Globe rupture with aphakia, aniridia, secondary glaucoma and late corneal decompensation: A multi-staged approach to management

Severe blunt ocular trauma may result in immediate and delayed complications requiring appropriate management algorithms. We hereby report a case of globe rupture, aphakia, traumatic aniridia, and secondary glaucoma in a 33-year-old male following road traffic accident. He was treated initially by primary repair followed by novel combined approach of aniridia IOL with Ahmed glaucoma valve implantation. Delayed corneal decompensation required deferred penetrating keratoplasty. After a follow-up of 3.5 years after last surgery, patient maintains good functional vision with stable IOL, clear corneal graft and controlled intraocular pressure. A meticulously planned and staged management approach appears better suited in complex ocular trauma in such scenarios giving a good structural and functional outcome

Predictores de mortalidad precoz en pacientes con trauma complejo hemorrágico / Early mortality predictors in patients with complex hemorrhagic trauma

RESUMEN Fundamento: El trauma complejo es un problema de salud a nivel mundial y cuando es de tipo hemorrágico la mortalidad es superior a los otros tipos de traumas complejos. Objetivo: Determinar las variables predictoras de mortalidad precoz en pacientes hospitalizados con trauma complejo hemorrágico en una institución hospitalaria del segundo nivel de atención en Cuba. Metodología: Se realizó un estudio transversal en el Hospital General Provincial Camilo Cienfuegos de Sancti Spíritus, durante 6 años. Se incluyeron 207 pacientes. Las variables se agruparon en sociodemográficas, enfermedades crónicas asociadas, mecanismo lesional, tipo de trauma, localización topográfica, tiempo entre admisión hospitalaria, diagnóstico y tratamiento, complicaciones precoces, tratamiento médico y quirúrgico, y mortalidad precoz. Se elaboró un árbol de decisión mediante el método Chaid exhaustivo, la variable dependiente fue la mortalidad por trauma complejo hemorrágico. Resultados: Predominaron los pacientes del sexo masculino (85 %), con 60 años y menos (83 %), con trauma contuso (57.5 %) y politraumatizados (42.5 %). Predominaron también los que presentaron acidosis metabólica (66.7 %), coagulopatía aguda (44.4 %), hipotermia (41.5 %). El 30 % de los pacientes falleció precozmente. El árbol de decisión tuvo una sensibilidad de 82.3 %, una especificidad de 97.2 % y un porcentaje global de pronóstico correcto del 92.8 %. Se identificaron 4 variables predictores de mortalidad: hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante. Conclusiones: La probabilidad más alta de fallecer precozmente durante un trauma complejo hemorrágico se da entre pacientes con hipotermia, acidosis metabólica, coagulopatía aguda y trauma penetrante.

ABSTRACT Background: Complex trauma is a worldwide health problem and when hemorrhagic, mortality is higher than other types of complex trauma. Objective: To determine predictive variables of early mortality in hospitalized patients with complex hemorrhagic trauma in a second care level hospital in Cuba. Methodology: A cross-sectional study was conducted at Camilo Cienfuegos Provincial General Hospital in Sancti Spíritus, for 6 years. 207 patients were included. The variables were grouped into sociodemographic, associated chronic diseases, injury mechanism, type of trauma, topographic location, time between hospital admission, diagnosis and treatment, early complications, medical and surgical treatment, and early mortality. A decision tree was developed using the exhaustive Chaid method, the dependent variable was mortality due to complex hemorrhagic trauma. Results: Male patients (85 %), 60 years and younger (83 %), with blunt trauma (57.5 %) and polytraumatized patients (42.5 %) predominated. Those who presented metabolic acidosis (66.7 %), acute coagulopathy (44.4 %), and hypothermia (41.5 %) also predominated. 30 % of patients died early. The decision tree had a sensitivity of 82.3 %, a specificity of 97.2 % and an overall percentage of correct forecast of 92.8 %. Four variables that predicted mortality were identified: hypothermia, metabolic acidosis, acute coagulopathy, and penetrating trauma. Conclusions: The highest probability of early dying during a complex hemorrhagic trauma occurs among patients with hypothermia, metabolic acidosis, acute coagulopathy and penetrating trauma.

The first instrument for complex PTSD assessment: psychometric properties of the ICD-11 Trauma Questionnaire

Objective: The ICD-11 Trauma Questionnaire (ITQ) was developed as a joint effort by researchers from several countries to evaluate post-traumatic stress (PTSD) and complex-PTSD (C-PTSD) symptoms. This study is part of a multi-center international collaborative research project that aims to provide psychometric support for this initial instrument in different languages, considering the specific contexts related to complex traumatization. This study verified the psychometric characteristics of the Portuguese version of the ITQ, evaluating symptoms beyond those described the existing literature. Methods: We examined the results of a convenience sample totaling 268 Portuguese and Angolan participants. Two instruments were applied: the ITQ, which evaluates symptoms resulting from a traumatic life event, and the Life Events Checklist (LEC), which evaluates stressful life events. The general characteristics of the scales are described, and reliability analysis and validity studies were performed. Results: Cronbach's alpha varied between 0.84 and 0.88, and the exploratory factorial analysis results were consistent with the concept of C-PTSD, with five components explaining 61.58% of scale variance. Conclusion: The results suggest good psychometric characteristics for the Portuguese version of the ITQ, and thus it can be included in protocols intended evaluating complex traumatic symptoms.

Thoracic limb salvage by fibular free flap

The treatment of most fractures of the ulna and radius is usually performed by anatomical reduction and internal fixation, when damage is extensive and local soft tissue cannot provide a complete wound coverage, locoregional flaps present a suitable reconstructive benefit. A 35-year-old male patient suffered an exposed diaphysio-metaphyseal fracture with multi-fragmented distal radius. The patient was evaluated during a 10-day period at the National Institute of Rehabilitation, where the osteosynthesis material and a severe infectious process with necrosis were identified. Necrosectomy of the posterior compartment and removal of the osteosynthesis material was performed, a skin defect of approximately 22x16 cm was observed with a bone gap of 6 cm of radius and ulna. a fibula-free flap is placed to correct the skin defect and an external fixative used for bone alignment. The fibular free flap presents an excellent therapeutic alternative in the resolution of bone gaps with extensive skin defect. Whenever a trained microsurgery team is available, current scales of limb injury should be considered but not utilized for therapeutic approach, always trying to shift amputation as the first option, to the very last one of them.

Application of three-dimensional digital reconstruction and printing technology in the clinical teaching of complex orthopedics / 中华医学教育探索杂志

Objective To explore the effect of 3d digital reconstruction and printing technology on the teaching of complex orthopedics. Methods A total of 90 interns in the Second Affiliated Hospital of Inner Mongolia Medical University from September 2016 to September 2017 were selected as research subjects. According to the different teaching methods, they were divided into control group (n=45) and experimental group (n=45). The former received traditional teaching;the latter used three-dimensional digital reconstruction and printing technology to print out complex fracture models of patients, digitally reproduced fracture classification, developed scientific surgical plans through fracture models, and simulated surgical fixation methods. Examination was divided into clinical skills and written exam according to exam outline requirements; Self-cognitive ability score included professional interest, fracture understanding, etc. The satisfaction of the medical students in the experimental group was determined using self-made questionnaires. t test was used to compare data between groups. Results Experimental groups' scores for surgical skills (84.36 ±0.28) and theoretical knowledge (87.55 ±0.44) were higher than the control group, and the differences were statistically significant (P<0.05). The professional interest of the experimantal group was higher than that of the control group, and the difference was statistically significant (P<0.05). The students' classroom atmosphere was significantly better compared with the control group, and the difference was statistically significant (P<0.05). Conclusion Using 3 d digital reconstruction and printing technology to establish modes in complex orthopedics teaching process can effectively improve interns' surgical skills and theoretical knowledge, and promote student satisfaction.

Validation of the Korean Version of the Trauma Symptom Checklist-40 among Psychiatric Outpatients / 정신신체의학

OBJECTIVES: Effects of multiple trauma are complex and extend beyond core PTSD symptoms. However, few psychological instruments for trauma assessment address this issue of symptom complexity. The Trauma Symptom Checklist-40 (TSC-40) is a self-report scale that assesses wide range of symptoms associated with childhood or adult traumatic experience. The purpose of the present study was to evaluate the validity of the Korean Version of the TSC-40 in a sample of psychiatric outpatients. METHODS: Data of 367 treatment-seeking patients with DSM-IV diagnoses were obtained from an outpatient department of psychiatric unit at a university hospital. The diagnoses were anxiety disorder, posttraumatic stress disorder, depressive disorder, adjustment disorder and others. Included in the psychometric data were the TSC-40, the Life events checklist, the Impact of Event Scale-Revised, the Zung's Self-report Depression Scale, and the Zung's Self-report Anxiety Scale. Cronbach's α for internal consistency were calculated. Convergent and concurrent validity was approached with correlation between the TSC-40 and other scales (PTSD, anxiety and depression). RESULTS: Exploratory factor analysis of the Korean Version of TSC-40 extracted seven-factor structure accounted for 59.55% of total variance that was contextually similar to a six-factor structure and five-factor structure of the original English version. The Korean Version of TSC-40 demonstrated a high level of internal consistency. (Cronbach's α=0.94) and good concurrent and convergent validity with another PTSD scale and anxiety and depression scales. CONCLUSIONS: Excellent construct validity of The Korean Version of TSC-40 was proved in this study. And subtle difference in the factor structure may reflect the cultural issues and the sample characteristics such as heterogeneous clinical population (including non-trauma related disorders) and outpatient status. Overall, this study TSCdemonstrated that the Korean version of TSC-40 is psychometrically sound and can be used for Korean clinical population.

Intervenções em terapia cognitivo-comportamental para trauma complexo: uma revisão sistemática / Cognitive behavior therapy interventions for complex trauma: a systematic review / Las intervenciones en terapia cognitivo-conductual para trauma complejo: una revisión sistemática

INTRODUÇÃO: Embora a Terapia Cognitivo-Comportamental (TCC) possua evidências que demonstram sua efetividade para o tratamento de Transtornos Relacionados ao Trauma e Estresse, alguns casos específicos apresentam baixa resposta. Tais casos estão associados à exposição recorrente a eventos traumáticos, de natureza interpessoal, durante a infância. Apesar de não haver consenso sobre a nomeação destes quadros clínicos, é possível que estejam associados ao diagnóstico de Trauma Complexo (TC). OBJETIVO: Este estudo objetivou revisar sistematicamente evidências sobre os efeitos da TCC para TC. MÉTODO: Realizou-se buscas no MEDLINE, Embase e ISI Web of Science. Artigos com desenho de estudo clínico randomizado, estudo clínico não randomizado e estudos não controlados com intervenções em TCC para TC foram incluídos. Apenas estudos com avaliações pré e pós-intervenção foram elegíveis. RESULTADOS: Identificou-se 369 estudos sendo 7 elegíveis para esta revisão. As intervenções abordaram vários sintomas envolvidos na proposta para diagnóstico de TC, incluindo sintomas pós-traumático, depressivos, de ansiedade e regulação emocional. CONCLUSÃO: Os artigos revisados demonstraram que intervenções terapêuticas, independente da natureza, possuem efeitos ao longo do tempo sobre sintomas de TC. A TCC revelou-se superior em comparação ao tratamento controle, sendo que tanto TCC em grupo como individual revelaram-se capazes de reduzir os sintomas de TC.

INTRODUCTION: Although Cognitive Behavior Therapy (CBT) has been shown effectiveness for treating posttraumatic stress disorders, there are some difficults regarding specfic cases. This cases are usually associated with a history of recurrent and prolonged exposure to traumatic events during the childhood. Since there is no consensus concerning the appointment of these clinical conditions, it is suggested that such cases could represent the diagnosis of Complex Trauma (CT). OBJECTIVE: This study aimed to investigate, through a systematic review, the efficacy of CBT for CT. METHOD: The searches were conducted in Pubmed, Embase and ISI Web of Science. Articles that described randomized controlled, non-randomized controlled and non-controlled studies which had interventions based on CBT for CT symptoms were included. RESULTS: The search identified 369 studies, and 7 were selected. The focus of CBT interventions comprised a variety of symptoms that have been proposed for the CT diagnosis, including posttraumatic and depressive symptoms, anxiety and emotional regulation. CONCLUSION: The results suggest that therapeutic interventions, regardless of type, have an effect over time on CT symptoms. CBT was more efficient compared to the control treatments. Both individual and group CBT were able to reduce CT symptoms.

INTRODUCCIÓN: A pesar de la Terapia Cognitivo-Conductual (TCC) tiener un cuerpo de evidencia que demuestra la eficacia para el tratamiento de desórdenes de estrés y trauma, algunos casos específicos tienen una baja respuesta. Estos casos están asociados con la exposición repetida a los acontecimientos traumáticos, de carácter interpersonal, durante la infancia. Aunque no existe un consenso en cuanto a la designación de estos cuadros clínicos, es posible que se asocie con un diagnóstico llamado Trauma Complejo (TC). META: Este estudio tuvo como objetivo investigar, a través de la revisión sistemática, estudios sobre los efectos de las intervenciones en la TCC para el TC. MÉTODO: Se realizaron búsquedas en MEDLINE, EMBASE, ISI Web of Science. Se incluyeron los artículos con diseño aleatorio estudio clínico, estudio clínico no aleatorizado y estudios no controlados con intervenciones en la TCC para la CT. Sólo los estudios con pre y post-intervención fueron elegibles. RESULTADOS: Se identificaron 369 estudios y son 7 electos para esta revisión. Las intervenciones discutieron diversos síntomas de TC, incluyendo los síntomas postraumáticos, depresivo, de ansiedad y regulación emocional. CONCLUSIÓN: Artículos revisados han demostrado que las intervenciones terapéuticas, independientemente de la naturaleza, tienen un efecto en el tiempo de los síntomas de la CT. La TCC ha demostrado ser superior en comparación con el tratamiento control. Tanto la TCC individual y grupal demostró ser capaz de reducir los síntomas de TC.

Brazilian version of the Structured Interview for Disorders of Extreme Stress - Revised (SIDES-R): adaptation and validation process / Versão brasileira da Structured Interview for Disorders of Extreme Stress - Revised (SIDES-R): processo de adaptação e validação

BACKGROUND: Posttraumatic stress disorder (PTSD) contemplates the impact of acute traumatic events, but the literature indicates that this is not true for chronic exposure to stress. In this sense, the category disorders of extreme stress not otherwise specified (DESNOS) has been proposed to characterize the behavior and cognitive alterations derived from exposure to continuous early life stress. The Structured Interview for Disorders of Extreme Stress - Revised (SIDES-R) was developed to investigate and measure DESNOS. Considering the lack of instruments designed to assess DESNOS, especially in Brazil, the aim of this study was to translate, adapt, and validate the contents of SIDES-R to Brazilian Portuguese (SIDES-R-BR). METHOD: The original interview was subjected to translation, back-translation, semantic equivalence and conceptual correspondence analyses by naive and specialized judges, respectively, an acceptability trial, and inter-rater validity analysis. RESULTS: The interview underwent semantic and structural adaptations considering the Brazilian culture. The final version, SIDES-R-BR, showed a mean understanding score of 4.98 on a 5-point verbal rating scale, in addition to a kappa coefficient of 0.853. CONCLUSION: SIDES-R-BR may be a useful tool in the investigation of DESNOS and contributes a valuable input to clinical research in Brazil. The availability of the instrument allows to test symptoms with adequate reliability, as verified by the kappa coefficient and translation steps (AU)

INTRODUÇÃO: O transtorno do estresse pós-traumático (posttraumatic stress disorder, PTSD) contempla o impacto de eventos traumáticos agudos, mas a literatura indica que o mesmo não se aplica a exposição crônica ao estresse. Nesse sentido, foi proposta a categoria transtornos de estresse extremo não especificados (disorders of extreme stress not otherwise specified, DESNOS). Com o objetivo de investigar e medir as alterações comportamentais e cognitivas relacionadas ao diagnóstico de DESNOS, foi desenvolvida a Structured Interview for Disorders of Extreme Stress - Revised (SIDES-R). Considerando a falta de instrumentos construídos para avaliar DESNOS, especialmente no Brasil, o objetivo deste estudo foi traduzir, adaptar e validar os conteúdos da SIDES-R para português brasileiro (SIDES-R-BR). MÉTODO: A entrevista original foi submetida a tradução, retrotradução, análise de equivalência semântica e correspondência conceitual por avaliadores leigos e especializados, respectivamente. Foi realizado teste de aceitabilidade e análise de validade interavaliadores. RESULTADOS: A entrevista passou por adaptações semânticas e estruturais considerando a cultura brasileira. A versão final, SIDES-R-BR, demonstrou um escore médio de compreensão de 4,98 em uma escala de avaliação verbal de 5 pontos, além de um coeficiente de kappa de 0,853. CONCLUSÃO: O SIDES-R-BR pode ser uma ferramenta útil na investigação de DESNOS e contribui com um input valioso para a pesquisa clínica no Brasil. A disponibilidade do instrumento permite testar sintomas com confiabilidade adequada, conforme verificado por meio do coeficiente de kappa e etapas de tradução (AU)