Rita de Cássia Almeida Vieira

Diffuse axonal injury: epidemiology, outcome and associated risk factors

Diffuse axonal injury (DAI), a type of traumatic injury, is known for its severe consequences. However, there are few studies describing the outcomes of DAI and the risk factors associated with it. This study aimed to describe the outcome for patients with a primary diagnosis of DAI 6 months after trauma and to identify sociodemographic and clinical factors associated with mortality and dependence at this time point. Seventy-eight patients with DAI were recruited from July 2013 to February 2014 in a prospective cohort study. Patient outcome was analyzed using the Extended Glasgow Outcome Scale (GOS-E) within 6 months of the traumatic injury. The mean Injury Severity Score was 35.0 (SD = 11.9), and the mean New Injury Severity Score (NISS) was 46.2 (SD = 15.9). Mild DAI was observed in 44.9% of the patients and severe DAI in 35.9%. Six months after trauma, 30.8% of the patients had died, and 45.1% had shown full recovery according to the GOS-E. In the logistic regression model, the severity variables – DAI with hypoxia, as measured by peripheral oxygen saturation, and hypotension with NISS value – had a statistically significant association with patient mortality; on the other hand, severity of DAI and length of hospital stay were the only significant predictors for dependence. Therefore, severity of DAI emerged as a risk factor for both mortality and dependence.

Effect of a positively charged water-in-oil microemulsion on the apparent pKa of a hydrophilic indicator

The effect of the water-in-oil microemulsion formed by benzylcetyldimethylammonium chloride in benzene on the apparent pKa value (hereafter written pK) of the hydrophilic indicator 2-hydroxy-5-methyl-trimethylanilinium chloride was studied spectrophotometrically as a function of the structure of the buffer (phosphate and tris) and the molar ratios of watersurfactant and buffersurfactant. The starting pH values of the buffer solutions (i.e., those measured before solubilization in the reversed micelle) were used to calculate the micellar pK values. These were found to depend on each one of the above mentioned variables. Buffer-independent pK values were obtained, however, if the starting pHs were corrected both for the ion exchange with the surfactant counter-ion, and for the effect of the low polarity of the micelle-solubilized water (relative to bulk water). The micelle-induced shift of the pK of the indicator is attributed to “medium” and electrostatic effects.

Quality of life of victims of traumatic brain injury six months after the trauma

OBJECTIVE to describe the quality of life of victims of traumatic brain injury six months after the event and to show the relationship between the results observed and the clinical, sociodemographic and return to productivity data. METHOD data were analyzed from 47 victims assisted in a trauma reference hospital in the municipality of Aracaju and monitored in an outpatient neurosurgery clinic. The data were obtained through analysis of the patient records and structured interviews, with the application of the World Health Organization Quality of Life, brief version, questionnaire. RESULTS the victims presented positive perceptions of their quality of life, and the physical domain presented the highest mean value (68.4±22.9). Among the sociodemographic characteristics, a statistically significant correlation was found between marital status and the psychological domain. However, the return to productivity was related to all the domains. CONCLUSION the return to productivity was an important factor for the quality of life of the victims of traumatic brain injury and should direct the public policies in promoting the health of these victims.OBJETIVOS: descrever a qualidade de vida das vitimas de trauma craniencefalico, apos seis meses do evento, e mostrar a relacao entre os resultados observados e os dados clinicos, sociodemograficos e retorno a produtividade. METODO: foram analisados dados de 47 vitimas assistidas em hospital referencia ao trauma, no municipio de Aracaju, SE, e acompanhadas em ambulatorio de neurocirurgia. Os dados foram obtidos pela analise dos prontuarios e entrevistas estruturadas, com aplicacao do questionario World Health Organization Quality of Life, versao breve. RESULTADOS: as vitimas apresentaram percepcao positiva de sua qualidade de vida e o dominio fisico (68,4±22,9) apresentou o maior valor medio. Entre as caracteristicas sociodemograficas, correlacao estatisticamente significante foi verificada entre estado civil e o dominio psicologico. Entretanto, o retorno a produtividade se relacionou com todos os dominios. CONCLUSAO: o retorno a produtividade foi fator importante para a qualidade de vida das vitimas de trauma craniencefalico e deve direcionar as politicas publicas na promocao a saude dessas vitimas.

Traumatic brain injury and hyperglycemia

We read with great interest the recent study by Shi et al [1] published in the Oncotarget. The management of modifiable risk factors in traumatic brain injury victims has a main role in the patients outcome and a inappropriate treatment is followed by a worse prognosis. Knowledge about the mechanism of hyperglycemia, comorbidities, potential causes, effects and associated factors can improve the treatment process associated with adequate therapeutics could reduce the complications and modify outcome of these victims [1, 2]. A strong point of the paper is providing a meaningful view of mechanisms of hyperglycemia after traumatic brain injury and the pathway that lead to systemic dysfunctions and the role of comorbidities, including iatrogenic factors [1]. However, in spite of the paper covers some themes, a important consideration that should be mentioned in this review is the definition of papers selection criteria [3, 4]. Hence, the use of a reproducible methodology in the construction of systematic review provides better scientific evidence and increase quality information [3, 4]. Other important point of concern is the concepts covered in the study. In trauma, especially those of severity in traumatic brain injury, stratification methods for standardized clinical assistance and research are widely disseminated in the medical literature [2, 5]. Liu-DeRyke et al [6] described clinical impact of early hyperglycemia during acute phase of traumatic brain injury, probably result from action of high glucose toxicity on neurons. The authors also have discussed several diagnosis and mechanisms of hyperglycemia, there are references to controversy regarding the use of intensive insulin therapy [7], but the authors did not present the best management of hyperglycemia for clinical use, which would make the review more complete and useful. Identify and delimit what are the limits for hyperglycemia (range of serum glucose), the epidemiological and clinical characteristics of the population of these studies [4]. We believe that future studies are necessary to evaluate treatment protocols of serum glucose target levels. However, these do not exclude the relevance of the results of this interesting paper. The review described by Shi et al [1] showed the importance of studying the hyperglycemia as a risk factor that could be modified by therapeutic measures. The correlation among the level of serum glucose, management of hyperglycemia and outcome remains on developement. This is a complex issue, presents particularities, and perhaps should be stratified according to level of blood glycemia, severity of TBI, length of hospitalization, outcome and comorbidities.

Assessment of selected quality fields of nursing care in neurosurgical wards

Dear editor We read with great interest the recent study by Ślusarz et al1 published in the Patient Preference and Adherence journal. The nurse has a key role in caring for the human being in a comprehensive and holistic manner, providing a systematic assistance in promotion, prevention, protection, and rehabilitation of patients.2 Patient satisfaction about the care provided by the nursing staff is an important aspect to evaluate the quality of care and contributes in the improvement of treatment processes.3,4 In the study by Ślusarz et al1 the importance of evaluation of nursing care and its influence on the quality of care were emphasized. A strong point of the paper is the instrument used to evaluate the patient expectations with respect to the service provided by the staff in several areas, which helps in identifying the areas of strengths and weaknesses of the quality of care. However, despite the questionnaire covers five areas, it is unspecific to assess the quality of nursing care. We believe that future studies are necessary to evaluate the quality of nursing care especially in the special population with neurosurgical diseases, and to identify the factors that influence the quality of assistance.3–5 An important consideration that should be mentioned in this study about evaluation of nursing care is hospital work context. In some health institutions, the nursing team may need to work in both professional administrative services and nursing care.6 Hence, it is important for the authors to report whether the nursing teams perform exclusive roles in patients assistance alone or in administrative functions also. Other important points of concern are that the authors do not mention details about sample size calculation and distribution of the sample in different institutions, which could ensure higher degrees of internal and external validity. The authors have presented results from a multicenter medical service-quality project executed by four university medical centers. Hence, information about distribution of the sample could enable comparison of the responses of patients regarding the evaluation of nursing care between different institutions, including number of patients and systematization of care provided by the nursing teams. These are some questions; however, these do not exclude the relevance of the results of this interesting paper.

Scales for assessment of patients with traumatic brain injury.

Dear editor We read with great interest the paper by Ślusarz et al1 published in the Patient Preference and Adherence. The functional recovery after traumatic brain injury (TBI) is related to the severity of the brain lesion and the time after TBI. The consequences of brain damage remain beyond the acute phase, extending and modifying for a long period after the traumatic event.2 Knowing the functional recovery after TBI is relevant to evaluating the results of new techniques and treatments to minimize the severity of the disability. As a result, the pathophysiology of disability after TBI and the mechanisms involved in functional recovery are the subject of investigations, which provide the foundation to direct rehabilitation programs and guide the development of individualized therapy after TBI.3 Ślusarz et al’s1 article focused on the role of establishing the relationships between measurements by the Glasgow Coma Scale (GCS) and the scales used for the assessment of functional capacity of TBI patients. Although some studies have described the recovery of patients of TBI after trauma, there are few studies that evaluate the different aspects of functional capacity in the acute phase after brain injury and factors related to outcome. We agree with Ślusarz et al1 that studying the functional capacity and assessing the activities of daily living in patients with TBI facilitate the planning of systematic assistance, implementation of neurological rehabilitation, reintegration of patients in society, and a better warranted quality of life. A strength of the study is to analyze the functional capacity assessed by different scales at admission and at discharge, highlighting the correlation of recovery in both periods with the level of awareness, and the comparison of different scales that assess functional capacity and activities of daily life. Our group has great interest in the assessment of functional recovery of TBI patients analyzed by different scales, in particular, patients with severe diffuse axonal injury (DAI).3,4 As discussed by Ślusarz et al,1 the evaluation of consciousness is a widely used prognostic parameter in the acute phase of trauma and identifies early the outcome of patients with severe TBI, and it is relevant in the face of the impairment of brain functions caused after TBI and the mechanisms involved in the recovery process. Clinical observations of TBI patients have suggested improvement during the first year, particularly during the first 6 months, with stabilizing of the recovery process thereafter.2,5–7 Research to assess the consequences for TBI patients showed that there is an improvement in functionality after trauma; however, how to measure functional recovery after TBI is still a challenge. Analysis of patients with severe TBI showed that advanced age and prolonged hospitalization were independent predictors of poor outcome after trauma.6 The lowest score of the Glasgow Coma Scale on admission is a factor associated with dependence or death of TBI patients, assessed 3 months after the trauma.7 Our research8 carried out with patients of DAI showed that severe DAI stood out as risk factor for mortality and dependence compared to focal injury. The length of hospitalization was identified as a risk factor related to dependence on outcome. In addition, other important scales can be used to assess functional recovery, mainly in severe trauma. We had used Katz scale and the Extended Glasgow Outcome Scale in patients with severe DAI, and we found similar results when assessing recovery at 6 months after DAI compared with results described by Ślusarz et al,1 using correlation results of the functional capacity scale and the functional index “Repty”. The results described by Sĺusarz et al1 showed the importance of studying the recovery of patients with TBI after trauma since it identified greater independence of the patients after hospital discharge and a correlation between the level of awareness and functional capacity. The identification of functional recovery and its correlation with the outcome can guarantee the quality of care provided to patients and provide a better quality of life. However, we believe that functional recovery analysis of TBI patients is a complex issue, presents particularities, and maybe should be stratified according to severity of trauma, including the creation of appropriate scales for mild TBI, separated from moderate and severe TBI.

Qualidade de vida das vitimas de trauma craniencefalico seis meses apos o trauma

OBJECTIVE to describe the quality of life of victims of traumatic brain injury six months after the event and to show the relationship between the results observed and the clinical, sociodemographic and return to productivity data. METHOD data were analyzed from 47 victims assisted in a trauma reference hospital in the municipality of Aracaju and monitored in an outpatient neurosurgery clinic. The data were obtained through analysis of the patient records and structured interviews, with the application of the World Health Organization Quality of Life, brief version, questionnaire. RESULTS the victims presented positive perceptions of their quality of life, and the physical domain presented the highest mean value (68.4±22.9). Among the sociodemographic characteristics, a statistically significant correlation was found between marital status and the psychological domain. However, the return to productivity was related to all the domains. CONCLUSION the return to productivity was an important factor for the quality of life of the victims of traumatic brain injury and should direct the public policies in promoting the health of these victims.OBJETIVOS: descrever a qualidade de vida das vitimas de trauma craniencefalico, apos seis meses do evento, e mostrar a relacao entre os resultados observados e os dados clinicos, sociodemograficos e retorno a produtividade. METODO: foram analisados dados de 47 vitimas assistidas em hospital referencia ao trauma, no municipio de Aracaju, SE, e acompanhadas em ambulatorio de neurocirurgia. Os dados foram obtidos pela analise dos prontuarios e entrevistas estruturadas, com aplicacao do questionario World Health Organization Quality of Life, versao breve. RESULTADOS: as vitimas apresentaram percepcao positiva de sua qualidade de vida e o dominio fisico (68,4±22,9) apresentou o maior valor medio. Entre as caracteristicas sociodemograficas, correlacao estatisticamente significante foi verificada entre estado civil e o dominio psicologico. Entretanto, o retorno a produtividade se relacionou com todos os dominios. CONCLUSAO: o retorno a produtividade foi fator importante para a qualidade de vida das vitimas de trauma craniencefalico e deve direcionar as politicas publicas na promocao a saude dessas vitimas.

Calidad de vida de las víctimas de trauma craneoencefálico seis meses después del trauma

OBJECTIVE to describe the quality of life of victims of traumatic brain injury six months after the event and to show the relationship between the results observed and the clinical, sociodemographic and return to productivity data. METHOD data were analyzed from 47 victims assisted in a trauma reference hospital in the municipality of Aracaju and monitored in an outpatient neurosurgery clinic. The data were obtained through analysis of the patient records and structured interviews, with the application of the World Health Organization Quality of Life, brief version, questionnaire. RESULTS the victims presented positive perceptions of their quality of life, and the physical domain presented the highest mean value (68.4±22.9). Among the sociodemographic characteristics, a statistically significant correlation was found between marital status and the psychological domain. However, the return to productivity was related to all the domains. CONCLUSION the return to productivity was an important factor for the quality of life of the victims of traumatic brain injury and should direct the public policies in promoting the health of these victims.OBJETIVOS: descrever a qualidade de vida das vitimas de trauma craniencefalico, apos seis meses do evento, e mostrar a relacao entre os resultados observados e os dados clinicos, sociodemograficos e retorno a produtividade. METODO: foram analisados dados de 47 vitimas assistidas em hospital referencia ao trauma, no municipio de Aracaju, SE, e acompanhadas em ambulatorio de neurocirurgia. Os dados foram obtidos pela analise dos prontuarios e entrevistas estruturadas, com aplicacao do questionario World Health Organization Quality of Life, versao breve. RESULTADOS: as vitimas apresentaram percepcao positiva de sua qualidade de vida e o dominio fisico (68,4±22,9) apresentou o maior valor medio. Entre as caracteristicas sociodemograficas, correlacao estatisticamente significante foi verificada entre estado civil e o dominio psicologico. Entretanto, o retorno a produtividade se relacionou com todos os dominios. CONCLUSAO: o retorno a produtividade foi fator importante para a qualidade de vida das vitimas de trauma craniencefalico e deve direcionar as politicas publicas na promocao a saude dessas vitimas.

Associacao do Valor Preditivo do New Injury Severity Score (Niss) Com A Escala de Resultados de Glasgow em Pacientes Com Lesao Axonial Difusa

Traumatic brain injury (TBI) affects large numbers of victims and constitutes a serious public health problem in Brazil. Diffuse axonal injury (DAI) is the most common consequence of TBI and it is responsible for most of the chronic sequelae. Analysis of the prognostic index new injury severity score (NISS) determines the severity of injuries by body region examined during the hospital stay and it is really useful in making decisions about treatment strategies and to predict mortality of victims. Given the above, the purpose of this study was to collect epidemiological data of victims with exclusive diagnosis of DAI and test the association of the predictive value of the NISS with the Glasgow Outcome Scale (GOS) at the hospital discharge. We analyzed medical records of 21 victims with exclusive diagnosis of DAI admitted to the DAI ambulatory at Clinics Hospital of the Faculty of Medicine, University of Sao Paulo, located in Sao Paulo city, from January 2011 to February 2012. The results show a predominance of male (76.2%) aged 24 years (±11.9) admitted during the morning (42.8%), on Saturday (23.8%), victims of motorcycle accidents (74 42%), referred to the hospital by prehospital specialized service (85.7%), with Glasgow Coma Scale less than or equal to 8 (76.2%); 71.4% of the victims were addmited at the Intensive Care Unit (ICU), with an lenght of hospital stay of 07 days (±20.46) and NISS mean of 36 (± 9.99). All victims had serious head injury with elevated head MAIS and severe disability (66.7%). Statistically significant association was found between NISS and the GOS. The severity of the victims with DAI by NISS is an important indicator of health care and can assist in the planning of multidisciplinary rehabilitation program specialist.

Transition State Structure for the Reversible Hydration of 1, 3-Dichloroacetone in the Presence of Aerosol-OT Reversed Micelles in Hexane

Rate and equilibrium constants, and the kinetic orders with respect to water for the reversible hydration of 1, 3-dichloroacetone (DCA) in the presence of bis-2-ethylhexyl sodium sulphosuccinate (Aerosol-OT or AOT) reversed micelles in hexane differ from those observed in aqueous dioxane. The transition state (TS) structure for the micellar reaction was probed by subjecting the reaction to a proton inventory study. The results show that the TS structure depends on the molar ratio water/surfactant (R). At a low R value (1.3) a TS including the ketone and one water molecule probably H-bonded to the surfactant, is implied. Proton inventories at higher R values (4.2, 8.3, and 11.1) indicate that a second water molecule is participating as a “general base”. In all cases, the results are compatible with an acyclic TS with one proton “in flight”, and the degree of proton transfer to the second water molecule increases as a function of increasing R. The activation parameters at different water concentrations agree with the proposed TS structures, and show that the micellar rate enhancement is mainly due to entropy increase.