BACKGROUND & AIMS: :The Bedford Orthopaedic Centre is situated in Umtata at the heart of the former homeland of the Transkei in the Eastern Cape of South Africa. It acts as an orthopaedic and trauma referral hospital for a mainly rural population approaching 4 million. This article focuses on the workload of the hospital over a 4-month period and like many hospitals in South Africa we highlight the difficulties it faces with the trauma epidemic.

背景与目标： : 贝德福德整形外科中心位于乌姆塔塔，位于南非东开普省特兰斯凯故居的中心。它是骨科和创伤转诊医院，主要是接近400万的农村人口。本文重点介绍了医院在4个月内的工作量，与南非的许多医院一样，我们强调了创伤流行所面临的困难。

BACKGROUND & AIMS: PROBLEM:Nurses are crucial members of the team caring for the acutely injured trauma patient. Until recently, nurses and physicians gained an understanding of leadership and supportive roles separately. With the advent of a multidisciplinary team approach to trauma care, formal team training and simulation has transpired. METHODS:Since 2007, our Level I trauma system has integrated TeamSTEPPS (Team Strategies & Tools to Enhance Performance & Patient Safety; Agency for Healthcare Research and Quality, Rockville, MD) into our clinical care, joint training of nurses and physicians, using simulations with participation of all health care providers. With the increased expectations of a well-orchestrated team and larger number of emergency nurses, our program created the Trauma Nurse Academy. This academy provides a core of experienced nurses with an advanced level of training while decreasing the variability of personnel in the trauma bay. Components of the academy include multidisciplinary didactic education, the Essentials of TeamSTEPPS, and interactive trauma bay learning, to include both equipment and drug use. Once completed, academy graduates participate in the orientation and training of General Surgery and Emergency Medicine residents' trauma bay experience and injury prevention activities. RESULTS:Internal and published data have demonstrated growing evidence linking trauma teamwork training to knowledge and self-confidence in clinical judgment to team performance, patient outcomes, and quality of care. IMPLICATIONS FOR PRACTICE:Although trauma resuscitations are stressful, high risk, dynamic, and a prime environment for error, new methods of teamwork training and collaboration among trauma team members have become essential.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:Existing methods to predict recovery after severe traumatic brain injury lack accuracy. The aim of this study is to determine the prognostic value of quantitative diffusion tensor imaging (DTI). METHODS:In a multicenter study, the authors prospectively enrolled 105 patients who remained comatose at least 7 days after traumatic brain injury. Patients underwent brain magnetic resonance imaging, including DTI in 20 preselected white matter tracts. Patients were evaluated at 1 yr with a modified Glasgow Outcome Scale. A composite DTI score was constructed for outcome prognostication on this training database and then validated on an independent database (n=38). DTI score was compared with the International Mission for Prognosis and Analysis of Clinical Trials Score. RESULTS:Using the DTI score for prediction of unfavorable outcome on the training database, the area under the receiver operating characteristic curve was 0.84 (95% CI: 0.75-0.91). The DTI score had a sensitivity of 64% and a specificity of 95% for the prediction of unfavorable outcome. On the validation-independent database, the area under the receiver operating characteristic curve was 0.80 (95% CI: 0.54-0.94). On the training database, reclassification methods showed significant improvement of classification accuracy (P < 0.05) compared with the International Mission for Prognosis and Analysis of Clinical Trials score. Similar results were observed on the validation database. CONCLUSIONS:White matter assessment with quantitative DTI increases the accuracy of long-term outcome prediction compared with the available clinical/radiographic prognostic score.

背景与目标：

BACKGROUND & AIMS: :The present study utilized longitudinal data from a high-risk community sample (N = 377; 166 trauma-exposed; 202 males; 175 females; 73% non-Hispanic Caucasian) to test pretrauma measures of adolescent internalizing and externalizing symptoms as unique prospective predictors of type of trauma exposure and PTSD over and above the influence of correlated family adversity (a composite of family conflict, stress, and parental psychopathology). Data were analyzed with logistic and multinomial logistic regressions. Results indicated that females, but not males, with higher levels of internalizing (OR = 2.91) and externalizing (OR = 2.37) symptoms during adolescence were significantly more likely to be exposed to assaultive violence (over and above family adversity). In fact, males with higher levels of internalizing symptoms were significantly less likely to be exposed to assaultive violence (OR = 0.54). Neither internalizing nor externalizing symptoms uniquely predicted exposure to traumatic events that did not involve assaultive violence. Among trauma-exposed participants, the unique association between internalizing symptoms and later PTSD yielded an odds ratio of 1.79 (p = .07) over and above the influences of family adversity, type of trauma exposure, and gender. Assaultive violence exposure fully mediated the association between females' externalizing symptoms and future PTSD. Findings may help inform the prevention of both assaultive violence exposure and PTSD.

背景与目标： : 本研究利用了来自高风险社区样本的纵向数据 (N = 377; 166创伤暴露; 202男性; 175女性; 73% 非西班牙裔高加索人) 测试青少年内在化和外在化症状的创伤前措施，作为创伤暴露类型和创伤后应激障碍的独特前瞻性预测因子，超越相关家庭逆境 (家庭冲突、压力和父母心理病理学的组合) 的影响。数据采用logistic和多项logistic回归分析。结果表明，女性而不是男性，在青春期具有较高水平的内在化 (或 = 2.91) 和外在化 (或 = 2.37) 症状的女性更容易遭受攻击性暴力 (超过家庭逆境)。事实上，具有较高水平内化症状的男性暴露于攻击性暴力的可能性显著降低 (OR = 0.54)。内部化或外部化症状都不能唯一地预测暴露于不涉及攻击性暴力的创伤事件。在创伤暴露的参与者中，内在化症状与后来的PTSD之间的独特关联产生了1.79的优势比 (p = .07)，超出了家庭逆境，创伤暴露类型和性别的影响。攻击性暴力暴露充分介导了女性外在症状与未来创伤后应激障碍之间的关联。研究结果可能有助于预防攻击性暴力暴露和PTSD。

BACKGROUND & AIMS: :HMGB1 is a nuclear protein that is released or secreted following trauma or severe cellular stress. Extracellular HMGB1 triggers inflammation and recruits leukocytes to the site of tissue damage. We review recent evidence that the ability of HMGB1 to recruit leukocytes may be entirely due to the formation of a heterocomplex with the homeostatic chemokine CXCL12. The HMGB1-CXCL12 heterocomplex acts on the CXCR4 receptor more potently than CXCL12 alone. Notably, only one of the redox forms of HMGB1, the one where all cysteines are reduced (all-thiol), can bind CXCL12. Both HMGB1 containing a disulfide bond between C23 and C45, which induces chemokine and cytokine release by activating TLR4, and HMGB1 terminally oxidized to contain a cysteine sulfonate are inactive in recruiting leukocytes. Thus, the chemoattractant and cytokine-inducing activities of HMGB1 are separable, and we propose that they appear sequentially during the development of inflammation and its resolution. The HMGB1-CXCL12 heterocomplex constitutes a specific target that may hold promise for the treatment of several pathologies.

背景与目标： : HMGB1是一种核蛋白，在创伤或严重的细胞应激后释放或分泌。细胞外HMGB1触发炎症并将白细胞募集到组织损伤部位。我们回顾了最近的证据，即HMGB1募集白细胞的能力可能完全是由于与稳态趋化因子cxcl12形成了异复合物。HMGB1-CXCL12的异源复合物比单独的CXCL12更有效地作用于CXCR4受体。值得注意的是，只有HMGB1的一种氧化还原形式 (所有半胱氨酸被还原的一种) 可以结合cxcl12。含有C23和C45之间的二硫键的HMGB1和通过激活TLR4诱导趋化因子和细胞因子释放的HMGB1，以及末端氧化为含有半胱氨酸磺酸盐的HMGB1在募集白细胞中均无活性。因此，HMGB1的趋化因子和细胞因子诱导活性是可分离的，我们建议它们在炎症的发展及其消退过程中依次出现。HMGB1-CXCL12的异源复合物构成特定的靶标，可以有望治疗几种病理。

BACKGROUND & AIMS: :Maxillofacial injuries are often seen in the emergency department. Fractures of the facial skeleton are commonly seen after assault, road traffic accidents, falls, and sporting injuries in a ratio mandibular:zygoma:maxillary of 6:2:1. Clinicians must be familiar with their management so that appropriate treatment may be used.

背景与目标： : 急诊科经常看到颌面受伤。在袭击，道路交通事故，跌倒和运动伤害后，通常会出现面部骨骼骨折，其比例为下颌: 骨瘤: 6:2:1上颌。临床医生必须熟悉其管理，以便可以使用适当的治疗方法。

BACKGROUND & AIMS: STUDY DESIGN:Case report of pedicle screw fixation in an infant with nonaccidental spine trauma. OBJECTIVE:To ensure awareness of nonaccidental pediatric spine trauma and describe a safe and effective method of treating a complex problem of thoracolumbar fracture-dislocation in an infant. SUMMARY OF BACKGROUND DATA:Nonaccidental pediatric spine trauma is rare, accounting for <1% of abuse. No previous cases of pedicle screw fixation have been described in a patient younger than 1 year of age. Prior treatment of this clinical entity has been treated with casts or wire-fixation. METHODS:An 8-month-old boy had a nonaccidental (also known as child abuse) traumatic T12-L1 fracture-dislocation. This was subsequently surgically corrected with posterior spinal fusion and instrumentation with pedicle screws. RESULTS:After surgery, the patient is doing well with no adverse effects from surgery. CONCLUSIONS:Although child abuse is a rare cause of spinal trauma, clinicians should do a full skeletal survey to ensure no other injuries are overlooked. Pedicle screw fixation can be used in infants with unstable traumatic spinal injuries, allowing earlier rehabilitation and return to normal activity level.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:An occult cardiac injury may be present in patients with an acute abdomen after penetrating thoracoabdominal trauma. This study assessed the use of a subxiphoid pericardial window (SPW) as a diagnostic manoeuvre in this setting. METHODS:This was a retrospective review of a trauma database (2001-2009). Patients presenting with a penetrating thoracoabdominal injury with an acute abdomen, and in whom there was concern about a potential cardiac injury from the site or tract of the injury, were included. RESULTS:Fifty patients with an indication for emergency laparotomy underwent a SPW for a possible cardiac injury. An occult haemopericardium was present at SPW in 14 patients (28 per cent) mandating, median sternotomy. Nine cardiac injuries (18 per cent) were identified including five tangential injuries and four perforations. The specific complication rate relating to the SPW was 2 per cent. CONCLUSION:The SPW is a useful technique at laparotomy to identify cardiac injuries in patients with penetrating thoracoabdominal injuries.

背景与目标：

BACKGROUND & AIMS: :Posttraumatic stress disorder (PTSD) and depressive symptoms have been theorized to mediate the relationship between trauma exposure and physical health symptoms. Although empirical evidence supports this premise, studies conducted to date have employed statistical mediation analyses that are now broadly criticized. Furthermore, the mediating roles of both PTSD and depressive symptoms have seldom been examined concurrently, and it remains unclear which PTSD symptom clusters uniquely mediate this relationship. The aim of the present study was to examine the mediating role of reexperiencing, avoidance/numbing, hyperarousal, and depressive symptoms in the relationship between trauma exposure and physical health symptoms. Participants were 516 Spanish female undergraduate students. Physical health symptoms were compared between those who reported trauma exposure (n = 266) and those who did not (n = 250). Data from trauma-exposed participants were analyzed using regression models with bootstrapping to test mediation. Results of the analyses showed that the trauma-exposed group reported significantly more physical health symptoms (r(2) = .035). Hyperarousal and depressive symptoms uniquely mediated the relationship between trauma exposure and physical health symptoms. Our findings clarify some of the mechanisms by which negative health consequences occur subsequent to trauma exposure.

背景与目标： : 创伤后应激障碍 (PTSD) 和抑郁症状已被理论化，以介导创伤暴露与身体健康症状之间的关系。尽管经验证据支持这一前提，但迄今为止进行的研究采用了统计中介分析，这些分析现在受到广泛批评。此外，很少同时检查PTSD和抑郁症状的中介作用，并且尚不清楚哪些PTSD症状簇唯一地介导了这种关系。本研究的目的是研究再经历，回避/麻木，过度觉醒和抑郁症状在创伤暴露与身体健康症状之间的关系中的中介作用。参与者是516名西班牙女本科生。在报告创伤暴露的患者 (n = 266) 和未报告创伤暴露的患者 (n = 250) 之间比较了身体健康症状。使用回归模型和自举测试中介来分析创伤暴露参与者的数据。分析结果表明，创伤暴露组报告了更多的身体健康症状 (r(2) = .035)。过度觉醒和抑郁症状独特地介导了创伤暴露与身体健康症状之间的关系。我们的发现阐明了创伤暴露后产生负面健康后果的一些机制。

BACKGROUND & AIMS: STUDY OBJECTIVE:We determine the effect of the duration of emergency department (ED) observation on computed tomography (CT) rate for children with minor blunt head trauma. METHODS:We performed a prospective cohort study of children with blunt head trauma and a Glasgow Coma Scale score greater than 14. We defined time from injury as the time from head injury to initial physician (emergency attending physician or fellow) assessment. For children who were observed in the ED before CT decisionmaking, we defined ED observation time as time from initial physician assessment to the decision whether to obtain a CT. After adjusting for time from injury, patient age, sex, physician type, and study month, we measured the effect of ED observation time on CT rate in each of the 3 Pediatric Emergency Care Applied Research Network Traumatic Brain Injury risk groups. RESULTS:Of the 1,605 eligible patients, we enrolled 1,381 (86%). Of the enrolled patients, 676 (49%) were observed in the ED and 272 (20%) had a CT performed. After adjustment, every hour of ED observation time was associated with a decrease in CT rate for children in all 3 traumatic brain injury risk groups: high risk (adjusted odds ratio [OR] 0.11; 95% confidence interval [CI] 0.05 to 0.24), intermediate risk (adjusted OR 0.28; 95% CI 0.21 to 0.36), and low risk (adjusted OR 0.47; 95% CI 0.31 to 0.73). All 8 children with a significant traumatic brain injury had an immediate CT. CONCLUSION:For children with minor blunt head trauma, ED observation time was associated with a time-dependent reduction in cranial CT rate, with no delay in the diagnosis of a significant traumatic brain injury.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:The utility of esophagogastroduodenoscopy (EGD) performed at the time of percutaneous endoscopic gastrostomy (PEG) is unclear. We examined whether EGD at time of PEG yielded clinically useful information important in patient care. We also reviewed the outcome and complication rates of EGD-PEG performed by trauma surgeons. METHODS:Retrospective review of all trauma patients undergoing EGD with PEG at a level I trauma center from 1/01-6/03. RESULTS:210 patients underwent combined EGD with PEG by the trauma team. A total of 37% of patients had unsuspected upper gastrointestinal lesions seen on EGD. Of these, 35% had traumatic brain injury, 10% suffered multisystem injury, and 47% had spinal cord injury. These included 15 esophageal, 61 gastric, and six duodenal lesions, mucosal or hemorrhagic findings on EGD. This finding led to a change in therapy in 90% of patients; either resumption/continuation of H2 -blockers or conversion to proton-pump inhibitors. One patient suffered an upper gastrointestinal bleed while on H2-blocker. It was treated endoscopically. Complication rates were low. There were no iatrogenic visceral perforations seen. Three PEGs were inadvertently removed by the patient (1.5%); one was replaced with a Foley, one replaced endoscopically, and one patient underwent gastric repair and open jejunostomy tube. One PEG leak was repaired during exploration for unrelated hemorrhage. Six patients had significant site infections (3%); four treated with local drainage and antibiotics, one requiring operative debridement and later closure, and one with antibiotics alone. CONCLUSION:EGD at the time of PEG may add clinically useful data in the management of trauma patients. Only one patient treated with acid suppression therapy for EGD diagnosed lesions suffered delayed gastrointestinal bleeding. Trauma surgeons can perform EGD and PEG with acceptable outcomes and complication rates.

背景与目标：

BACKGROUND & AIMS: :We analysed the trauma triage system at a specific level I trauma centre to assess rates of over- and undertriage and to support recommendations for system improvements. The triage process is designed to estimate the severity of patient injury and allocate resources accordingly, with potential errors of overestimation (overtriage) consuming excess resources and underestimation (undertriage) potentially leading to medical errors.We first modelled the overall trauma system using risk analysis methods to understand interdependencies among the actions of the participants. We interviewed six experienced trauma surgeons to obtain their expert opinion of the over- and undertriage rates occurring in the trauma centre. We then assessed actual over- and undertriage rates in a random sample of 86 trauma cases collected over a six-week period at the same centre. We employed Bayesian analysis to quantitatively combine the data with the prior probabilities derived from expert opinion in order to obtain posterior distributions. The results were estimates of overtriage and undertriage in 16.1 and 4.9% of patients, respectively. This Bayesian approach, which provides a quantitative assessment of the error rates using both case data and expert opinion, provides a rational means of obtaining a best estimate of the system's performance. The overall approach that we describe in this paper can be employed more widely to analyse complex health care delivery systems, with the objective of reduced errors, patient risk and excess costs.

背景与目标： : 我们在特定的I级创伤中心分析了创伤分类系统，以评估过度和不足分类的发生率，并支持有关系统改进的建议。分类过程旨在估计患者伤害的严重程度并相应地分配资源，其中潜在的高估错误 (overtriage) 消耗了多余的资源，而低估 (undertriage) 则可能导致医疗错误。我们首先使用风险分析方法对整个创伤系统进行建模，以了解参与者行为之间的相互依赖性。我们采访了六位经验丰富的创伤外科医生，以获取他们对创伤中心发生的过度和漏诊率的专家意见。然后，我们评估了在同一中心六周内收集的86例创伤病例的随机样本中的实际分流率和分流不足率。我们采用贝叶斯分析将数据与从专家意见得出的先验概率定量结合，以获得后验分布。结果分别是16.1和4.9% 患者的超分流和不足分流的估计值。这种贝叶斯方法可以使用案例数据和专家意见对错误率进行定量评估，从而提供了一种合理的方法来获得系统性能的最佳估计。我们在本文中描述的总体方法可以更广泛地用于分析复杂的医疗保健提供系统，目的是减少错误，患者风险和超额成本。

BACKGROUND & AIMS: PURPOSE:The purpose of this study is to examine the effect of establishing a dedicated operating room for unscheduled orthopedic cases and to evaluate a group of patients with isolated femur fractures. The frequency of after-hours surgery and the impact of patients who present with acute orthopedic injuries are reviewed. METHODS:A retrospective review of all orthopedic cases from the operating room scheduling system at a level-one trauma center was undertaken from October 2003 to September 2005. Before October 2004, unscheduled cases were placed on a shared add-on list, and no special priority was given to orthopedic cases. Additionally, a subset of adult patients with isolated femoral shaft fractures was identified to evaluate time from admission to surgery, operative time, frequency of transfer of care between surgeons, and total length of hospital stay. RESULTS:The number of orthopedic cases was 1799 in fiscal year 2004 (FY04) and 2046 in FY05, an increase of 14%. Overall, the hospital experienced an increase in level-one trauma activations from 1450 in FY04 to 1580 in FY05 (8.2%), and an increase in the number operative trauma cases from 447 to 494 (9.5%). Cases after 7:00 pm declined from 197 in FY04 to 165 in FY05, a decrease of 16%. Cases between midnight and 7:00 am declined from 63 in FY04 to 35 in FY05, a decrease of 44%. For the subset of femur fracture patients, transfer of care to another operating surgeon occurred 4.5 times more frequently. The median delay between admission and surgery increased from 5.7 hours to 10.9 hours. Median case duration increased from 106 to 127 minutes. CONCLUSIONS:It is possible to dramatically decrease the occurrence of after-hours orthopedic surgery in a level-one trauma center through the use of a dedicated room for unscheduled orthopedic trauma cases. Benefits include less frequent activation of after-hours operating room resources, fewer disruptions to the OR schedule and office hours, and more frequent fracture care by orthopedic traumatologists. The impact of a longer delay between admission and surgical treatment and more frequent transfer of care between surgeons deserves further evaluation.

背景与目标：

BACKGROUND & AIMS: :External laryngeal trauma is rare, accounting for less than 1% of all trauma cases seen at major centers. We report the case of a man who experienced multiple injuries, including an external laryngeal trauma. The primary signs and symptoms of his laryngeal trauma were hoarseness, hemoptysis, the loss of his laryngeal prominence (Adam's apple), neck tenderness, traumatic emphysema in the neck, and a small penetrating wound to the right of the laryngeal prominence. The patient underwent immediate tracheostomy and surgical exploration. On long-term followup, his voice quality and airway patency improved. This case illustrates the importance of rapid identification and early management of laryngotracheal trauma in a patient with multiple injuries.

背景与目标： : 喉外创伤很少见，占主要中心所有创伤病例的不到1%。我们报告了一名男子遭受多处伤害，包括喉部外部创伤的情况。喉部创伤的主要体征和症状是声音嘶哑，咯血，喉部突出 (亚当的苹果) 的丧失，颈部压痛，颈部外伤性肺气肿以及喉部突出右侧的小穿透伤口。患者立即接受气管切开术和手术探查。在长期随访中，他的声音质量和气道通畅性得到改善。该病例说明了在多发伤患者中快速识别和早期处理喉气管创伤的重要性。

BACKGROUND & AIMS: :This study used resting-state functional magnetic resonance imaging (fMRI) to investigate whether functional connectivity is altered in people developing post-traumatic stress disorder (PTSD) following recent trauma. Sixty-two participants who had experienced recent acute traumatic events underwent a 7.3 min resting fMRI scan within 2 days post accident. Of these, 22 participants were diagnosed with PTSD within 1 to 6 months. Nineteen age- and sex-matched subjects without PTSD were selected as the trauma-exposed control group. Posterior cingulate cortex connectivity was determined from 17 PTSD patients and 15 control subjects by investigating synchronic low-frequency fMRI signal fluctuations using a temporal correlation method. To assess the relationship between PTSD symptom severity and PCC connectivity, the contrast image representing areas correlated with the PCC was correlated with the 17 PTSD subjects' Clinician Administered PTSD Scale (CAPS) scores at diagnosis. Compared with the control group, PTSD patients exhibited decreased functional connectivity in the right lingual and right middle temporal gyri, and left lingual/posterior cingulate cortex. The left inferior temporal gyrus, right middle temporal gyrus, left middle temporal gyrus/insula, left medial frontal lobe/anterior cingulate cortex, and right medial frontal gyrus also showed increased connectivity within two days post accident. A negative correlation was found between PCC connectivity and CAPS scores in the left medial prefrontal cortex (mPFC). These results suggest that patients who develop PTSD exhibit different resting-state patterns of neuronal activity following recent trauma. Abnormal FC of mPFC may be a major risk factor predisposing patients to the development of PTSD.

背景与目标： : 这项研究使用静息状态功能磁共振成像 (fMRI) 来调查最近发生创伤后发生创伤后应激障碍 (PTSD) 的人的功能连接是否发生改变。62名最近经历过急性创伤事件的参与者在事故发生后2天内接受了7.3分钟的静息fMRI扫描。其中，22名参与者在1至6个月内被诊断出患有PTSD。选择19名年龄和性别匹配的无PTSD受试者作为创伤暴露对照组。通过使用时间相关方法调查共时低频fMRI信号波动，确定了17名PTSD患者和15名对照受试者的后扣带回皮层连通性。为了评估PTSD症状严重程度与PCC连通性之间的关系，将代表与PCC相关区域的对比图像与17名PTSD受试者的临床医生在诊断时给予的PTSD量表 (CAPS) 评分相关。与对照组相比，PTSD患者的右舌和右中颞回以及左舌/后扣带回皮质的功能连接降低。事故发生后两天内，左侧颞下回，右侧颞下回，左侧颞下回/岛叶，左侧内侧额叶/前扣带回和右侧内侧额叶也显示连接增加。在左侧内侧前额叶皮层 (mPFC) 的PCC连通性与CAPS评分之间发现负相关。这些结果表明，发生PTSD的患者在最近的创伤后表现出不同的静息状态神经元活动模式。mPFC的FC异常可能是导致患者发生PTSD的主要危险因素。