Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
The unmatched challenge.
- Jeevan P Marasinghe (15 November 2005)
-
The trauma of doing nothing
- EDWARD. O KOMOLAFE, MORENIKEJI A. KOMOLAFE (16 November 2005)
-
Trauma research and uncertainty
- Jorge H. Mejia-Mantilla, Miguel Arango (14 December 2005)
|
|
|||
|
Jeevan P Marasinghe, Medical officer 3-Premature Baby unit,De Soyza Hospital for women,Colombo,Sri Lanka.
Send response to journal:
|
Injuries due to trauma specially injuries to brain continuous to be an enormous public health problem. The economic and emotional cost of trauma is staggering. It is particularly evident in a developing country like Sri Lanka with an ethnic problem and a superimposed war which runs for more than two decades. The figures are alarming in some developed countries also. The annual incidence of traumatic brain injuries in United States has been estimated to be 180-200 cases per 100 000 population, which means that they have about 600 000 new cases per year. The commonest reasons are motor traffic accidents, falls, assaults and sports injuries. The assessment and initial life saving treatment has been improved over the last few decades because of an improved understanding of the distribution of mortality and the mechanisms that contribute to morbidity and mortality in trauma. But trauma care is still a major challenge to health care professionals due to lack of availability of evidence based interventions in trauma service. Unfortunately, Sri Lanka does not have a sound system to participate or to carry out large clinical trials in trauma care. I think it is high time that we also at least incorpoted to large international clinical trials and be an active participant of them. It is the duty of the authorities to solve the problems in funds, publication and ethical clearance. jeevanmarasinghe@yahoo.com Competing interests: None declared |
|||
|
|
|||
|
EDWARD. O KOMOLAFE, senior lecturer/consultant neurosurgeon DEPARTMENT OF SURGERY, OBAFEMI AWOLOWO UNIVERSITY, ILE-IFE, OSUN STATE, NIGERIA. POST CODE 20001, MORENIKEJI A. KOMOLAFE
Send response to journal:
|
Trauma is no doubt a global public health problem and in many parts of the world a leading cause of death and disability. The burden of trauma is great and drains the finances of people and nations. Trauma mostly affect young and productive individuals which are the mainstay of both family and national economy, and in situations where the victims survived many are disabled and are a constant drain on the economy. The required attention for studies into trauma research is grossly lacking. With the recent increase of unrest, communal and tribal conflicts, wars, terrorism and the rise of natural disasters such as earthquakes, hurricanes and tornados, in addition to various accidents from car, train, boat, and airplane crashes, in which a lot of people sustain one form of injury or the other, we should pay more attention to trauma prevention. However clinical trials into further understanding of trauma pathophysiology, validation of current treatment modalities, and effectiveness of new treatment options should also be encouraged. A worldwide and large scale trauma research is possible and should be encouraged. This was demonstrated in the CRASH study1, 2. No age, sex, nation, race, religion, social status, professional group etc are immune to trauma, so all hands must be on deck. Ways to reduce the disparity between the advanced world and the developing nations should also be promoted, and then many nations in the third world will be aware and fully participate in such global efforts. Locally, in our practice setting and the nation, our constraining factors include lack of awareness of such studies, no or poor government policies and legislation, delay in the processing and obtaining required ethical committees approvals, poor communication between collaborators particularly with the international coordinating centre, lack of a local research team, and lack of interest from many factors as enumerated by the authors but most especially adequate reward of participation. It is definite that trauma incidence will continue to increase with the associated mmorbidity and mortality, however the greatest trauma is not to give adequate attention to this global epidemic. Adequately funded and researched trauma trials will go a long way in reducing the burden of trauma on individuals, families and the nations. References: 1. CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004 Oct 9;364(9442):1321-8. 2. Crash Trial Collaborators. Final results of MRC CRASH, a randomised placebo-controlled trial of intravenous corticosteroid in adults with head injury-outcomes at 6 months. Lancet. 2005 Jun 21;365(9475):1957-9. Competing interests: None declared |
|||
|
|
|||
|
Jorge H. Mejia-Mantilla, Intensive Care Physician, Colombian Coordinator for Crash 2 trial Fundacion Clinica Valle del Lili, Cali, Colombia, Miguel Arango
Send response to journal:
|
Recently, Professor Ian Roberts highlighted the importance of trauma as the second cause of death and disability adjusted life years all over the world (1). Unfortunately, most trauma victims are found in low / middle income countries where preventive strategies are weak or non existent and probably hard to implement in the near future (2). Physicians in developing countries often overlook the fact that trauma is a major source of mortality and morbidity and the clinical and research attitudes are not consistent with the importance of the problem. As Roberts points out, explanations for this situation can be multifactorial: lack of interest in the topic by major journals, lack of emphasis on the problem by medical school, and lack of financial support for education / research in trauma. Since the value of trauma is neglected, getting funds for research is a major issue. Many simple procedures and cheap interventions could probably be useful in the care of trauma victims, but as they are poorly studied, their impact on patient outcome is unknown and good evidence based guidelines to support their use are scarce. Certainly, it is time to insist on clinical research that will evaluate simple interventions that could potentially evolve in a positive clinical outcome for trauma patients. In this way, although not in trauma field, the work of Rivers and colleagues about resuscitative measures for septic patients is very interesting (3). They show us the critical importance of fixing goals and timing interventions in order to achieve greater efficiency in managing resources and achieving better outcome. Their contribution was to demonstrate the key roles on timing and systematic approach in managing a frequent clinical situation. Another central consideration about research in trauma setting is the complexity to standardize care, to uniform the inclusion criteria and to recruit the patient early enough. The principle of uncertainty used in the first CRASH trial (4) is a major step forward in the design of clinical trials in which the conditions for research closely represent the real clinical arena. The drawbacks of this approach are that regulatory agencies and research committees often misunderstand it. We should join our efforts to increase the awareness of the medical community about the importance of this epidemic. With everyone’s little input, we can increase the pressure on medical educational program and public health systems to produce better programs and get more commitment to find solutions to help decreasing the incidence of trauma and to improve knowledge about treatment strategies. We want to support both the view of the importance of large collaborative trials, and the proposal to temper the regulations in the case of research in the emergency setting, particularly the research conducted by non-commercial agencies, like the CRASH trials. This should drive us to better information to guide a prompt reaction of health systems to improve care and outcome of trauma victims. References 1. Roberts I., Shakur H., Edwards P., Yates D., Sandercock P. Trauma care research and the war on uncertainty. BMJ 2005;331;1094-1096 2. Word Health Organization 2002. A 5-year WHO strategy for road traffic injury prevention. http://www.who.int/violence_injury_prevention/ 3. Rivers E., Nguyen B., Havstad S., Ressler J., Muzzin A., Knoblich B., Peterson E. And Tomlanovich M. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368- 77 4. Peto R. and Baigent C. Trials: the next 50 years. BMJ 1998; 317:1170-1 Competing interests: Participants in CRASH2 trial |
|||