘤2例,胸主动脉夹层和心包破裂各1例。CT增强扫描结果与手术、临床随访结果相吻合。结论：64层螺旋CT增强扫描是全面而准确地诊断急诊胸部创伤的重要影像技术,可以对CT平扫不能确定的心脏、大血管的损伤情况作出明确判断,对临床救治方案的早期确定具有重要的指导意义。     

Calponin control of cerebrovascular reactivity: therapeutic implications in brain trauma

Calponin (Cp) is an actin-binding protein first characterized in chicken gizzard smooth muscle (SM). This review discusses the role of Cp in mediating SM contraction, the biochemical process by which Cp facilitates SM contraction and the function of Cp in the brain. Recent work on the role of Cp in pathological states with emphasis on traumatic brain injury is also discussed. Based on past and present data, the case is presented for targeting Cp for novel genetic and pharmacological therapies aimed at improving outcome following traumatic brain injury (TBI).     

新型氨基酸制剂对创伤大鼠血游离氨基酸的影响

观察了富含牛磺酸 (Tau)、谷氨酰胺 (Gln)以及高支链氨基酸 (HBCAA)的新型氨基酸制剂对创伤大鼠血中游离氨基酸浓度的影响。结果表明 ,创伤后三天起 ,血浆游离氨基酸总和均显著降低 ,对照组基本无改变 ;创伤后Tau、BCAA、精氨酸以及天冬氨酸等具有抗氧化和免疫调节作用的氨基酸含量明显降低 ,新处方使用一周后其浓度有效回升 ,且效果好于 17种氨基酸 ,从而有利于机体伤口的愈合。这些结果为进一步阐明复合氨基酸制剂促进创伤愈合的作用及其开发应用提供了理论依据     

Role of thromboelastography in clinical emergency trauma patients

This study aimed to investigate dynamic changes in thromboelastography (TEG) and evaluate its value for emergency trauma patients. TEG values (R, K, Angle, MA and CI) were detected l, 3, and 7 days post trauma. Followup prognosis data were recorded among all patients and correlations between TEG changes and prognosis were assessed. The results revealed that the K and R volumes of the poor prognosis group were obviously higher than those of the good prognosis group at each time point; while the Angle, MA, and CI volumes of the poor prognosis group were relatively lower than those of the good prognosis group, and showed a little rising tendency. This study suggests that variables measured by TEG were closely associated with prognosis evaluation, and highlighted the dangers of coagulation disorder at early stage. TEG is of benefit in evaluating the function of coagulation in clinical emergency trauma patients.     

Incidence and distribution of postcranial fractures in the prehistoric population of San Pedro de Atacama,northern Chile

Trauma incidence analysis in skeletal populations has been very popular among skeletal biologists during the last two decades. In this context, the work of Lovejoy and Heiple ([1981] Am. J. Phys. Anthropol. 55:529–541) has been quoted as a landmark because their analysis rested on a populational approach, avoiding simple assumptions about cause and etiology. In this study, we apply to the prehistoric population of San Pedro de Atacama, northern Chile, an approach similar to that carried out by Lovejoy and Heiple (1981). The results obtained point to a peak of risk of fractures among old people, estimated age around 45 years. The distribution of fractures by sex and age suggests that the prevailing etiology is related to accidents and not violence. When the frequencies of fractures are compared, the Libben population shows a much higher incidence than the Atacamenean population. It is suggested that this difference can be explained by peculiarities of the subsistence economies of the two populations. Am J Phys Anthropol 109:253–258, 1999. © 1999 Wiley-Liss, Inc.     

Interpersonal violence between 18th century Native Americans and Europeans in Ohio

During the winter of 1778-1779, a garrison of 176 individuals lived within the walls of a Revolutionary era stronghold named Ft. Laurens on the banks of the Tuscarawas River, near the present-day town of Bolivar, Ohio. At least 21 individuals were buried in the fort's cemetery during its occupation, 13 of whom were supposedly killed and scalped by Native Americans while gathering firewood and foraging horses. The purpose of this study is to build on previous work by Sciulli and Gramly ([1989] Am J. Phys. Anthropol. 80:11-24) by adding a more detailed analysis of the traumatic lesions, in order to better understand what happened to the victims. Lesions were analyzed based on type, location, and dimensions, as well as their overall pattern on the skeleton. Results indicate that multiple blows to the cranium were common. Out of 12 observable crania, the order of blows could be determined in only one case. Eleven of 12 of the observable crania from ambush victims and four of the seven nonambush victims exhibited lesions consistent with scalping. Evidence of postcranial trauma was noted on four individuals: one was an ambush victim, and the other three were killed at other times. No evidence of gunshot wounds was found.     

糖尿病患者拔牙创区微生物分布的临床研究

探讨糖尿病患者拔牙术后创区微生物分布情况 ,为临床防治术后感染提供理论依据。随机选取 3 9例已确诊为糖尿病的拔牙患者 ,在术后即刻采取拔牙创的渗出物 ,按 1 0倍系列稀释 ,培养微生物 ,然后进行分离、纯化和鉴定菌。结果从标本中培养出 1 87株微生物 ,鉴定到属或种 ,共获得 1 1种不同的细菌 ,常见的 7种。研究结果表明 ,糖尿病患者拔牙创区常见微生物依次为链球菌、萘瑟氏菌、梭杆菌、产黑色素拟杆菌、拟杆菌 ,韦荣菌属、二氧化碳嗜纤维菌属等。其中 ,链球菌、萘瑟氏菌为优势菌。     

Prehistoric trepanation in the Cuzco region of Peru: a view into an ancient Andean practice

In this study, patterns of prehistoric trepanation in the southern highlands of Peru were examined through an analysis of 11 Cuzco-region burial sites. Trepanations were found in 66 individuals, with several individuals exhibiting more than one trepanation, for a total of 109 perforations observed. The predominant methods used were circular cutting and scraping-methods that proved highly successful with an overall 83% survival rate and little ensuing infection. Survival rates showed a significant increase over time, apparently reflecting improvements in trepanation technique through experimentation and practical experience. Practitioners avoided certain areas of the cranium and employed methods that reduced the likelihood of damage to the cerebral meninges and venous sinuses. In many cases, trepanation as a medical treatment appears to have been prompted by cranial trauma, a finding that corroborates other studies pointing to cranial trauma as a primary motivation for the surgical procedure.     

0.1％西吡氯铵含漱液对牙外伤纤维夹板固定术后菌斑形成的抑制作用

目的 观察0.1％西吡氯铵含漱液对牙外伤纤维夹板固定术后菌斑形成的抑制作用.方法 牙外伤患者40例随机分为2组,应用双盲法分别给予患者0.1％西吡氯铵含漱液漱口(试验组)或0.12％氯己定含漱液漱口(对照组).每天5次,分别在晨起、睡前、三顿饭后各漱口1次,每次含15 mL,持续漱口60 s,漱口后1h内禁饮食,7d为一疗程.就诊当天(1 d)、4d和8d,按照Quigley-Hein指数(Turesky改良)测定菌斑指数.结果 中期检查试验组和对照组菌斑指数组间比较差异无统计学意义(P＞0.05);终点检查试验组和对照组菌斑指数组间比较差异无统计学意义(P＞0.05).结论 0.1％西吡氯铵含漱液可抑制牙外伤纤维夹板固定术后菌斑的形成,有利于牙周损伤的愈合.     

Study on oxidative stress in patients with abdominal trauma

Reactive oxygen species have been implicated in the etiology of multiple organ dyspepsia syndrome and infection's complications in patients with trauma. But the oxidative stress and antioxidants levels in abdominal trauma have not yet been studied. Therefore, this study was planned to measure lipid peroxidation for oxidative stress and reduced glutathione, catalase and superoxide dismutase (SOD) for antioxidant levels in plasma & heamolysate of 30 patients with abdominal trauma and 30 controls. From this study we can summarize that there was an increase in oxidative stress and decrease in antioxidant levels (causing oxidative stress) on day zero in patients with abdominal trauma. This oxidative stress on day zero was not related to the development of complications. There was no significant difference in oxidative stress between patients with solitary and multiple abdominal organ injury and also between patients with hollow viscus injury and solid organ injury on day zero. From this study, we conclude that in patients with abdominal trauma there was increase in oxidative stress and decrease in antioxidant levels on day zero.