Dissertations / Theses on the topic 'Compensation, injury, trauma, outcome'

Doctor of Philosophy
Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

Doctor of Philosophy
Work-related injuries and road traffic injuries are common causes of morbidity and are major contributors to the burden of disease worldwide. In developed countries, these injuries are often covered under compensation schemes, and the costs of administering these schemes is high. The compensation systems have been put in place to improve the health outcomes, both physical and mental, of those injured under such systems; yet there is a widespread belief, and some evidence, that patients treated under these schemes may have worse outcomes than if they were treated outside the compensation system. Chapter One of this thesis explores the literature pertaining to any effect that compensation may have on patient outcomes. It is noted that the concept of “compensation neurosis” dates from the nineteenth century, with such injuries as “railway spine”, in which passengers involved in even minor train accidents at the time, would often have chronic and widespread symptoms, usually with little physical pathology. Other illnesses have been similarly labelled over time, and similarities are also seen in currently diagnosed conditions such as repetition strain injury, back pain and whiplash. There are also similarities in a condition that has been labelled “shell shock”, “battle fatigue”, and “post-traumatic stress disorder”; the latter diagnosis originating in veterans of the Vietnam War. While there is evidence of compensation status contributing to the diagnosis of some of these conditions, and to poor outcomes in patients diagnosed with these conditions, there is little understanding of the mechanism of this association. In contrast to popular stereotypes, the literature review shows that malingering does not contribute significantly to the effect of compensation on health outcomes. Secondary gain is likely to play an important role, but secondary gain is not simply confined to financial gain, it also includes gains made from avoidance of workplace stress and home and family duties. Other psychosocial factors, such as who is blamed for an injury (which may lead to retribution as a secondary gain) or the injured person’s educational and occupational status, may also influence this compensation effect. The literature review concludes that while the association between compensation and health after injury has been widely reported, the effect is inconsistent. These inconsistencies are due, at least in part, to differences in definitions of compensation (for example, claiming compensation versus using a lawyer), the use of different and poorly defined diagnoses (for example, back pain), a lack of control groups (many studies did not include uncompensated patients), and the lack of accounting for the many possible confounding factors (such as measures of injury severity or disease severity, and socio-economic and psychological factors). The literature review also highlighted the variety of different outcomes that had been used in previous studies, and the paucity of literature regarding the effect of compensation on general health outcomes. This thesis aims to explore the association between compensation status and health outcome after injury. It addresses many of the methodological issues of the previously published literature by, i selecting study populations of patients with measurable injuries, ii clearly defining and separating aspects of compensation status, iii including control groups of non-compensated patients with similar injuries iv allowing for a wide variety of possible confounders, and v using clearly defined outcome measures, concentrating on general health outcomes. Before commencing the clinical studies reported in Chapters Three and Four, a systematic review and meta-analysis was performed to quantify and analyse the effect of compensation on outcome after surgery. This allowed a clearly defined population of studies to be included, and was relevant to the thesis as the surgeries were performed as treatment of patients who had sustained injuries. The study, which is reported in Chapter Two, hypothesised that outcomes after surgery would be significantly worse for patients treated under compensation schemes. The study used the following data sources: Medline (1966 to 2003), Embase (1980 to 2003), CINAHL, Cochrane Controlled Trials Register, reference lists of retrieved articles and textbooks, and contact with experts in the field. The review included any trial of surgical intervention where compensation status was reported and results were compared according to that status, and no restrictions were placed on study design, language or publication date. Data extracted were study type, study quality, surgical procedure, outcome, country of origin, length and completeness of follow-up, and compensation type. Studies were selected by two unblinded independent reviewers, and data were extracted by two reviewers independently. Data were analysed using Cochrane Review Manager (version 4.2). Two hundred and eleven papers satisfied the inclusion criteria. Of these, 175 stated that the presence of compensation (worker's compensation with or without litigation) was associated with a worse outcome, 35 found no difference or did not describe a difference, and one paper described a benefit associated with compensation. A meta-analysis of 129 papers with available data (20,498 patients) revealed the summary odds ratio for an unsatisfactory outcome in compensated patients to be 3.79 (95% confidence interval 3.28 to 4.37, random effects model). Grouping studies by country, procedure, length of follow-up, completeness of follow-up, study type, and type of compensation showed the association to be consistent for all sub-groups. This study concludes that compensation status is associated with poor outcome after surgery, and that this effect is significant, clinically important and consistent. Therefore, the study hypothesis is accepted. However, as data were obtained from observational studies and were not homogeneous, the summary effect should be interpreted with caution. Determination of the mechanism for the association between compensation status and poor outcome, shown in the literature review (Chapter One) and the systematic review (Chapter Two) required further study. Two studies were designed to further explore this association and these are reported in Chapters Three and Four. The retrospective study reported in Chapter Three, the Major Trauma Outcome Study (MTOS), aimed to explore the association between physical, psychosocial, and compensation-related factors and general health after major physical trauma. The primary hypothesis predicted significantly poorer health outcomes in patients involved in pursuing compensation, allowing for possible confounders and interactions. The study also examined other health outcomes that are commonly associated with compensation, and examined patient satisfaction. Consecutive patients presenting to a regional trauma centre with major trauma (defined as an Injury Severity Score greater than 15) were surveyed between one and six years after their injury. The possible predictive factors measured were: general patient factors (age, gender, the presence of chronic illnesses, and the time since the injury), injury severity factors (injury severity score, admission to intensive care, and presence of a significant head injury), socio-economic factors (education level, household income, and employment status at the time of injury and at follow-up), and claim-related factors (whether a claim was pursued, the type of claim, whether the claim had settled, the time to settlement, the time since settlement, whether a lawyer was used, and who the patient blamed for the injury). Multiple linear regression was used to develop a model with general health (as measured by the physical and mental component summaries of the SF-36 General Health Survey) as the primary outcome. The secondary outcomes analysed were: neck pain, back pain, post-traumatic stress disorder, and patient satisfaction. On multivariate analysis, better physical health was significantly associated with increasing time since the injury, and with lower Injury Severity Scores. Regarding psychosocial factors, the education level and household income at the time of injury were not significantly associated with physical health, but pursuit of compensation, having an unsettled claim, and the use of a lawyer were strongly associated with poor physical health. Measures of injury severity or socio-economic status were not associated with mental health. However, the presence of chronic illnesses and having an unsettled compensation claim were strongly associated with poor mental health. Regarding the secondary outcomes, increasing neck pain and back pain were both significantly associated with lower education levels and the use of a lawyer, but not significantly associated with claiming compensation. The severity of symptoms related to post-traumatic stress disorder was not associated with measures of injury severity, but was significantly and independently associated with the use of a lawyer, having an unsettled compensation claim, and blaming others (not themselves) for the injury. The strongest predictor of patients’ dissatisfaction with their progress since the injury was having an unsettled compensation claim, and as with the other secondary outcomes, patient satisfaction was not significantly associated with injury severity factors. Factors relating to the compensation process were among the strongest predictors of poor health after major trauma, and were stronger predictors than measures of injury severity. The hypothesis that general physical and mental health would be poorer in patients involved in seeking compensation for their injury was accepted. This study concludes that the processes involved with claiming compensation after major trauma may contribute to poor health outcomes. The prospective study reported in Chapter Four, the Motor Vehicle Accident Outcome Study (MVAOS), aimed to explore the effect of compensation related factors on general health in patients suffering major fractures after motor vehicle accidents (MVAs). The study hypothesized that general health would be poorer in patients claiming compensation for their injuries. Patients presenting to 15 hospitals with one or more major fractures (any long bone fracture, or fracture of the pelvis, patella, calcaneus or talus) after a motor vehicle accident were invited to participate in this prospective study. Initial data was obtained from the patient and the treating doctors. Both the patients and treating surgeons were followed up with a final questionnaire at six months post injury. General factors (age, gender, treating hospital, country of birth, presence of chronic illnesses and job satisfaction), injury factors (mechanism of injury, number of fractures, and the presence of any non-orthopaedic injuries), socioeconomic factors (education level, income, and employment status), and compensation-related factors (whether a claim was made, the type of claim, whether a lawyer was used, and who was blamed for the injury) were used as explanatory variables. The primary outcome was general health as measured by the physical and mental component summaries of the SF-36 General Health Survey. The secondary outcomes were neck pain, back pain, and patients’ ratings of satisfaction with progress and of recovery. Multiple linear regression was used to develop predictive models for each outcome. Completed questionnaires were received from 232 (77.1%) of the 301 patients included in the study. Poor physical health at six months was strongly associated with increasing age, having more than one fracture, and using a lawyer, but not with pursuit of a compensation claim. Poor mental health was associated with using a lawyer and decreasing household income. Increasing neck pain and back pain were both associated with the use of a lawyer and with lower education levels. Higher patient satisfaction and patient-rated recovery were both strongly associated with blaming oneself for the injury, and neither were associated with pursuit of compensation. Although the use of a lawyer was a strong predictor of the primary outcomes, the pursuit of a compensation claim was not remotely associated with these outcomes, and therefore the study hypothesis was rejected. The studies reported in this thesis are compared in the final chapter, which concludes that poor health outcomes after injury are consistently and strongly associated with aspects of the compensation process, particularly the pursuit of a compensation claim, involvement of a lawyer, and having an unsettled claim. Compensation systems may be harmful to the patients that these systems were designed to benefit. Identification of the harmful features present in compensation systems my allow modification of these systems to improve patient outcomes.

Introduction There is substantial evidence of an association between seeking financial compensation and poor injury recovery and Return to Work (RTW). The causal nature of this relationship remains complex and imprecise. Many compensation related measures are generic and do not encompass the complexity of scheme design or the socio-political environment in which they operate. This is particularly relevant in Australia where all states and territories provide access to financial compensation following motor vehicle related trauma. In addition, motor vehicle related trauma is a significant contributor to the burden of injury and work disability. Early identification of predictors (including compensation related factors) is essential for developing efficacious interventions and purposeful scheme policy and design to facilitate injury recovery and RTW. Accordingly, the overarching aim of this thesis is to explore the impact of seeking financial compensation on injury recovery following motor vehicle related orthopaedic trauma. Initially, Chapter 1 provides the background and historical context of how compensation schemes were thought to influence physical and psychological health. It includes an overview of the current burden of injury, and relevant scheme design. Given the background to this relatively new field of research, mixed methods were employed across three areas: a systematic review (Chapter 2); qualitative studies (Chapters 3 and 4); and an inception cohort study (Chapters 5-7). Methods and results In Chapter 2, the aim of the systematic review is to identify associations between specific compensation related factorsand health outcomes following musculoskeletal injury from prognostic and/or intervention studies. Searches were conducted using electronic medical journal databases. Selection criteria included: prognostic factors associated with validated health outcomes; six or more months follow up; and multivariate statistical analysis. Twenty nine articles were assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to determine evidence levels. The results are mixed. There is strong evidence of an association between compensation status and poorer psychological function; and legal representation and poorer physical function. There is moderate evidence of an association between compensation status and poorer physical function; and legal representation and poorer psychological function. There is limited evidence of an association between compensation status and increased pain. No studies reported positive associations between compensation status and a health or functional outcome. In Chapters 3 and 4, qualitative methods are used to examine the impact of seeking financial compensation with greater granularity. The aims are: firstly, to explore the factors that influence recovery from serious injuries, particularly differences between people with compensable and non-compensable injuries; and secondly, to understand people’s perceptions and experiences of the claims process after sustaining mild-moderate compensable injuries, and to explore ways to assist and improve those experiences. The first eight focus groups (34 attendees, 21 compensable) were conducted two to seven years post injury within the trauma service of a University Teaching Hospital. The second five focus groups (32 attendees) were conducted one year post injury within a single Compulsory Third Party (CTP) personal injury scheme. All were audio-recorded and transcribed. The methodology was based on a grounded theory approach using thematic analysis and constant comparison to generate coding categories for themes. Data saturation was reached. Analyst triangulation was used to ensure credibility of results. Key themes for the first series are: astrong sense of entitlement and injustice; a difficult claims and settlement process; an inability to move on with life during the claims process, an extreme dislike of medico-legal assessments; the necessity of legal representation to assist with the claims process; and a perceived lack of trust about having to prove an injury or disability (Chapter 3). Key themes for the second series are: complexity of the claims process; requirement of legal representation; injury recovery expectations; importance of timely healthcare decision making; and improvements for injury recovery. To assist with injury recovery, access to objective information about the claims process using online technology and social media was considered paramount (Chapter 4). In Chapters 5-7, an inception cohort study was conducted following moderate-severe injuries. The aims are: firstly, to investigate the predictors of seeking financial compensation, namely making a claim and seeking legal representation at six months (Chapter 5); secondly, to determine the predictors (including compensation related factors) of time to RTW (Chapter 6); and thirdly, to investigate the influence of seeking financial compensation (i.e. making a claim) on injury recovery. Admitted patients were recruited prospectively from two trauma hospitals with upper and/or lower extremity fractures following a motor vehicle crash. Baseline data were collected within two weeks of injury, follow up data at six, 12 and 24 months (by written questionnaire). Additional demographic and injury-related information was retrieved from hospital databases. Main outcomes were: time to RTW (number of days); Short Form-36 Version 2.0 (SF36v2), Physical/Mental Component Scores (PCS/MCS); Post Traumatic Stress Disorder (PTSD) Checklist Civilian Version (PCL-C); and Global Rating of Change (GRC) scale. Analysis involved: descriptive statistics for baseline characteristics; comparison of compensable and non-compensable participants with Analysis of Variance (ANOVA) and chi-squared tests; for predictors, logistic regression, Cox proportional hazards regression models, and linear mixed models were used. There were 452 participants. Baseline characteristics showed: mean age 40 years; 75% male; 74% working pre-injury; 30% in excellent pre-injury health; 56% sustained serious injuries (Injury Severity Score [ISS] 9-15); 61% had a low-middle range household income; 35% self-reported at-fault in the crash; and 61% made a claim at six months. Participant follow up data was available at six, 12 and 24 months for 301(67%), 271(60%), and 230(51%) respectively. Results showed that there are no significant differences in pre-injury or baseline health status between those who made a claim and those who did not, but these measures largely related to physical health. As an outcome, seeking financial compensation at six months is associated with a higher pre-injury Body Mass Index (BMI) rather than injury-related factors, and seeking legal representation at six months is solely related to socio-economic factors (Chapter 5). For those working pre-injury (n=334, 74%), a longer time to RTW is associated with greater injury severity and lower occupational skill levels; while a shorter time to RTW is associated with recovery expectations for usual activities within 90 days, full-time pre-injury work hours, and very good self-assessed pre-injury health status. Legal representation (analysed at six months only) is not associated with time to RTW (Chapter 6). As a predictor, seeking financial compensation is associated with poor injury recovery, mainly for mental health status (MCS) and PTSD (PCL-C). However, the differences are of marginal clinical significance. Irrespective of compensation status, the majority have poor injury recovery on all measures over time, especially for mental health (Chapter 7). Conclusions In summary, these results contribute to existing evidence that seeking financial compensation is associated with poor injury recovery, particularly mental health status. The causal nature of the relationship remains complex but it is posited that part of the explanation lies in scheme policy and design including legislative framework. Background pre-injury factors, namely pre-existing physical and mental health status, psychosocial and socioeconomic factors also play a role. There are opportunities to trial interventions that could improve injury recovery and/or decrease work disability. Collectively, these include screening for risk factors of poor recovery and/or RTW, access to early appropriate treatment and rehabilitation, and vocational rehabilitation for those most vulnerable. None of these are novel but they can be problematic to implement in a compensable environment.Reducing the adversarial aspects of the claims process is important and could possibly alleviate the need to seek legal representation. Some initiatives are likely to require legislative change but others could be implemented with moderate resources. Ongoing mixed methods and interdisciplinary research with an emphasis on modifiable factors is recommended.

Abstract Traumatic brain injury can be a catastrophe for an individual and a huge economic burden for a society. Such injuries are common especially among young men and as many as half of the patients are under the influence of alcohol at the time of injury. Traumatic brain injuries can also frequently cause epileptic seizures. On the other hand, epileptic seizures are often caused by alcohol. A significant reduction in the tax on alcohol in Finland in 2004 led to a 10% increase in its consumption at the population level and a considerable increase in mortality rate among patients with alcoholic liver diseases. The risk of subsequent epileptic seizures and traumatic brain injuries among intoxicated head trauma subjects has not been evaluated before. The present cohort consists of all subjects who were admitted to the emergency room at Oulu University Hospital in 1999 on account of head trauma. These subjects were then followed-up for 10 years, which enabled the effect of the tax reduction on the long-term outcome to be observed. The effect of being under the influence of alcohol at the time of the index head trauma on the onset of a new epileptic seizure problem and further traumatic brain injuries was investigated. The mortality rate among head trauma subjects with harmful drinking increased significantly after the reduction in the alcohol tax, and the subjects with recorded alcohol-related seizure problems experienced an increased risk of death after the price reduction. Head trauma under the influence of alcohol predicted both new-onset seizure problems and traumatic brain injury during the follow-up. The results are in accordance with the previous observations of a rapid increase in mortality among heavy drinkers following a sharp reduction in alcohol prices. Inebriated head trauma subjects have an increased risk of subsequent traumatic brain injury and epileptic seizure
Tiivistelmä Traumaattinen aivovamma voi olla potilaalle katastrofi ja yhteiskunnalle valtava taloudellinen tappio. Aivovammat ovat yleisiä erityisesti nuorilla miehillä, ja jopa puolet niistä tapahtuu alkoholin vaikutuksen alaisena. Aivovammat aiheuttavat usein epileptisiä kohtauksia, jotka toisaalta usein johtuvat alkoholista. Vuonna 2004 Suomessa tapahtunut mittava alkoholiveron alennus lisäsi väestötasolla alkoholin kokonaiskulutusta 10 % vuoden aikana. Kuolleisuus erityisesti alkoholimaksasairauksiin lisääntyi voimakkaasti. Aiemmin ei ole tiedetty humalassa ilmaantuneen pään vamman vaikutuksesta potilaan riskiin saada uusi aivovamma tai uusi epileptinen kohtaus. Tutkimuskohortin muodostivat vuonna 1999 Oulun yliopistollisen sairaalan päivystyksessä hoidetut päähän vammautuneet potilaat. Heitä seurattiin rekisteritietojen avulla vuoden 2009 loppuun, minkä ansiosta voitiin tutkia veronalennuksen vaikutusta potilaiden pitkäaikaisennusteeseen. Tutkimuksessa havainnoitiin humalassa tapahtuneen pään vamman vaikutusta epileptisen kohtauksen ja uuden aivovamman ilmaantumiseen seuranta-aikana. Haitallisesti alkoholia käyttävien päähän vammautuneiden potilaiden kuolleisuus lisääntyi merkitsevästi alkoholiveron alennuksen jälkeen. Myös alkoholiin liittyvän epileptisen kouristuksen sairastaneilla kuolleisuus lisääntyi merkitsevästi. Alkoholin vaikutuksen alaisena tapahtunut pään vamma oli riskitekijä uudelle epileptiselle kohtaukselle sekä uudelle aivovammalle seuranta-aikana. Tulokset vahvistavat aiempia havaintoja siitä, että alkoholin hinnan voimakas lasku lisää nopeasti alkoholin suurkuluttajien kuolleisuutta. Humalassa päätään loukanneella on lisääntynyt riski saada uusi aivovamma sekä uusi epileptinen kohtaus

Introdução: O Trauma and Injury Severity Score (TRISS) é considerado padrão ouro na análise de probabilidade de sobrevida do doente traumatizado, apesar de suas limitações. Vários têm sido os esforços na tentativa de torná-lo mais acurado, tendo em vista seu importante papel nos Programas de Melhoria de Qualidade em Trauma. Objetivos: Propor três novos ajustes à equação do TRISS e comparar suas performances com o TRISS e o TRISS-like originais e com esses índices e o NTRISS com coeficientes ajustados à população do estudo; identificar se a técnica de imputação múltipla aumenta a acurácia das equações derivadas de bancos de dados com perdas e comparar o desempenho dos novos modelos quando derivados e aplicados em diferentes grupos de vítimas traumatizadas. Método: Trata-se de um estudo multicêntrico, retrospectivo, com vítimas de trauma internadas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC FMUSP) e no Centro de Trauma da Universidade da Califórnia San Diego Medical Center (UCSD MC), no período de 1º de janeiro de 2006 a 31 de dezembro de 2010. As informações dos doentes foram agrupadas em Bancos de Dados Derivação e Teste, sendo o primeiro utilizado para derivar as equações e o segundo para validar as equações geradas. Os coeficientes dos modelos foram estabelecidos pela análise de regressão logística. A curva Receiver Operating Characteristics (ROC) foi utilizada para avaliar a performance dos modelos e o algoritmo de DeLonge et al. para comparar as áreas sob as curvas (AUC). Resultados: A casuística foi composta de 2.416 doentes do HC FMUSP (São Paulo, Brasil) e 8.172 participantes do UCSD MC (San Diego, EUA). Os novos modelos propostos foram o NTRISS-like, que incluiu as variáveis Melhor Resposta Motora (MRM), Pressão Artéria Sistólica (PAS), New Injury Severity Score (NISS) e idade; o TRISS SpO2, com as variáveis Escala de Coma de Glasgow, PAS, saturação periférica de oxigênio (SpO2), Injury Severity Score, além da idade e o NTRISSlike SpO2 (MRM + PAS + SpO2 + NISS + idade). Todas as equações tiveram coeficientes ajustados para trauma contuso e penetrante. A técnica de imputação múltipla aplicada à derivação das equações não melhorou a acurácia dos modelos. Os modelos TRISS original, TRISS, TRISS-like e NTRISS com coeficientes ajustados e as novas propostas não apresentaram diferença estatisticamente significativa em sua performance. As novas equações ajustadas aos dados de São Paulo e as geradas com informações de San Diego apresentaram diferentes AUC ao serem aplicadas nos dois grupos de doentes dessas localidades. A acurácia sempre foi maior quando as equações foram aplicadas na população de San Diego. Conclusões: Os novos modelos apresentaram boa acurácia (cerca de 89,5%) e desempenho similar a outros ajustes do índice TRISS anteriormente publicados; portanto, podem ser utilizados nas avaliações de qualidade da assistência ao traumatizado. Os ajustes dos índices de probabilidade de sobrevida à realidade local de sua aplicação não melhoraram seu desempenho, resultado que reforça a incerteza sobre a necessidade desses ajustes, conforme o local de aplicação do índice.
Introduction: Trauma and Injury Severity Score (TRISS) is considered the \"gold standard\" in the analysis of survival probability of trauma patients, despite its limitations. There have been several efforts to make it more accurate because of its important role in Trauma Quality Improvement Programmes. Objectives: To propose three new adjustments to the TRISS equation and compare their performances with the TRISS and TRISS-like originals and these indices and NTRISS with coefficients adjusted to the study population; identify if the multiple imputation technique increases the accuracy of the equations derived from databases with missing; and to compare the performance of the new models when derivatives and applied to different groups of trauma patients. Methods: This is a multicenter, retrospective study with trauma victims admitted to the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC FMUSP) and the Trauma Center at the University of California San Diego Medical Center (UCSD MC) for the period between January 1st, 2006 and December 31st, 2010. The information of patients were grouped into two different databases: derivation and testing; the first one served to derive the equations and the second was used to validate the equations generated. The model coefficients were established by logistic regression analysis. Receiver Operating Characteristic curve (ROC) was used to evaluate the performance of the models and De Long et al. algorithm to compare the areas under the curves (AUC). Results: The casuistic consisted of 2,416 patients from HC FMUSP (São Paulo, Brazil) and 8,172 participants from UCSD MC (San Diego, USA). The new models proposed were NTRISS-like which included the variables Best Motor Response (BMR), Systolic Blood Pressure (SBP), New Injury Severity Score (NISS) and age; TRISS SpO2 that included the variables Glasgow Coma Scale, SBP, saturation of peripheral oxygen (SpO2), Injury Severity Score and age; and NTRISS-like SpO2 (BMR + SBP + SpO2 + NISS + age). All equations had adjusted coefficients for blunt and penetrating trauma. The multiple imputation technique applied in the derivation of the equations did not improve the accuracy of the models. The original TRISS, and TRISS, TRISS-like and NTRISS with adjusted coefficients and the new proposals showed no statistically significant difference in performance. The new equations fitted to the São Paulo data and generated with information from San Diego showed different AUC when applied in the two patient groups in these localities. The accuracy was always higher when the equations were applied to the population of San Diego. Conclusions: The new models demonstrated good accuracy (about 89.5%) and similar performance to other TRISS adjustments previously published, and may be used in assessments of quality of care for traumatized. The survival probability scores adjustments to the local reality of its application did not improve its performance, a result that reinforces the uncertainty about the need for such adjustments, as the application site index.

Severe perineal trauma with injury to the anal sphincter at childbirth can have a profound effect on the physical and psychological wellbeing of women. This thesis describes literature examining resulting outcomes including effects on body image. It describes patient-based outcome measures used to capture this information, and evaluation of their psychometric properties. Body Image can be defined as an individual's perceptions and feelings about their own body. There is a growing interest in how this concept can influence quality of life and psychosocial dysfunction in medical disorders. This thesis aimed to examine relationships between severity of perineal trauma, general and genital specific body image and potentially influences such as symptoms of pelvic floor dysfunction. No patient-reported outcome measure validated for use in women after anal sphincter injury exists and this thesis also aimed to psychometrically evaluate an existing electronic questionnaire, ePAQ (electronic personal assessment questionnaire), for this application. In the thesis, a retrospective review of body image and physical outcomes attending a perineal clinic shows over half of women report perceived changes in body image after anal sphincter injury, with negative effects on self-esteem. A prospective observational cohort study explored genital and general body image in primiparous women grouped according to degree of perineal trauma or caesarean delivery. Women completed the Female Genital Self Image Score, the modified Body Image Score, ePAQ and the Edinburgh Postnatal Depression Scale a mean of 15.5 weeks (standard deviation 1.6) after delivery. There were significant differences in genital body image scores between the groups, but not in general body image, with regression analysis showing the greatest influence on genital body image to be the anatomical extent of the trauma. Embedded into this study was the evaluation of reliability (internal consistency and test-retest) and validity (face, content and construct) of ePAQ in the group of women with anal sphincter tears. This thesis presents the first research to quantify issues surrounding severe perineal trauma and body image and demonstrates that more severe trauma leads to a poorer genital body image. It also reports psychometric evaluation of ePAQ in women after anal sphincter injury providing the first single instrument with validity and reliability for use in this context.

Thesis (M.S.)--Boston University
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In this pilot study, 28 subjects ages 0 to 6 years who had sustained head injuries were assessed as to their functional status at one and six months post hospital discharge. The functional assessments used were the Rand Child Health Scale, the Battelle Developmental Inventory Screening Test, the Battelle Developmental Inventory Motor Domain, and the Pediatric Evaluation of Disability Inventory. Correlations between these functional measures and trauma scores reported through the National Pediatric Trauma Registry (Glasgow Coma Scale; Injury Severity Score, and Pediatric Trauma Score) were calculated to determine the predictive capacity of the trauma scores in determining functional outcome. The trauma scores were not found to be reliable predictors of functional outcome in these young children.
2031-01-01

In der vorliegenden Arbeit wird die Erstellung eines computergestützten Systems zum multimodalen zerebralen Monitoring von Patienten mit schwerem Schädel-Hirn-Trauma beschrieben. Das multimodale zerebrale Monitoring dient der Erfassung, graphischen Darstellung und elektronischen Speicherung von physiologischen Meßdaten. Zur kontinuierlichen Überwachung der zerebralen Sauerstoffversorgung wurden die jugularvenöse Oxymetrie, die Hirngewebe-Sauerstoffpartialdruckmessung und die Nah-Infrarot-Spektroskopie hinsichtlich ihrer Stabilität und Sensitivität vergleichend getestet. Weiterhin erfolgte die prospektive Untersuchung der Inzidenz zerebraler hypoxischer Episoden, ihrer möglichen Ursachen, sowie des Einfluß der zerebralen Hypoxie auf das neurologische Outcome er Patienten mit schwerem Schädel-Hirn-Trauma. Zur kontinuierlichen Überwachung der zerebralen Oxygenierung ist gegenwärtig die Messung des lokalen Hirngewebe-pO2 am besten geeignet. Als häufigste Ursachen der zerebralen Hypoxie wurden die systemische Hypokapnie, ein verminderter zerebrale Perfusionsdruck und ein erhöhter intrakranieller Druck identifiziert. Das akkumulierte Auftreten zerebraler hypoxischer Episoden für mehr als 30 Minuten war mit einem signifikant schlechteren neurologischen Outcome der Patienten verbunden. Durch die Einführung weiterer Methoden zur invasiven und nicht-invasiven Überwachung von Patienten mit schwerem Schädel-Hirn-Trauma, wie zum Beispiel der zerebralen Mikrodialyse, können zukünftig die metabolischen Veränderungen durch eine zerebrale Hypoxie untersucht werden.
Cerebral hypoxia is considered the main cause of secondary damage to the vulnerable brain following severe traumatic brain injury, and critical care management is primarily focused on the prevention of cerebral hypoxic events. Goals of this study were: First, the development of a computerized multimodal cerebral monitoring system to continuously acquire, display, and record data from multiple monitoring devices. Second, the comparative study of different methods for monitoring of cerebral oxygenation, as there are jugular venous oxygen saturation, near-infrared spectroscopy, and brain tissue oxygen tension. Third, the prospective determination of a critical hypoxic threshold, the incidence of cerebral hypoxia, the influence of standard therapeutic maneuvres to treat intracranial hypertension on cerebral oxygenation, the significance of possible causes of cerebral hypoxia, and the influence of cerebral hypoxia on neurological outcome. The multimodal monitoring system was successfully established on a neurosurgical intensice care unit. Monitoring of local brain tissue pO2 was most appropriate for monitoring of cerebral oxygenation. The critical hypoxic threshold in brain tissue pO2 was 10 mmHg. Standard therapeutic maneuvres to treat elevated intracranial pressure were, in part, unsuccessful in improving cerebral oxygen delivery. Cerebral hypoxic episodes were predominantly associated with arterial hypocarbia and low cerebral perfusion pressure. Patients with a total of more than 30 minutes of cerebral hypoxic events had a significantly worse neurological outcome. Future investigations using cerebral microdialysis will help to further improve insight into pathophysiology and metabolic changes following traumatic brain injury.

Introdução: Entre as lesões traumáticas, a lesão axonal difusa (LAD) tem sido apontada como a que ocasiona os piores desfechos. Destacam-se entre as consequências dessa lesão as mudanças comportamentais das vítimas que frequentemente rompem o equilíbrio em sua vida social e de seus familiares. Logo, conhecer as mudanças de comportamento dessas vítimas e os fatores relacionados foi relevante para contribuir para uma reabilitação adequada que facilitasse a reintegração das vítimas de LAD à sociedade, além de fundamentar uma melhor assistência aos familiares. Objetivos: Descrever as mudanças comportamentais das vítimas após LAD segundo informações de familiares, nos períodos de 3, 6 e 12 meses após o trauma, e identificar fatores associados a essas mudanças e a sua evolução. Método: Foram incluídas no estudo vítimas de LAD de 18 a 60 anos de idade, atendidas em hospital referência para lesões traumáticas na cidade de São Paulo e incluídas em serviço ambulatorial específico para seu tratamento. Foi realizado um estudo de coorte prospectivo com três abordagens às vítimas e familiares: 3, 6 e 12 meses após LAD. Para avaliar as mudanças comportamentais foi aplicado um questionário elaborado para identificar tais mudanças segundo percepção de familiares. A diferença da pontuação na Escala Likert desse questionário, antes e após o trauma, permitiu identificar as mudanças comportamentais das vítimas. Foi aplicado o modelo de efeitos mistos para identificar as mudanças comportamentais significativas e o efeito do tempo na sua evolução. Esse modelo também foi utilizado para verificar associações entre variáveis sociodemográficas, gravidade da LAD e mudanças comportamentais. Resultados: Mudanças comportamentais desfavoráveis foram observadas na grande maioria dos participantes deste estudo (81,2% a 91,6%). Alterações favoráveis foram menos frequentes, apontadas em torno de 50% dos casos. Predominaram entre os comportamentos com mudanças desfavoráveis a irritabilidade, o esquecimento e a dependência, presentes em 54,6% dos casos, seguidos pela ansiedade (45,8%), depressão (39,6%) e oscilação de humor (31,2%). Quanto às mudanças favoráveis, foram mais frequentes a impulsividade (18,7%), a irritabilidade (16,7%), a oscilação de humor (16,7%) e o temperamento explosivo (14,6%). Entre antes e após o trauma, houve diferença estatisticamente significativa (p0,05) para ansiedade, dependência, depressão, irritabilidade, esquecimento e oscilação de humor. Para esses comportamentos, as médias da intensidade das alterações foram sempre negativas, evidenciando a tendência de mudança desfavorável após LAD. A análise da evolução desses comportamentos mostrou que as mudanças observadas após a lesão mantiveram-se na mesma intensidade até 12 meses após trauma. Na análise de fatores associados, observou-se relação entre depressão e renda per capita familiar mensal, bem como entre idade e irritabilidade. A gravidade da LAD se associou com dependência e com a evolução da ansiedade entre 3 e 12 meses após trauma. Conclusão: Mudanças comportamentais foram consequências muitíssimo frequentes para as vítimas de LAD e não foi notada melhora dessas alterações até 12 meses após lesão. A irritabilidade, o esquecimento e a dependência foram comportamentos alterados na maioria dos casos, gerando impacto negativo sobre a participação dos indivíduos na comunidade. A renda per capita familiar mensal, a idade e gravidade da LAD tiveram relação com as alterações comportamentais.
Introduction: Among traumatic injuries, diffuse axonal injury (DAI) has been reported as the one that causes the worst outcomes. Behavioral changes are consequences of this injury that frequently break the balance between victims social life and their families. Thus, learning about behavioral changes of these victims and the related factors was relevant to contribute to a suitable rehabilitation that facilitates the reintegration of the victims of DAI in the society besides providing a better assistance to relatives. Objectives: Describe behavioral changes of DAI victims according to relatives information in the periods of 3, 6 and 12 months after trauma and identify associated factors to these changes and its course. Method: The study included victims of DAI, aged between 18 and 60 years old, assisted in a referral hospital for traumatic injuries in Sao Paulo and included in specific ambulatory service for treatment. A prospective cohort study of three assessments was carried out with victims and relatives: 3, 6 and 12 months after DAI. To evaluate behavioral changes, a questionnaire was designed as per identify such changes according to the perception of family members. The difference in the Likert Scale Score based on this questionnaire, before and after trauma, lead to identify behavioral changes of the victims. The mixed effects model was used to identify significant behavioral changes and the effect of time on the evaluation. This model was also used to verify associations with sociodemographic variables, severity of DAI and behavior changes. Results: Unfavourable behavioral changes were observed in the majority of the participants of this study (81.2% to 91.6%). Favourable changes were less frequent, indicated in around 50% of the cases. Irritability, memory deficits and dependence were prevalent among the behaviours with unfavourable changes in 54.6% of the cases, followed by anxiety (45.8%), depression (39.6%) and liability of mood (31.2%). When it comes to favourable changes, impulsivity (18.7%), irritability (16.7%), liability of mood (16.7%) and explosive temperament (14.6%) were more frequent. Comparing before and after trauma, there was significant statistical difference (p0,05) in anxiety, dependence, depression, irritability, memory deficits and liability of mood. Regarding these behaviours the alterations in intensity means were always negative, demonstrating the tendency of unfavourable changes after DAI. The analysis of the evolution of these behaviours showed that the changes observed after injury remained at the same intensity up to 12 months post trauma. In the analysis of the associated factors, there was relationship between depression and monthly family per capita income, age and irritability, and the severity of DAI was associated to dependence and anxiety evolution between 3 and 12 months after trauma. Conclusion: Behavioral changes were frequent consequences for DAI victims and no improvement of these alterations was noticed until 12 months after injury. Irritability, memory deficits and dependence were changed behaviours in most cases, generating a negative impact on the participation of individuals in the community. Monthly per capita family income, age and severity of DAI were related to behavioral changes

Introdução: A lesão axonial difusa (LAD) se destaca entre os ferimentos traumáticos pela gravidade de suas consequências. Entretanto, são poucas as pesquisas que descrevem a recuperação das vítimas e os fatores associados às consequências dessa lesão. Ampliar o conhecimento nessa área e relevante para introduzir novas técnicas na assistência prestada, planejar tratamentos e monitorar a evolução das vítimas. Objetivo: Descrever a recuperação das vítimas com diagnóstico principal de LAD ate 6 meses após trauma e identificar fatores sociodemograficos e clínicos associados a óbito e dependência aos 6 meses após a lesão. Método: Estudo do tipo coorte prospectivo, com dados coletados na internação, alta hospitalar, 3 e 6 meses após a LAD. Fizeram parte do estudo vítimas de LAD com idade 18 anos e 60 anos, admitidas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no período de julho de 2013 a fevereiro de 2014, com escore na escala de coma de Glasgow (ECGl) 8. A recuperação das vítimas de LAD foi analisada pelas diferenças dos resultados da aplicação da escala de Katz e escala de resultados de Glasgow ampliada (ERGA) em 3 períodos de avaliação (alta, 3 e 6 meses após LAD). Foram testadas associações entre variáveis de interesse e óbito, além de dependência até avaliação final. A regressão logística múltipla foi utilizada para identificar modelos para esses desfechos. Resultados: A casuística compôs-se de 78 vítimas com idade média de 32 anos (dp=11,9), 83,3% envolvida em acidentes de transporte e 89,7% do sexo masculino. A média do Injury Severity Score foi de 35,0 (dp=11,9) e do New Injury Severity Score (NISS), 46,2 (dp=15,9). Para a Maximum Abbreviated Injury Scale/cabeça, a média foi de 4,6 (dp=0,5). LAD leve foi observada em 44,9% das vítimas e a grave em 35,9%. Até 6 meses, 30,8% das vítimas foram a óbito e a pontuação média na ERGA dos sobreviventes evoluiu de 3,8 (dp=1,2) na alta para 2,1 (dp=1,6) aos 3 meses e 1,2 (dp=1,6) na avaliação final. Para a escala de Katz, as médias foram de 8,5 (dp=5,5) na alta, de 3,2 (dp= 5,5) aos 3 meses e 1,8 (dp=4,5) aos 6 meses. Diferenças estatisticamente significativas foram observadas na comparação dos resultados de todos os tempos. Apresentaram significância estatística no modelo de regressão logística para óbito as variáveis de gravidade da LAD com hipóxia pela SpO2 e hipotensão com NISS; para dependência, a gravidade da LAD e tempo de internação hospitalar permaneceram no modelo isoladamente. Conclusões: Foi elevada a mortalidade; entretanto, a grande maioria dos sobreviventes alcançou condições condizentes com vida independente aos 6 meses. Nesse período, a recuperação das vítimas foi expressiva, ainda que mais acentuada nos 3 primeiros meses. A LAD grave destacou-se como fator de risco para óbito e dependência. A quase totalidade das vítimas com essa lesão morreu ou estava dependente aos 6 meses após trauma. Como fatores de risco para óbito, também foram identificados o NISS, a hipóxia pela SpO2 e a hipotensão e, para dependência, o tempo de internação hospitalar
Introduction: Diffuse axonal injury (DAI) stands out from other traumatic injuries because of the severity of its consequences. However, few studies describe outcome and the factors associated to outcome of this type of injury. Enhance knowledge in this area is important to introduce new techniques in the delivery of care, treatment planning and to monitor the recovery of DAI. Objective: Describe outcome of victims with primary diagnosis of DAI 6 months after trauma and identify sociodemographic and clinical factors associated to mortality and dependence 6 months after injury. Method: Prospective cohort study with data from admission, discharge, 3 and 6 months after DAI. Participants were DAI victims aged 18 years and 60 years old, admitted to the Hospital das Clínicas da Universidade de São Paulo from July 2013 to February 2014, with a Glasgow Coma Scale (GCS) 8. The outcome of victims was analyzed by the differences found between the results of the Katz scale and the Extended Glasgow Outcome scale (GOS-E) in three different periods (discharge, 3 and 6 months after DAI). Associations between variables of interest and mortality, and dependence to final evaluation were tested. Multiple logistic regression was applied to identify models of these outcomes. Results: The sample consisted of 78 victims with an average age of 32 years (SD=11.9), 83.3% involved in traffic accidents, and 89.7% were male. The mean Injury Severity Score was 35.0 (SD=11.9) and the New Injury Severity Score (NISS) was 46.2 (SD=15.9). For the Maximum Abbreviated Injury Scale/head, the average was 4.6 (SD=0.5). Mild DAI was observed in 44.9% of the victims and severe DAI was observed in 35.9%. Up to 6 months, 30.8% of the victims died and the average score in GOS-E survivors increased from 3.8 (SD=1.2) at discharge to 2.1 (SD=1.6) at 3 months and 1.2 (SD=1.6) at the final evaluation. According to Katz scale, the average was 8.5 (SD=5.5) at discharge, 3.2 (SD=5.5) at 3 months and 1.8 (SD=4.5) at 6 months. Statistically significant differences were observed comparing the results from all periods. In the regression model for mortality the variables of DAI severity with hypoxia by SpO2 and hypotension with NISS were statistically relevant; for dependence, the DAI severity and the hospitalization period remained in the model alone. Conclusions: Besides the high mortality, the vast majority of survivors reached conditions consistent with independent living at 6 months after injury. During this period, the recovery of victims was increased, although more pronounced in the first 3 months. Severe DAI stood out as a risk factor for mortality and dependence. Almost all the victims died or were dependent six months after trauma. NISS, hypoxia by SpO2 and hypotension were also identified as risk factors related to mortality; the length of hospitalization was identified as a risk factor related to dependence on outcome

Survival after severe burns has improved in recent decades, but there is limited information on the course of recovery after surviving a burn and on factors that can affect recovery. The aims of this thesis were to investigate the occurrence of physical and psychological problems after burns, and to examine the consequences of psychological problems for the clinical management of burn patients. Three groups of consecutive patients who were treated at the Burn Unit at Uppsala University Hospital between 1980 and 2005 were included in the studies. The Burn Specific Health Scale (BSHS) was used for self-report of burn-specific aspects of health. Personality traits and coping strategies as psychological factors during recovery were examined with the Swedish universities Scales of Personality (SSP) and the Coping with Burns Questionnaire (CBQ). Presence of symptoms of posttraumatic stress were assessed with the Impact of Event Scale-Revised (IES-R), and the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) was used to determine the concurrent validity of the IES-R as a measure of Posttraumatic Stress Disorder (PTSD). Furthermore, the effect of pre-injury psychiatric morbidity on perceived health one year after injury was assessed. Both pruritus and nightmares were common problems after burns; 59% of the individuals in the study reported pruritus and 43% reported nightmares. Neuroticism-related personality traits and avoidant coping strategies were associated with an increased risk of having pruritus or nightmares. The presence of nightmares could be used as a screening tool for high scores in the IES-R. The IES-R was in turn shown to be a good, although overly inclusive, test for the diagnosis of PTSD. Pre-injury psychiatric morbidity predicted perceived outcome in six out of nine burn-specific health domains. These studies show that psychological factors and psychiatric morbidity affect outcome after burns.

Traumatic brain injury (TBI) is a leading cause of disability worldwide. Annually, 150 to 200/1,000,000 people become disabled as a result of brain trauma. Axonal degeneration is a critical, early event following TBI of all severities but whether axon degeneration is a driver of TBI remains unclear. Molecular pathways underlying the pathology of TBI have not been defined and there is no efficacious treatment for TBI. Despite this significant societal impact, surprisingly little is known about the molecular mechanisms that actively drive axon degeneration in any context and particularly following TBI. Although severe brain injury may cause immediate disruption of axons (primary axotomy), it is now recognized that the most frequent form of traumatic axonal injury (TAI) is mediated by a cascade of events that ultimately result in secondary axonal disconnection (secondary axotomy) within hours to days. Proposed mechanisms include immediate post-traumatic cytoskeletal destabilization as a direct result of mechanical breakage of microtubules, as well as catastrophic local calcium dysregulation resulting in microtubule depolymerization, impaired axonal transport, unmitigated accumulation of cargoes, local axonal swelling, and finally disconnection. The portion of the axon that is distal to the axotomy site remains initially morphologically intact. However, it undergoes sudden rapid fragmentation along its full distal length ~72 h after the original axotomy, a process termed Wallerian degeneration. Remarkably, mice mutant for the Wallerian degeneration slow (Wlds) protein exhibit ~tenfold (for 2–3 weeks) suppressed Wallerian degeneration. Yet, pharmacological replication of the Wlds mechanism has proven difficult. Further, no one has studied whether Wlds protects from TAI. Lastly, owing to Wlds presumed gain-of-function and its absence in wild-type animals, direct evidence in support of a putative endogenous axon death signaling pathway is lacking, which is critical to identify original treatment targets and the development of viable therapeutic approaches. Novel insight into the pathophysiology of Wallerian degeneration was gained by the discovery that mutant Drosophila flies lacking dSarm (sterile a/Armadillo/Toll-Interleukin receptor homology domain protein) cell-autonomously recapitulated the Wlds phenotype. The pro-degenerative function of the dSarm gene (and its mouse homolog Sarm1) is widespread in mammals as shown by in vitro protection of superior cervical ganglion, dorsal root ganglion, and cortical neuron axons, as well as remarkable in-vivo long-term survival (>2 weeks) of transected sciatic mouse Sarm1 null axons. Although the molecular mechanism of function remains to be clarified, its discovery provides direct evidence that Sarm1 is the first endogenous gene required for Wallerian degeneration, driving a highly conserved genetic axon death program. The central goals of this thesis were to determine (1) whether post-traumatic axonal integrity is preserved in mice lacking Sarm1, and (2) whether loss of Sarm1 is associated with improved functional outcome after TBI. I show that mice lacking the mouse Toll receptor adaptor Sarm1 gene demonstrate multiple improved TBI-associated phenotypes after injury in a closed-head mild TBI model. Sarm1-/- mice developed fewer beta amyloid precursor protein (βAPP) aggregates in axons of the corpus callosum after TBI as compared to Sarm1+/+ mice. Furthermore, mice lacking Sarm1 had reduced plasma concentrations of the phosphorylated axonal neurofilament subunit H, indicating that axonal integrity is maintained after TBI. Strikingly, whereas wild type mice exhibited a number of behavioral deficits after TBI, I observed a strong, early preservation of neurological function in Sarm1-/- animals. Finally, using in vivo proton magnetic resonance spectroscopy, I found tissue signatures consistent with substantially preserved neuronal energy metabolism in Sarm1-/- mice compared to controls immediately following TBI. My results indicate that the Sarm1-mediated prodegenerative pathway promotes pathogenesis in TBI and suggest that anti-Sarm1 therapeutics are a viable approach for preserving neurological function after TBI.

Kompleksnost visokoenergetskih preloma platoa i pilona tibije i njihova udruženost sa značajnim povredama mekog tkiva oko pripadajućeg zgloba veoma je dobro opisana. Lečenje ima za cilj da multifragmentarni prelomi platoa i pilona tibije postanu stabilni, artikularno poravnani, bezbolni, da koleno i skočni zglob budu pokretni i da se minimizira rizik do nastanka posttraumatskog osteoartritisa. Aparat po Ilizarovu sa nategnutim iglama, koristi opterećenje da stvori jedinstvenu podršku za zglob i stabilnu imobilizacju preloma da se postigne njegovo srastanje. Ovo omogućuje ranu pokretljivost zgloba bez rizika od gubitka redukcije. Cilj istraživanja je procena i poređenje rezultata lečenja unutarzglobnih višekomadnih preloma kostiju proksimalnog i distalnog okrajka potkolenice tretiranih spoljnjim unilateralnim rigidnim fiksatorom i aparatom po Ilizarovu primenom ASAMI koštanog skoring sistema i funkcionalnog skoring sistema po Karlstrom – Olerudu.Takođe je jedan od ciljeva istraživanja bio da se uoče faktori koji utiču na različite rezultate lečenja unutarzglobnih višekomadnih preloma kostiju gornjeg i donjeg okrajka potkolenice tretiranih spoljnim unilateralnim rigidnim fiksatorom i aparatom po Ilizarovu. Istraživanje je dizajnirano kao kontrolisana komparativna klinička studija a podaci su se prikupljali retrospektivno i delom prospektivno na osnovu medicinske dokumentacije od 2008. do 2013. godine. Studija je u potpunosti izvedena na Klinici za ortopediju i traumatologiju Kliničkog centra Vojvodina u Novom Sadu. Studija je obuhvatila ukupno 103 ispitanika kod kojih je u toku 2008 do 2013. godine postavljena dijagnoza unutarzglobnog višekomadnog preloma gornjeg ili donjeg okrajka tibije. Ispitanici koji su obuhvaćeni ovim kliničkim istraživanjem razvrstani su u tri grupe: Prvu grupu od 53 ispitanika činili su oni sa višekomadnim unutarzglobnim otvorenim ili zatvorenim prelomima gornjeg ili donjeg okrajka kostiju potkolenice lečenih isključivo spoljnjim unilateralnim rigidnim fiksatorom. Drugu grupu ispitanika, njih 31, činili su oni sa višekomadnim unutarzglobnim otvorenim ili zatvorenim prelomima gornjeg ili donjeg okrajka kostiju potkolenice lečenih isključivo aparatom po Ilizarovu. Treću grupu činila su 19 ispitanika sa višekomadnim unutarzglobnim otvorenim ili zatvorenim prelomima gornjeg ili donjeg okrajka kostiju potkolenice koji su lečenje započeli spoljnjim unilateralnim rigidnim fiksatorom, a u kasnijem periodu zbog nastalih komplikacija (loše srastanje, produženo srastanje, nesrastanje, infekcija, pseudoartroza) lečenje nastavili konverzijom spoljnjeg unilateralnog rigidnog fiksatora u aparat po Ilizarovu. Osnovni izvor podataka za prikazano istraživanje bio je protokol formiran za svakog bolesnika pojedinačno, istorije bolesti i poliklinička evidencija. Za potrebe istraživanja dizajniran je protokol istraživanja gde su se prikupljeni podaci analizirali hronološki : podaci o pacijentu, klinički nalaz na prijemu, postoperativni tok, monitoring aparata, klinički nalaz na otpustu i klinički nalaz na kontrolama od 6, 12 i 18 meseci. Kliničke nalaze na kontrolama na 6, 12 i 18 meseci beležili smo upotrebom skoring sistema ASAMI ( Udruženja za istraživanje i primenu metoda po Ilizarovu) – za koštane rezultate, i Karlstrom – Oleruda za procenu funkcionalnih rezultata. Neki do najvažnih rezultata dobijenih prilikom ovog istraživanja jesu da je najbrže vreme srastanja imala grupa Ilizarov, nakon 16±2 nedelja. Grupa konverzija zabeležila je prosečno vreme srastanja u 17±2 nedelji, dok je kod ispitanika u grupi fiksator zabeženo srastanje u 21±4 nedelji. Pojava površnih i dubokih infekcija značajno je veća kod grupe tretiranih spoljnim unilateralnim fiksatorom nego kod grupa tretiranih aparatom po Ilizarovu. Vreme postizanje ranog, punog oslonca na operisani ekstremitet je značajno kraće kod grupe Ilizarov i konverzija nego kod grupe fiksator. Procena koštanih rezultata korišćenjem ASAMI bodovnog sistema koštanog srastanja ukazuje na statistički značajno bolje rezultate kod grupa Ilizarov i konverzija u odnosu na grupu spoljnji fiksator u periodu praćenja i analize na 6,12 i 18 meseci. Funkcionalni rezultati primenom sistema funkcionalne evaluacije po Karlstrom – Olerudu govore u prilog značajno statistički boljim rezultatima kod grupe Ilizarov i konverzija u odnosu na grupu spoljni fiksator u periodima praćenja i analize na 6,12 i 18 meseci. Na osnovu dobijenih rezultata dolazimo do zaključka da je tretman ispitanika sa multifragmentarnim, intraarikularnim prelomima gornjeg i donjeg okrajka kostiju potkolenice znatno efikasniji aparatom po Ilizarovu što sveukupno daje smernice za brži i kvalitetniji oporavak ispitanika i njihov povratak svakodnevnim aktivnostima sa što manjim posttraumatskim sekvelama.
The complexity of high-energy fractures of the tibia plateau and pilons and their association with significant violations of the soft tissue around the corresponding joint is well described in the literature. Main aim of the treatment is to multiple fractures of the tibia plateau and pilon become stable, articularly aligned, without pain, and with full motion in the knee and ankle joint with minimum risk for post-traumatic osteoarthritis. Ilizarov apparatus with taut needles is used to create a unique load support for the ankle and create conditions for good healing. This strong stability allows early joint movement, without risk of loss position of fracture parts. The aim of this research is assessment and comparation of the results of treatment, for intraarticular multiple fractures of the proximal and distal part of lower leg tretaed with unilateral external rigid fixator and Ilizarov apparatus, with ASAMI bone scoring system and functional scoring sistem by Karlstrom – Olerud. One of the goals of the study was to detect factors which affecting different treatment results of the intraarticular multiple fractures of the proximal and distal part of lower leg, tretaed with unilateral external rigid fixator and Ilizarov apparatus. The study was designed as a controlled comparative clinical study and data were collected retrospectively and prospectively form medical records from 2008 to 2013. The study has been fully implemented at the Department for orthopedic surgery and traumatology in the Clinical Center of Vojvodina in Novi Sad and included 103 patients who had intraarticular multiple fractures of the proximal and distal part of tibia. Subjects covered in this clinical study were classified into three groups: The first group of 53 patients were with intraartiulary multifragmentary open or closed fractures of the upper or distal part of lower leg, treated exclusively with unilateral external rigid fixator. The second group included 31 patients with intraarticular open or closed fractures of the upper or distal lower leg, treated exclusively with Ilizarov apparatus. 19 patients made the third group with intraarticulary open or closed fractures of the upper or distal lower leg, which were treated at the begining with unilateral external rigid fixator and later because of the complications (poor or prolonged healing, nonunion, infection and pseudoarthrosis) tretment was continued by Ilizarov apparatus. The main source of data for this study was protocol wich was established for each patient individually. In this protocol collected data analyzed by date: patient data, clinical findings at admission, postoperative course, monitoring apparatus, clinical findings at discharge and clinical findings at the controls which were at 6, 12 and 18 months after surgery. Clinical findings at control examinations (6, 12 and 18 months after surgery), we recorded by scoring system ASAMI (Association for the Study and Application of the Methods of Ilizarov) - that represent the results of the bone healing, and Karlstrom - Olerud for assessment functional outcomes. The most important results were: the fastest time of bone union was in the group of Ilizarov, and it was after 16 ± 2 weeks and the third group (conversion group) recorded an average time after 17 ± 2 weeks, while the patients in the first group (external fixator) had average time of union after 21 ± 4 week. The appearance of superficial and deep infection was significantly higher in the group treated with unilateral external fixator than in the group treated by the Ilizarov apparatus. Fastest full weight bearing on the injured leg, had patients in the group treated with Ilizarov apparatus. Evaluation of results using bone ASAMI fusion scoring system indicating a statistically significantly better results in the conversion and Ilizarov group compared to the group of external fixator in the period of monitoring at 6,12 and 18 months after surgery. Functional results by Karlstrom - Olerud scoring system show statistically significantly better results in the Ilizarov and conversion group contrary to the external fixator group in periods of monitoring at 6,12 and 18 months. Based on these results we conclude that the treatment of subjects with intraarticulary, multifragmentary fractures of the upper and lower part of the lower leg are more efficient after Ilizarov apparatus which provides overall guidance for faster and better recovery of patients and their return to their daily activities with minimal post-traumatic sequelae.

Тешка траума се може дефинисати на неколико различитих начина. Најчешће коришћена дефиниција укључује коришћење Injury Severity Score ( ISS скор). Ако је вредност ISS скор >15, ради се о тешкој трауми. Траума је временски осетљиво стање, због тога је за збрињавање тешко повређених пацијената неопходна добра сарадња различитих нивоа здравствене заштите и здравствених стручњака различитих специјалности. У претходних неколико деценија, због сложенијег процеса лечења и великих трошкова, дошло је до потребе за што објективнијом проценом стања повређеног и исхода лечења. Циљ: Упоредити сензитивност и специфичност T-RTS скорa (Triage Revised Trauma Score), CRAMS скалe (Circulation, Respiration, Abdomen, Motor and Speech), МGAP скора (Mechanism, Glasgow coma scale, Age, and arterial Pressure) и GAP скора (Glasgow coma scale, Age, and arterial Pressure) примењених на прехоспиталном нивоу, проценити могућности прехоспитално примењених RTS, CRAMS, МGAP и GAP скорова у предикцији исхода лечења повређеног пацијента и утврдити значај појединачних фактора, одређиваних на прехоспиталном нивоу током иницијалног прегледa повређеног, за процену тежине повреде и предикцију исхода лечења повређеног. Истраживање је проспективног, опсервационог карактера. У истраживање су укључени пацијенти старији од 18 година, које су лекари Заводa за хитну медицинску помоћ Нови Сад (ЗЗХМП НС) и Службe хитне медицинске помоћи Дома здравља Бечеј (СХМП ДЗ Бечеј) збрињавали на терену након трауме, а потом их транспортовали у Ургентни центар Клиничког центра Војводине (УЦ КЦВ). На основу вредности ISS скора пацијенти су сврстани у једну од две групе: група А- пацијенти код којих је ISS скор након завршене дијагностике изнад 15- тешка траума и група Б -пацијенти код којих је након завршене дијагностике ISS скор ≤15- лака траума. У групи А је било 50, а у групи Б 257 пацијената. За граничне вредности скорова које означавају да траума није лака, највећу сензитивност у оцени тежине трауме је имао GAP скор 98,8%, а највећу специфичност MGAP скор 62%. У предвиђању исхода лечења, највећу сензитивност је имао RTS скор за предикцију 95,2%, а специфичност GAP скор и CRAMS скала 87,5%. MGAP скор, а пошто је у снажној корелацији са њим и GAP скор, мерени прехоспитално, су се издвојили као независни предиктор у оцени тежине трауме и предвиђању исхода лечења повређеног. Т- RTS скор и CRAMS скала су се издвојили као појединачни предиктори у оцени тежине трауме, али не и као независни предиктори. RTS скор за предикцију нема статистичку значајност у предвиђању исхода лечења повређеног, за разлику од CRAMS скале која има, али се није издвојила као независни предиктор исхода лечења. Осим наведених траума скорова, као независни предиктори у оцени тежине трауме издвојили су се: систолни крвни притисак, SaO2 у периферној крви мерена пулсном оксиметријом, повреда главе и врата и повреда грудног коша. За предвиђање исхода лечења повређеног само се SaO2 у периферној крви мерена пулсном оксиметријом издвојила као појединачни предиктор, али не и као независни предиктор исхода.
Teška trauma se može definisati na nekoliko različitih načina. Najčešće korišćena definicija uključuje korišćenje Injury Severity Score ( ISS skor). Ako je vrednost ISS skor >15, radi se o teškoj traumi. Trauma je vremenski osetljivo stanje, zbog toga je za zbrinjavanje teško povređenih pacijenata neophodna dobra saradnja različitih nivoa zdravstvene zaštite i zdravstvenih stručnjaka različitih specijalnosti. U prethodnih nekoliko decenija, zbog složenijeg procesa lečenja i velikih troškova, došlo je do potrebe za što objektivnijom procenom stanja povređenog i ishoda lečenja. Cilj: Uporediti senzitivnost i specifičnost T-RTS skora (Triage Revised Trauma Score), CRAMS skale (Circulation, Respiration, Abdomen, Motor and Speech), MGAP skora (Mechanism, Glasgow coma scale, Age, and arterial Pressure) i GAP skora (Glasgow coma scale, Age, and arterial Pressure) primenjenih na prehospitalnom nivou, proceniti mogućnosti prehospitalno primenjenih RTS, CRAMS, MGAP i GAP skorova u predikciji ishoda lečenja povređenog pacijenta i utvrditi značaj pojedinačnih faktora, određivanih na prehospitalnom nivou tokom inicijalnog pregleda povređenog, za procenu težine povrede i predikciju ishoda lečenja povređenog. Istraživanje je prospektivnog, opservacionog karaktera. U istraživanje su uključeni pacijenti stariji od 18 godina, koje su lekari Zavoda za hitnu medicinsku pomoć Novi Sad (ZZHMP NS) i Službe hitne medicinske pomoći Doma zdravlja Bečej (SHMP DZ Bečej) zbrinjavali na terenu nakon traume, a potom ih transportovali u Urgentni centar Kliničkog centra Vojvodine (UC KCV). Na osnovu vrednosti ISS skora pacijenti su svrstani u jednu od dve grupe: grupa A- pacijenti kod kojih je ISS skor nakon završene dijagnostike iznad 15- teška trauma i grupa B -pacijenti kod kojih je nakon završene dijagnostike ISS skor ≤15- laka trauma. U grupi A je bilo 50, a u grupi B 257 pacijenata. Za granične vrednosti skorova koje označavaju da trauma nije laka, najveću senzitivnost u oceni težine traume je imao GAP skor 98,8%, a najveću specifičnost MGAP skor 62%. U predviđanju ishoda lečenja, najveću senzitivnost je imao RTS skor za predikciju 95,2%, a specifičnost GAP skor i CRAMS skala 87,5%. MGAP skor, a pošto je u snažnoj korelaciji sa njim i GAP skor, mereni prehospitalno, su se izdvojili kao nezavisni prediktor u oceni težine traume i predviđanju ishoda lečenja povređenog. T- RTS skor i CRAMS skala su se izdvojili kao pojedinačni prediktori u oceni težine traume, ali ne i kao nezavisni prediktori. RTS skor za predikciju nema statističku značajnost u predviđanju ishoda lečenja povređenog, za razliku od CRAMS skale koja ima, ali se nije izdvojila kao nezavisni prediktor ishoda lečenja. Osim navedenih trauma skorova, kao nezavisni prediktori u oceni težine traume izdvojili su se: sistolni krvni pritisak, SaO2 u perifernoj krvi merena pulsnom oksimetrijom, povreda glave i vrata i povreda grudnog koša. Za predviđanje ishoda lečenja povređenog samo se SaO2 u perifernoj krvi merena pulsnom oksimetrijom izdvojila kao pojedinačni prediktor, ali ne i kao nezavisni prediktor ishoda.
Severe trauma could be defined in several ways. The most commonly used definition includes Injury Severity Score (ISS) and severe trauma is determined if ISS >15. Trauma management is a time sensitive issue and a coordination between different levels of health system and many specialists is vital in the treatment of severe trauma. In the last decades, a need for the objective evaluation of the severity of trauma and its outcome was perceived due to the complex management and treatment of trauma and its costs. Aim of the study: to compare the sensitivity and specificity between prehospital scores T-RTS (Revised Trauma Score), CRAMS (Circulation, Respiration, Abdomen, Motors, Speech), MGAP (Mechanism, Glasgow Coma Scale, Age, Arterial Pressure) and GAP (Glasgow Coma Scale, Age, Arterial Pressure), to assess the predictability of prehospital scores (RTS, CRAMS, MGAP and GAP) in the outcome of traumatized patients, to determine the significance of individual factors, initially determined during the prehospital evaluation, in evaluating the severity of trauma and the outcome of treatment. Patients enrolled into this prospective observational study were older than 18, prehospitally treated on the trauma site by the doctors of the Institute of the Emergency Medicine Novi Sad and Health Centre Bečej – Emergency Medical Service and afterward transported into the Emergency Centre Novi Sad. Based on ISS values, patients were divided into two groups: Group A – severe trauma (50 patients; ISS>15) and Group B – mild trauma (257 patients; ISS≤15). For the broder values of scores, determining the severity of trauma, GAP had the highest sensitivity (98%), while MGAP had the highest specificity (62%). RTS had the highest sensitivity in predicting the outcome (95.2%), while GAP and CRAMS had specificity of 87.5%. Prehospital MGAP score, in strong correlation with GAP, was singled out for its independent predictive value in determining the severity of trauma and its outcome. T-RTS and CRAMS stood out to be individual – but not independent – predictors in evaluating the severity of trauma. RTS was not statistically significant in predicting the outcome, in contrast with CRAMS. However, CRAMS was not singled out as an independent predictor of the outcome. In addition to the scores, independent predictors of the severity of trauma were: systolic blood pressure, arterial oxygen saturation (SaO2) by using the pulse oximeter, head, neck and thorax injuries. Only SaO2 proved to be a single – but not independent – predictor of the outcome.

Le retentissement psychologique d’événements sources de responsabilité, quels qu’ils soient – acte de terrorisme, perte d’un être cher, harcèlement moral… – est spécifique du fait de ses caractères protéiforme et invisible. Tout d’abord, le premier d’entre eux tient au fait qu’en matière psychologique tant les atteintes que les souffrances en résultant sont diverses. Ainsi, d’un point de vue lésionnel, certains événements vont s’avérer plus traumatisants que d’autres, principalement ceux au cours desquels le sujet a été confronté à sa propre mort. Concernant la souffrance, un sujet peut tout aussi bien souffrir émotionnellement d’une altération de sa propre intégrité – par exemple physique avec le diagnostic d’une pathologie grave – que d’un tort affectant celle d’un proche (e.g. décès, handicap). Un retentissement qualifié d’invisible ensuite, puisqu’il apparaît bien plus aisé d’identifier une atteinte à l’intégrité physique qu’une atteinte à l’intégrité psychique. De plus, certaines atteintes psychologiques sont totalement insaisissables en raison de leur caractère éminemment diffus. L’objet de cette démonstration est donc de savoir comment le droit de la responsabilité civile va appréhender la victime de ce retentissement psychologique. Sa prise en charge ne pourra être que particulière du fait de l’interaction inévitable entre les sphères juridique et psychologique.Afin de le découvrir sera proposée, dans un premier temps, une conceptualisation de la victime psychologique se fondant sur la réalité psychopathologique. Deux grandes distinctions nourrissent cette réflexion. L’une est de nature juridique ; il s’agit de la distinction du dommage et du préjudice. L’autre est d’origine psychopathologique ; elle oppose le choc émotionnel au traumatisme psychique. Leur entrecroisement permettra d’élaborer différents cas de manifestation de la souffrance psychologique et de dessiner les contours de la qualité de victime. Dans un second temps, au titre de l’indemnisation de la victime psychologique, tant l’appréciation que l’évaluation de ses préjudices seront examinées. Les répercussions du traumatisme psychique voire du choc émotionnel vont parfois être si importantes que l’indemnisation ne pourra se cantonner à la seule souffrance éprouvée. Des conséquences de nature différente, par exemple patrimoniales, devront être prises en considération. À cette fin, une typologie des préjudices de la victime sous analyse mérite d’être mise en place. Des règles d’indemnisation distinctes seront érigées en fonction du préjudice subi. Un préjudice présumé, notamment à partir d’un dommage, ne pourra logiquement être compensé de la même façon que des préjudices non présumables, c’est-à-dire soumis à expertise. En somme, le système d’indemnisation à instaurer se devra d’être en phase avec le système de révélation de la souffrance qui aura été précédemment établi.Ainsi, cette étude se propose de construire un réel statut fondateur de la victime psychologique. Une fois cette notion cardinale intégralement conceptualisée, un régime d’indemnisation s’en inférant sera rationnellement avancé
The psychological impact of the events, which are the source of responsibility, be they acts of terrorism, loss of a loved one, psychological harassment, is specific to characteristics both protean and invisible. The first among them is due to the fact that in psychological matter injuries and the resulting suffering are both varied. As such, from the injury point of view, certain events will prove to be more traumatizing than others. Principally those during which the subject has been faced with his own death. Concerning suffering, a subject can as well emotionally suffer a change in his own integrity – for example the physical one with a diagnosis of a serious illness – that of a sort damage which affects that of a loved one (e.g. death or handicap). Then, the impact is considered invisible. It appears much more simple indeed, to identify harm to physical integrity as a harm to psychic integrity. More so, certain psychological harms are totally imperceptible by reason of their eminently diffuse characteristic. The object of this demonstration is therefore to know how civil liability law will comprehend the victim of such a psychological impact. Its comprehension will be particular given the inevitable interaction between the judicial and psychological spheres.In order to better understand this, we will first propose a conceptualization of the psychological victim that blends into psychopathological reality. Two major distinctions feed this thought. One is legal nature, which relates to the distinction between prejudice and harm. The other is psychopathological in nature which opposes emotional shock and psychic trauma. Their intertwining allows us to elaborate different cases of manifestation of psychological suffering and define the contours of the qualities of the victim. Secondly, regarding compensation for a psychological victim, both the appreciation and the evaluation of these prejudices will be examined. The repercussions of psychic trauma, or even emotional shock can sometimes be so grave that compensation cannot restrict itself only to the experienced suffering. Consequences of different natures, for example patrimonial ones, must be taken into consideration. To this end, a division of the prejudices of the psychological victim should be put in place. Distinct rules of compensation will be established based on the prejudice endured. A prejudice presumed, originating notably from a harm, cannot logically be compensated in the same fashion as non-presumable prejudices that require a forensic assessment. In short, the system of compensation must be in phase with the system of disclosure of suffering that has been previously established. As a result, this study proposes to construct a true founding status of a psychological victim. Once this principal notion has been completely conceptualized, we can use it to create a rational compensation scheme

Les lésions traumatiques de la moelle épinière entraînent de graves conséquences d’un point de vue personnel, physique et social chez les individus qui en sont victimes. La prise en charge médicale et chirurgicale de ces patients évolue au fil de l’amélioration des connaissances sur ce qui favorise la récupération neurologique et la qualité de vie à long terme. Pour le chirurgien du rachis, les facteurs modifiables qui influencent de façon significative l’issue neurologique à long terme chez les blessés médullaires thoraco-lombaires sont peu explorés dans la littérature. Le délai entre le trauma et l’exécution du geste chirurgical est un de ces facteurs, mais la définition de chirurgie précoce chez cette population spécifique demeure à être objectivée. De plus, il n’y a pas de paramètres sur le scan préopératoire ayant été décrit pour aider la prise en charge en fonction de l’issue neurologique à long-terme. L’objectif général de ces travaux est de préciser ce qui influence la récupération neurologique chez les patients paraplégiques ayant subi une fracture dans la région thoraco-lombaire et évaluer l’impact de la morphologie de la fracture sur l’effet du délai entre le traumatisme et la chirurgie de décompression et de stabilisation de la colonne vertébrale. Le premier volet de ce mémoire concerne l’étude du seuil de délai chirurgical associé à une récupération neurologique optimale. Pour ce faire, une étude clinique rétrospective a été menée en évaluant plusieurs issues neurologiques à long terme chez une cohorte prospective de 35 patients blessés médullaires secondairement à un traumatisme vertébral de la région thoraco-lombaire. Déterminer de façon objective le seuil de délai optimal pour la récupération neurologique a été possible en utilisant une méthode statistique faisant intervenir des modèles de prédiction sous la forme d’arbres décisionnels élaborés par partition objective récursive. Cette méthode a démontré que la chirurgie de décompression et de stabilisation entreprise dans les 21 heures suivant le moment du traumatisme augmente la probabilité d’améliorer l’état neurologique 12 mois après le traumatisme, en termes de sévérité (grade) de la lésion et du niveau neurologique. Le deuxième volet du mémoire concerne l’étude de la morphologie de la fracture la plus commune de la région thoraco-lombaire, la fracture de type « burst ». De nombreux paramètres radiologiques sont connus et définissent ce type de fracture mais aucun n’a été bien évalué en fonction de la récupération neurologique à long terme. Une deuxième étude clinique rétrospective implique l’étude du scan préopératoire à la recherche de paramètres reliés à l’issue neurologique chez les blessés médullaires avec atteinte motrice sévère. Trois caractéristiques morphologiques fortement associées à la récupération ont été identifiées : la présence d’une fracture complète de la lame, le recul de plus de 4 mm de la portion inférieure du mur postérieur du corps vertébral et la présence de comminution du fragment de corps vertébral rétropulsé dans le canal spinal. Ces paramètres sont des facteurs de pronostic défavorable de récupération neurologique plus importants que l’atteinte neurologique initiale ou l’estimation du degré d’énergie impliquée durant le traumatisme. Puisque ces paramètres décrivent la géométrie du canal spinal endommagé lors d’une fracture de type « burst », ils offrent un reflet de l’énergie locale dissipée dans le canal spinal et transmise aux éléments neuraux. Le troisième volet du mémoire implique l’intégration des nouvelles connaissances issues des deux articles présentés, à la recherche de l’influence de certains paramètres morphologiques sur l’effet de la chirurgie précoce sur la récupération neurologique. Les analyses complémentaires effectuées sur la cohorte de patients atteints de fracture de type « burst » n’ont pas démontré que l’avantage procuré par une chirurgie de décompression et stabilisation précoce était modifié ou altéré par la présence d’un des paramètres démontrés comme importants d’un point de vue neurologique. Ces travaux permettent de mieux guider le chirurgien du rachis dans la planification du geste chirurgical de par une meilleure compréhension des facteurs prédictifs de l’issue neurologique à long terme. En déterminant un seuil de délai objectif optimal de 21 heures, ils permettent d’établir une recommandation pour la définition même de la chirurgie précoce chez le blessé médullaire thoraco-lombaire. Ils proposent également une base pour l’étude subséquente de nouveaux paramètres clés quantifiables sur le scan préopératoire, un examen essentiel et disponible chez tous les patients, et de leur relation potentielle avec le choix de l’approche chirurgicale idéale ainsi qu’avec de multiples issues neurologiques et non-neurologiques.
Traumatic spinal cord injury (TSCI) is a debilitating condition that leads to many adverse consequences on a personal, physical and social standpoint for the injured victim. Medical and surgical care evolved along with the progression of understanding regarding what factors lead to better neurological recovery and overall quality of life in paralyzed patients. With respect to surgical care, modifiable factors significantly related to neurological recovery in thoracolumbar TSCI are not well known. In this regard, the optimal timing threshold for surgical spinal decompression and stabilization has not been demonstrated objectively. Moreover, there are no radiological parameter on the pre-operative computed tomography scan (CT scan) that have been shown to predict long term neurological outcome. The main goal of the presented work is to provide precise identification of such factors, and therefore evaluate the impact of the spine fracture specific morphological features on the effect of early surgical care. The first part involves the assessment of the optimal surgical timing threshold for neurological recovery. A retrospective clinical study was conducted to evaluate several neurological outcome measures in a prospective cohort of 35 thoracolumbar TSCI patients. Thresholds were obtained from the elaboration of prediction models with the use of Classification And Regression Tree (CART) statistical analysis. The first article demonstrated that for optimal recovery of the neurological level of injury, a timing threshold of a maximum of 21 hours should ideally be respected between the traumatic event and the beginning of the surgical intervention. The second part encompasses the study of the morphology of the fractured vertebrae in thoracolumbar burst fractures. Many radiological descriptors are used to describe these severe spine compression injuries but few have been evaluated with regards to neurological recovery. A second retrospective clinical study was conducted and associated a thorough examination of the preoperative CT scan reconstructions to the assessment of long term neurological outcome. Three morphologic parameters were found to be linked to poor prognostic of neurological recovery: complete lamina fracture, comminution of the posteriorly retropulsed fragment and vertebral body postero-inferior corner translation of 4 mm or more. Such features, all three describing the disrupted anatomy of the spinal canal, could be potential indicators of the amount of energy locally dissipated to the neural elements. These parameters were found to be more important to predict neurological outcome than the initial neurologic examination and global trauma energy indicators. The third part integrates the notions derived from the two presented studies and aims to assess for the influence of the presence of specific fracture parameters on the effect of early surgery regarding neurological outcome. Additional analyses did not show that the advantage of early surgery, defined in the first article, was influenced by the presence of any of the relevant fracture features demonstrated in the second article. Therefore, this work emphasizes on the importance of early surgery for better neurological recovery and serves to guide the surgeon in planning the timing of the intervention. Defining the concept of early surgery is key in implementing future retrospective or prospective research protocols. It also highlights the importance of new morphological features of the most common type of thoracolumbar fracture. It sets standards for further research involving preoperative CT scan parameters and their potential relationship with surgical approach, neurological and non-neurological outcomes.