Background: The National Trauma Data Bank (NTDB) is plagued by the problem of missing physiological data. The Glasgow Coma Scale score, Respiratory Rate and Systolic Blood Pressure are an essential part of risk adjustment strategies for trauma system evaluation and clinical research. Missing data on these variables may compromise the feasibility and the validity of trauma group comparisons. Aims: To evaluate the validity of Multiple Imputation (MI) for completing missing physiological data in the National Trauma Data Bank (NTDB), by assessing the impact of MI on 1) frequency distributions, 2) associations with mortality, and 3) risk adjustment. Methods: Analyses were based on 170,956 NTDB observations with complete physiological data (observed data set). Missing physiological data were artificially imposed on this data set and then imputed using MI (MI data set). To assess the impact of MI on risk adjustment, 100 pairs of hospitals were randomly selected with replacement and compared using adjusted Odds Ratios (OR) of mortality. OR generated by the observed data set were then compared to those generated by the MI data set. Results: Frequency distributions and associations with mortality were preserved following MI. The median absolute difference between adjusted OR of mortality generated by the observed data set and by the MI data set was 3.6% (inter-quartile range: 2.4%-6.1%). Conclusions: This study suggests that, provided it is implemented with care, MI of missing physiological data in the NTDB leads to valid frequency distributions, preserves associations with mortality, and does not compromise risk adjustment in inter-hospital comparisons of mortality.

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Objectives: The present study was designed to investigate the role of a mitochondrial enzyme pyruvate dehydrogenase (PDH) on the severity of brain injury, and the effects of pyruvate treatment in rats with traumatic brain injury (TBI). Materials and Methods: We examined rats subjected to closed head injury using a fluid percussion device, and treated with sodium pyruvate (antioxidant and substrate for PDH enzyme). At 72 h post injury, blood was analyzed for blood gases, acid-base status, total PDH enzyme using a dipstick test and malondialdehyde (MDA) levels as a marker of oxidative stress. Brain homogenates from right hippocampus (injured area) were analyzed for PDH content, and immunostained hippocampus sections were used to determine the severity of gliosis and PDH E1-∞ subunit. Results: Our data demonstrate that TBI causes a significant reduction in PDH enzyme, disrupt-acid-base balance and increase oxidative stress in blood. Also, lower PDH enzyme in blood is related to the increased gliosis and loss of its PDH E1-∞ subunit PDH in brain tissue, and these effects of TBI were prevented by pyruvate treatment. Conclusion: Lower PDH enzyme levels in blood are related to the global oxidative stress, increased gliosis in brain, and severity of brain injury following TBI. These effects can be prevented by pyruvate through the protection of PDH enzyme and its subunit E-1.

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Background: Facial fractures and concomitant cranial injuries carry the significant potential for mortality and neurological morbidity mainly in young adults. Aims and Objectives: To analyze the characteristics of head injuries and associated facial injuries, the management options and outcome following cranio-facial trauma. Methods: This retrospective review was performed at Justice K. S. Hegde Charitable Hospital, and associated A. B. Shetty Memorial Institute of Dental sciences, Deralakatte, Mangalore. Following Ethical Committee approval, hospital charts and radiographs of 100 consecutive patients of cranio-facial trauma managed at the Department of Oral and Maxillofacial Surgery and Neurosurgery between January 2004 and December 2004 were reviewed. Results: Majority of the patients were in the 2nd to 4th decade (79%) with a male to female ratio of -8.09:1. Road traffic accidents were the common cause of craniofacial trauma in present study (54%) followed by fall from height (30%). Loss of consciousness was the most common clinical symptom (62%) followed by headache (33%). Zygoma was the most commonly fractured facial bone 48.2% (alone 21.2%, in combination 27.2%). Majority of patients had mild head injury and managed conservatively in present series. Causes of surgical intervention for intracranial lesions were compound depressed fracture, contusion and intracranial hematoma. Operative indications for facial fractures were displaced facial bone fractures. Major causes of mortality were associated systemic injuries. Conclusion: Adult males are the most common victims in craniofacial trauma, and road traffic accidents were responsible for the majority. Most of the patients sustained mild head injuries and were managed conservatively. Open reduction and internal fixation with miniplates was used for displaced facial bone fractures.

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Hair dye poisoning has been emerging as one of the important causes of intentional self harm in the developing world. Hair dyes contain paraphenylene-diamine and a host of other chemicals that can cause rhabdomyolysis, laryngeal edema, severe metabolic acidosis and acute renal failure. Intervention at the right time has been shown to improve the outcome. In this article, we review the various manifestations, clinical features and treatment modalities for hair dye poisoning.

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As of April 25 ^th 2009, 11.00 AM, eight human cases of swine influenza A virus infection have been identified in the United States in California and Texas. There is also established evidence of similar cases across the United States border in Mexico. Experts from the Centers for Disease Control and Prevention in cooperation with World Health Organization and public health experts from Canada and Mexico are leading an exhaustive investigation to find the source of infection and infected people. We present a profile of this illness from the available literature.

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In early May 2008, Cyclone Nargis (CN) tore across the southern coastal regions of Myanmar, pushing a tidal surge through villages and rice paddies. The almost 12 foot wall of water and wind speed of over 200 km/hr killed tens of thousands of people and left hundreds of thousands homeless and vulnerable to injury and disease. Out of the 7.35 million living in the affected townships of Labutta, Bogale, Pyinsalu, Yangon, and many more, approximately 2.4 million were affected. Overall, more than 50 townships were affected by this most devastating cyclone in Asia since 1991. The Delta region, Myanmar's Rice Bowl, was severely damaged. The low-lying villages were submerged. There was widespread destruction of homes, critical infrastructure of the villages, roads, ferries, water, fuel, and electricity supplies. Our team from Singapore (called Team Singapore) reached out to at least 10 different villages during the time we were there. We ran mobile clinics daily at several locations and these operated from warehouses, temples, schools or any make shift buildings. The journey to the remote villages may take between 1 and 2 hours by road or by boat. We also ran mobile clinics at the township hospital, the rural healthcare centers, and an orphanage.

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Peripartum cardiomyopathy (PPCM) is a rare life-threatening cardiomyopathy of unknown cause that occurs in the peripartum period in previously healthy women. ^[1] the symptomatic patients should receive standard therapy for heart failure, managed by a multidisciplinary team. The diagnosis of PPCM rests on the echocardiographic identification of new left ventricular systolic dysfunction during a limited period surrounding parturition. Diagnostic criteria include an ejection fraction of less than 45%, fractional shortening of less than 30%, or both, and end-diastolic dimension of greater than 2.7 cm/m ² body surface-area. This entity presents a diagnostic challenge because many women in the last month of a normal pregnancy experience dyspnea, fatigue, and pedal edema, symptoms identical to early congestive heart failure. There are no specific criteria for differentiating subtle symptoms of heart failure from normal late pregnancy. Therefore, it is important that a high index of suspicion be maintained to identify the rare case of PPCM as general examination showing symptoms of heart failure with pulmonary edema. PPCM remains a diagnosis of exclusion. No additional specific criteria have been identified to allow distinction between a peripartum patient with new onset heart failure and left ventricular systolic dysfunction as PPCM and another form of dilated cardiomyopathy. Therefore, all other causes of dilated cardiomyopathy with heart failure must be systematically excluded before accepting the designation of PPCM. Recent observations from Haiti ^[2] suggest that a latent form of PPCM without clinical symptoms might exist. The investigators identified four clinically normal postpartum women with asymptomatic systolic dysfunction on echocardiography, who subsequently either developed clinically detectable dilated cardiomyopathy or improved and completely recovered heart function.

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Background: Hi-fidelity simulation is becoming accepted as a teaching tool for medical providers. Advanced simulations allow educators to test difficult clinical scenarios. The goal of this study was to test the diagnostic and treatment skills of a third-year medical student faced with a simulated patient having evidence of a stable pneumothorax. Students are then expected to evaluate the teaching simulation in comparison to traditional methods. Methods: The case was one of a 12 cases in the "high stakes" Clinical Performance Exam. The patient with evidence of a stable pneumothorax was chosen to evaluate both diagnostic abilities and decision making in therapeutic options. Students were assessed using a university-wide standardized checklist: diagnosis, management, and interaction with the simulator. Immediately following the simulation, the students evaluated the experience. Results: The exam was given to 117 students. The correct diagnosis was made by 115/117 (98%). Treatment was considered acceptable in a majority of students, Send patient to the Emergency Department 77%, Oxygen 26% and Analgesia 39%. The follow-up survey completed by 78% of the students revealed the students felt comfortable with the simulators, but had concerns about the exam. Students liked the simulator as an educational tool 88% of the time. Conclusions: Simulation was used in a year-end exam and majority of students chose the correct diagnosis and treatment plan. It was also found that a significant percentage of students performed an unnecessary and potentially harmful procedure. The survey revealed that students were concerned about distractions and realism, but overall expressed desire for more education using simulation.

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Background: Medical errors and adverse events (AE), though common worldwide, have never been studied in India. We believe that though common these are under reported. Aim: The aim of this study was to study medical errors and consequent AE in patients presenting with trauma and bowel perforation peritonitis. Methods: Five hundred and eighty-six consecutive patients with trauma or peritonitis, presenting to surgery emergency of UCMS-GTBH, were prospectively studied using review form (RF) 1 and 2. AE was defined as an outcome not expected to be part of the illness. RF 1 was filled for all and indicated if AE was present or not. RF2 was filled when RF 1 indicated presence of AE; it further confirmed the occurrence of AE and pointed to the type of medical error and resultant disability. All results were expressed as percentage. Results: There were 500 (85%) males. Mean age of the patients was 31 years. There were 332 patients with peritonitis and 254 with trauma. AE and its consequences were present in 185 (31.5%) and 183 (31.2%) patients, respectively. Consequences were as follows: disability - 157 (85%), increased hospital stay and/or increased visits in the OPD - 28 (15.3%) and both-101 (55.2%) patients. Disabilities were: death - 62 (40%), temporary disability - 90 (58%) and permanent disability - 05 (3.1%) patients. AE in 133 (71.8%) patients was definitely (level of confidence 6) due to error in healthcare management. All AE were considered preventable. Error of omission accounted for AE in 122 (65.9%) patients. System and operative errors were the commonest, 84.3% and 82.7%, respectively. One hundred and sixty-seven (90%) patients had multiple errors. Conclusions: The study proves that medical errors and AE are a serious problem in our set-up and calls for immediate system improvement.

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September 11 ^th events taught us, members of the medical community, that we need to prepared for the worst. Nuclear terror is no longer science fiction. Radiological weapons of mass terror come in three flavors: The first one is nuclear. Since 1992, there have been six known cases of highly enriched uranium or plutonium being intercepted by authorities as it passed in or out of the former Soviet Union. Constructing a nuclear fission weapon requires high-level expertise, substantial facilities, and lots of money. All three of which would be difficult, although not impossible, for a terrorist group to pull off without state support. However, terrorists could carry out potential mass destruction without sophisticated weaponry by targeting nuclear facilities using conventional bombs or hijacked aircrafts. Terror attacks could also carry out mass panic and radioactive contamination of people and environment by dispersal of radioactive materials with or without the use of conventional explosive devices. Most medical and para-medical personnel are not familiar with CBRN terror and radiation casualties. To lessen the impact of those potential attacks and provide care for the greatest number of potential survivors, the community as a whole - and the medical community in particular - must acquire the knowledge of the various signs and symptoms of exposure to irradiation and radioactive contamination as well as have a planned response once such an attack has occurred. Based on knowledge of radiation hazards, medical emergency planers should analyze the risks of each scenario, offer feasible solutions and translate them into internationally accepted plans that would be simple to carry out once such an attack took place. The planned response should be questioned and tested by drills. Those drills should check the triage, evacuation routes, decontamination posts, evacuation centers and receiving hospitals. It is crucial that the drill will consist of simulated casualties that will follow the evacuation route from point zero to the ED. Knowledge and exercise will reduce terror (fear) from radiation and help the community as a whole better cope with such an event. This article will review the general information of radiation types, their biological damage, clinical appearance and general concepts of nuclear event planning, focusing on medical response and focus on the Israeli perspective.

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Diaphragmatic injuries are relatively rare and result from either blunt or penetrating trauma. Regardless of the mechanism, diagnosis is often missed and high index of suspicion is vital. The clinical signs associated with a diaphragmatic hernia can range from no outward signs to immediately life-threatening respiratory compromise. Establishing the clinical diagnosis of diaphragmatic injuries (DI) can be challenging as it is often clinically occult. Accurate diagnosis is critical since missed DI may result in grave sequelae due to herniation and strangulation of displaced intra-abdominal organs. We present a case of polytrauma with rib fracture and delayed appearance of diaphragmatic hernia manifesting as difficult weaning from ventilatory support.

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Bacterial meningitis remains a major cause of death and long-term neurologic sequelae worldwide. We present a case of fatal Klebsiella pneumoniae meningitis and concomitant disseminated intravascular coagulation (DIC) in a 72-year-old woman with diabetes mellitus (DM). Both blood and cerebrospinal fluid cultures grew Klebsiella pneumoniae . Due to advanced age, newly recognized DM, K. pneumoniae bacteremia, and DIC, the prognosis of our patient was poor. Eight hours after arrival to the emergency department, cardiopulmonary resuscitation was necessary in this patient, but she died despite an early diagnosis and appropriate antibiotic therapy.

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This paper defines a specific plan which allows two separate institutions, with different capabilities, to function as a single receiving entity in the event of a mass casualty incident. The street between the two institutions will be closed to traffic and a two-phase process initiated. Arriving ambulances will first be quickly screened to expedite the most critical patients followed by formal triage and directing patients to one of the two facilities. Preparation for this plan requires prior coordination between local authorities and the administrations of both institutions. This plan can serve as a general model for disaster preparedness when two or more institutions with different capabilities are located in close proximity.

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Oral anticoagulants are an established treatment modality in the prophylaxis of thromboembolic events in various clinical scenarios. Needless to say that, bleeding is a natural adverse effect of this drug. Most of the times bleeding is inconsequential. But nevertheless massive and fatal bleeding can occur occasionally. The case reported here is rare, as the patient presented with massive hemoperitoneum due to mesenteric hemorrhage and hemorrhagic infarction of small bowel necessitating Laparotomy resection.

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During trauma the abdomen is one region which cannot be ignored. Due to its Complex anatomy it is very important that all the areas in the abdomen be examined both clinically and radiologicaly to rule out any abdominal bleeding as a cause of Hemorrhagic Shock Following Trauma. Our case justifies the above.

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Connecting care Competencies and Culture are core fundamentals in responding to disasters. Thick coordination between professionals, communities and agencies in different geographical areas is crucial to the happening of appropriate preparedness and thus efficient response and mitigation of a disaster. In the next few articles, we present diverse examples related to the preparedness and recovery process to adverse disasters across the globe

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