2017年 · 第20卷第05期

Purpose: To identify and appraise the published studies assessing interventions accounting for reducing fatigue and sleepiness while driving. Methods: This systematic review searched the following electronic databases: Medline, Science direct, Scopus, EMBASE, PsycINFO, Transport Database, Cochrane, BIOSIS, ISI Web of Knowledge, specialist road injuries journals and the Australian Transport and Road Index database. Additional searches included websites of relevant organizations, reference lists of included studies, and issues of major injury journals published within the past 15 years. Studies were included if they investigated interventions/exposures accounting for reducing fatigue and sleepiness as the outcome, measured any potential interventions for mitigation of sleepiness and were written in English. Meta-analysis was not attempted because of the heterogeneity of the included studies. Results: Of 63 studies identified, 18 met the inclusion criteria. Based on results of our review, many interventions in the world have been used to reduce drowsiness while driving such as behavioral (talking to passengers, face washing, listening to the radio, no alcohol use, limiting the driving behavior at the time of 12 p.m. - 6 a.m. etc), educational interventions and also changes in the environment (such as rumble strips, chevrons, variable message signs, etc). Meta-analysis on the effect of all these interventions was impossible due to the high heterogeneity in methodology, effect size and interventions reported in the assessed studies. Conclusion: Results of present review showed various interventions in different parts of the world have been used to decrease drowsy driving. Although these interventions can be used in countries with high incidence of road traffic accidents, precise effect of each intervention is still unknown. Further studies are required for comparison of the efficiency of each intervention and localization of each intervention according to the traffic patterns of each country.

Purpose: Traffic injuries are among the leading causes of mortality and morbidity worldwide. Pedestrians have been considered as a high-risk group among road users, especially in middle- or low-income communities. This study attempted to determine the burden of pedestrians' fatalities in Fars, the southern province of Iran using years of life lost (YLL) approach. Methods: The data used in this study were retrieved from Fars Forensic Medicine Organization database on pedestrian traffic accidents. The YLL from 2009 to 2013 was estimated using the method presented by World Health organization. Some epidemiological characteristics of pedestrians' fatalities were analyzed by SPSS. Results: Although YLL among 1000 male pedestrians decreased from 2.5 in 2009 to 1.5 in 2013, it increased from 0.9 to 2.1 among 1000 females during the same period. Higher proportion of death was found in female, illiterate, and married pedestrians (p < 0.001). In addition, mortality was higher in pedestrians living the cities, during daytime, at home, and in hospitals (p < 0.001). Conclusion: Consistent with the global trends, burden of pedestrian accidents in Fars was also exceptionally high. Considering the national and cultural aspects of different countries, improving the safety of pedestrians demands a multi-dimensional approach with interventional factors concerning policies, rules, pedestrians, motor vehicles and environmental conditions taken into consideration.

Purpose: Unsafe behaviors are an important cause of accidents in adolescent age groups. This study was designed to examine the behaviors of adolescent pedestrians in southern Iran. Methods: This is a descriptive analytical cross-sectional study. The study population consisted of high school students in Shiraz, capital city of Fars Province, Iran. Five hundred and sixteen students were selected by multi-stage sampling. Data were collected by the use of three questionnaires, which included Persian copies of adolescent road user behavior questionnaire (ARBQ), Duke University Religious Index (DUREL), as well as the context and independent variables questionnaire. Results: The results showed that a decrease in dangerous behaviors on the road resulted in an increase in respondents' intrinsic religiosity. Also, engagement in unsafe crossing behavior in the road decreased with increasing respondents' intrinsic religiosity. Another finding showed that female students were less involved in dangerous play and planned protective behaviors on the road. Conclusion: Findings clearly indicate that intrinsic religiosity has a significant role in reducing the risky road behaviors of students. Hence, religion may improve road safety in school students' road behavior in Iran.

Purpose: To investigate effects of neuro-immuno-modulation on wound healing by observing changes of cytokines and hypothalamic-pituitary-adrenal (HPA) axis hormones in acute stress reaction in rats with wound and combined local radiation injury. Methods: Sixty female Wistar rats (weighting 200 ± 20 g) were randomly divided into normal control group, wound group and combined wound-local radiation (CWR) group (25 Gy local radiation post wound), 20 rats in each group. Contents of IL-1β, IL-6 and IFN-γ and IL-4 in serum were measured and changes of adrenocorticotropic hormone (ACTH) and glucocorticoid (GC) in serum were analyzed by using enzyme-linked immunosorbent assay and radioimmunologic assay, respectively at different time points post wound and radiation. Results: (1) The level of IFN-γ, one of the Th1 cell cytokines increased significantly at 14 d post CWR, which was markedly higher than that in control group and wound group. However, the level of IL-4, IL-1β and IL-6, one of the Th2 cell cytokines, did not show obvious change. (2) Ratio of Th1/Th2 (IFN-γ/IL-4) in wound group and CWR group increased significantly at 7 d after wound and radiation, which suggested that Th1/Th2 balance drifted to Th1 immune response. The ratio of Th1/Th2 in wound group returned to the normal level up to 14 d after the wound and radiation, while the Th1/Th2 ratio in CWR group increased persistently and was much higher than that in control and wound groups. (3) Level of serous ACTH and GC in CWR group increased at 3 d post wound and radiation, and among them, level of GC showed statistically significant increase, which was much higher than that in control and wound groups. Conclusion: Level of serous neurohormone GC in rats increased significantly immediately after wound and radiation; while the level of IFN-γ showed significant increase only up to 14 d after wound and radiation, and the Th1/Th2 imbalance sustained till 28 d post wound and radiation. In order to reduce acute damage caused by CWR, organic immune system and nerve system showed up a marked regulate effects simultaneously and mutually. Nonetheless, the excessive stress induced by CWR causes disturbance of immunoregulation, which is one of the key reasons for delayed wound healing in CWR.

Purpose: As trauma is a public health problem, different programs have been designed to prevent injuries. The aim of this study was to evaluate the effectiveness of an educational model that measures the adolescents' attitudes towards the rules of road safety, alcohol and road accidents in Colombia. Methods: A pedagogical model evaluating the effect of road safety education and adolescents' attitudes towards and experiences of alcohol and road accidents in Colombia was created. After the education concluded, this educational process is analyzed by its impact on adolescents' behavior. The educational program included 160 adolescents with the mean age being 17.5 years. Results: The test results indicated that before the educational program 80% of adolescents did not use a safety element when driving, while after the educational program the percentage of no helmet use among adolescents decreased from 72.5% to 24.3% (p = 0.0001) and driving a vehicle under the state of drunkenness from 49.3% to 8.1% (p = 0.0001). Conclusion: An educational model aimed at preventing injuries caused by traffic accidents is shown to be effective in generating changes in adolescents' customs of and attitudes towards alcohol and road safety standards in Colombia.

Purpose: There are some studies which showed neurofeedback therapy (NFT) can be effective in clients with traumatic brain injury (TBI) history. However, randomized controlled clinical trials are still needed for evaluation of this treatment as a standard option. This preliminary study was aimed to evaluate the effect of NFT on continuous attention (CA) and short-term memory (STM) of clients with moderate TBI using a randomized controlled clinical trial (RCT). Methods: In this preliminary RCT, seventeen eligible patients with moderate TBI were randomly allocated in two intervention and control groups. All the patients were evaluated for CA and STM using the visual continuous attention test and Wechsler memory scale-4th edition (WMS-IV) test, respectively, both at the time of inclusion to the project and four weeks later. The intervention group participated in 20 sessions of NFT through the first four weeks. Conversely, the control group participated in the same NF sessions from the fifth week to eighth week of the project. Results: Eight subjects in the intervention group and five subjects in the control group completed the study. The mean and standard deviation of participants' age were (26.75 ± 15.16) years and (27.60 ± 8.17) years in experiment and control groups, respectively. All of the subjects were male. No significant improvement was observed in any variables of the visual continuous attention test and WMS-IV test between two groups (p ≥ 0.05). Conclusion: Based on our literature review, it seems that our study is the only study performed on the effect of NFT on TBI patients with control group. NFT has no effect on CA and STM in patients with moderate TBI. More RCTs with large sample sizes, more sessions of treatment, longer time of follow-up and different protocols are recommended.

Purpose: Recording vital signs is important in the hospital setting and the quality of this documentation influences clinical decision making. The Modified Early Warning Score (MEWS) uses vital signs to categorise the severity of a patient's physiological derangement and illustrates the clinical impact of vital signs in detecting patient deterioration and making management decisions. This descriptive study measured the quality of vital sign recordings in an acute care trauma setting, and used the MEWS to determine the impact the documentation quality had on the detection of physiological derangements and thus, clinical decision making. Methods: Vital signs recorded by the nursing staff of all trauma patients in the acute care trauma wards at a regional hospital in South Africa were collected from January 2013 to February 2013. Investigatormeasured values taken within 2 hours of the routine observations and baseline patient information were also recorded. A MEWS for each patient was calculated from the routine and investigator-measured observations. Basic descriptive statistics were performed using EXCEL. Results: The details of 181 newly admitted patients were collected. Completion of recordings was 81% for heart rate, 88% for respiratory rate, 98% for blood pressure, 92% for temperature and 41% for GCS. The recorded heart rate was positively correlated with the investigator's measurement (Pearson's correlation coefficient of 0.76); while the respiratory rate did not correlate (Pearson's correlation coefficient of 0.02). In 59% of patients the recorded respiratory rate (RR) was exactly 20 breaths per minute and 27% had a recorded RR of exactly 15. Seven percent of patients had aberrant Glasgow Coma Scale readings above the maximum value of 15. The average MEWS was 2 for both the recorded (MEWS(R)) and investigator (MEWS(I)) vitals, with the range of MEWS(R) 0—7 and MEWS(I) 0—9. Analysis showed 59% of the MEWS(R) underestimated the physiological derangement (scores were lower than the MEWS(I)); 80% of patients had a MEWS(R) requiring 4 hourly checks which was only completed in 2%; 86% of patients had a MEWS(R) of less than three (i.e. not necessitating escalation of care), but 33% of these showed a MEWS(I) greater than three (i.e. actually necessitating escalation of care). Conclusion: Documentation of vital signs aids management decisions, indicating the physiological derangement of a patient and dictating treatment. This study showed that there was a poor quality of vital sign recording in this acute care trauma setting, which led to underestimation of patients' physiological derangement and an inability to detect deteriorating patients. The MEWS could be a powerful tool to empower nurses to become involved in the diagnosis and detection of deteriorating patients, as well as providing a framework to communicate the severity of derangement between health workers. However, it requires a number of strategies to improve the quality of vital sign recording, including continuing education, increasing the numbers of competent staff and administrative changes in vital sign charts.

Purpose: Nurses played a critical role in performing triage during the Iran-Iraq War. However, their experiences in triage have not been discussed. Therefore, the current study aimed to investigate the triage experiences of civilian nurses during the Iran-Iraq War. Methods: Oral history method and in-depth interviews were used to collect data to gain the nurses' experiences in triage. Results: Four themes were extracted from the data, which were the development of triage, challenging environment to perform triage, development of mobile triage teams, and challenges of triage chemical victims for nurses. Conclusion: Triage is an important skill for nurses to manage critical situations such as disasters and wars. Nurses have to be competent in performing triage. Involvement in critical situations helps the nurses learn and gain more experience on how to manage unexpected events.

Purpose: Flail chest (FC) injuries represent a significant burden on trauma services because of its high morbidity and mortality. Current gold standard conservative management strategies for FC, are now being challenged by renewed interest in surgical rib fixation. This retrospective epidemiological study sets out to evaluate FC patients, and quantify the natural history of this injury by studying the injury patterns, epidemiology and mortality of patients sustaining FC injuries admitted to a major trauma centre (MTC). Methods: A retrospective cohort analysis has been conducted at an MTC with full trauma service. All patients (age > 16 years) sustaining FC were included. Patient demographics, injury characteristics and inpatient stay information were extracted. Results: Two hundred and ninety-three patients were identified, with a mean injury severity score (ISS) of 28.9 (range 9—75), average age of 56.1 years (range of 16—100), and a male predominance (78%). Road traffic accidents accounted for 45% (n = 132) of injuries, whilst 44% were fall or jump from height (n = 129). Associated lung contusion was present in 133 patients (45%) while 76% of patients were found to have 5 or more ribs involved in the flail segment (n = 223) with 96% (n = 281) having a unilateral FC. Inpatient treatment was required 19.9 days (range 0—150 days) with 59% of patients (n = 173) requiring intensive care unit (ICU) level care for 8.4 days (range 1—63) with 61.8% requiring mechanical ventilation (n = 107) for 10.5 days (range 1—54), and 7.8% underwent rib fixation with rib plates (n = 23). The mortality rate was found to be 14% (n = 42). A non-significant trend towards improved outcomes in the conservative group was found when compared with the fixation group; ventilation days (6.94 vs 10.06, p = 0.18) intensive treatment unit (ITU) length of stay (LOS) (12.56 vs 15.53, p = 0.28) and hospital LOS (32.62 vs 35.24, p = 0.69). Conclusion: This study has successfully described the natural history of flail chest injuries, and has found a nonsignificant trend towards better outcomes with conservative management. With the cohort and management challenges now defined, work on outcome improvement can be targeted. In addition the comparability of results to other studies makes collaboration with other MTCs a realistic proposal.

Antivenom is the most effective method currently available for the treatment of poisonous snake bite. Allergic reactions to antivenom have been reported in the past. Here we shared a case of allergic reactions to antivenom in an old male patient who was bitten twice by the same snake (probably same one) at the same biting site within a month whereas the patient did not show any allergic disorder in the first bitten. Envenomations twice in a short period time by the same kind of snake are very rare. Physician should be alert to the occurrence of allergic reactions in treating this type of patients with antivenom. The skin allergy test has a certain value in predicting the allergic response before the second use of antivenom. Desensitization may reduce the incidence of allergic reactions, but this is insufficient. Rather than non-IgE-mediated immediate hypersensitivity, patients receiving the second treatment of antivenom may develop IgE-mediated immediate hypersensitivity. Once happened, the antivenom treatment should be stopped promptly and anti-allergy treatment should be given immediately.

Locking of the metacarpophalangeal (MCP) joint is commonly caused by hyperextension of the thumb or moderate flexion of the index or middle finger. We report a rare case of vertical locking of the MCP joint of the little finger in a 16-year old female after blunt trauma to the little finger. The MCP joint was locked when positioned at approximately 90-degree-flexion and could not extend actively or passively. A manual reduction was easily achieved and no immobilization was applied. Vertical locking of the MCP joint can be easily reduced, and immobilization is unnecessary after reduction. Correct diagnosis prior to reduction and differentiation from other types of locking are essential to prevent overtreatment.

Central venous catheters (CVCs) are widely used in various puncture and drainage operations in intensive care units (ICUs) in recent years. Compared to conventional operating devices, CVC was welcomed by clinicians because of the advantages of easy use, less damage to the body and convenient fixation process. We came across a patient with severe acute pancreatitis (SAP) who developed cardiac arrest due to thoracic cavity massive bleeding 24 h after thoracocentesis with CVC. Thoracotomy surgery was carried out immediately, which confirmed an intercostal artery injury. The patient was discharged from hospital without any neurological complications two months later. Here we report this case to remind all the emergency department and ICU physicians to pay more attention to the complication of thoracic cavity bleeding following thoracocentesis conducted by CVC.

Hypoxia leads to increased red blood cells and blood viscosity at high altitude while moderate trauma increases coagulation in blood. Under the above-mentioned conditions, venous sinus thrombosis is more likely to occur. A patient suffering bilateral acetabular fractures together with the gradual disturbance of consciousness was admitted to our hospital. Though computed tomography arteriogram (CTA) of the brain displayed normal blood vessels; bilateral thalamus and brainstem infarction were found on head computed tomography (CT) and Galen vein thrombosis on cerebral computed tomography venography (CTV). Dehydration and tracheotomy were immediately conducted with antiplatelet, anticoagulant and neurotrophic medicine administered to the patient. After three days' treatment, the patient's consciousness gradually improved and eventually became clear enough to leave the hospital. On follow-up, no dysfunction was documented.