Early Outcomes of Pelvic Trauma Patients - Complications, ICU Stay and Treatment Concepts in Two ATLS Compliant Trauma Centers: Germany and Qatar

PURPOSE OF THE STUDY Pelvic trauma causes severe threats especially to polytraumatized patients. Not only it is in itself a possible cause for significant bleeding, but it also indicates a high risk for intra-abdominal injuries. The initial treatment of patients with pelvic trauma follows the ATLS principles of priority-oriented treatment. To examine the value of this highly standardized concept and to evaluate the effect of different patient collectives on early outcome parameters, two large collectives from Germany and Qatar were analyzed regarding injury parameters and early outcomes. MATERIAL AND METHODS Patients were recruited in Hamad General Hospital, Doha, Qatar (HGH) and BG Trauma Center Ludwigshafen, Germany (BG). All patients that were treated with a pelvic fracture between 2013 and 2016 were included in this retrospective analysis. Demographic parameters were collected as well as type of injury and the frequency of complication parameters as pneumonia, acute kidney failure, ARDS, sepsis and amount of blood transfusion. 1436 patients with pelvic fracture (645 from BG and 791 from HGH) were recruited. The mean age was 57.4 years in the BG and 33.6 years in the HGH group (p<0.000). The mean ISS was 17.81 in the BG and 15.88 in the HGH group (p=0.009). The mean pelvic AIS was 2.65 in the BG and 2.25 in the HGH group (p<0.000). RESULTS The mean frequency of complications was 9.3% in the BG and 9.9% in the HGH group (p=0.128). The mean frequency of ARDS was significantly higher in the BG group than in the HGH group (5.6% vs. 1.8%, p<0.000). The mean frequency of blood transfusion was significantly lower in the BG group than in the HGH group (28.8% vs. 39.2%, p<0.000). CONCLUSIONS Despite significant differences in the two collectives, this analysis shows comparable results regarding early outcome parameters in patients with pelvic injuries. In total, pelvic injuries are accompanied by a relatively high complication risk and need to be evaluated and treated according to priority-based algorithms. Key words: ATLS®, pelvic injury, complications, polytrauma.

[Exploring Early Maladaptative Schema (EMS) in adults with bipolar disorder: A systematic review of the scientific literature]

OBJECTIVES

Clinical heterogeneity during euthymic states is a crucial issue in bipolar disorders. Indeed, actual data are not sufficient to understand why some patients are unharmed by subthreshold symptoms and have functional impairments whereas others have a functional remission but have subthreshold symptoms. Based on the Ball model, cognitive and schematic vulnerability interact with genetic vulnerability and trigger affective symptoms with the intervention of stressful life events. Furthermore, according to this model, adjustment and adaptation to illness assessed by functional outcome and illness experience are associated with this cognitive and schematic vulnerability. So, theoretical arguments support that childhood adversity and temperamental deregulation characterize patients with bipolar disorders. Thus, the aim of this study is to systematically review studies of Early Maladaptive Schemas in bipolar disorder, to determine whether Early Maladaptive Schemas have specificity in bipolar disorder in comparison with other populations, and to identify which Early Maladaptive Schemas could be activated. The challenge of this review is to identify if the taking of early maladaptive schemas into account could allow us to better identify, understand and manage bipolar disorders.

METHODS

This systematic review was led according to the Preferred Reporting Items for Systematic review and Meta-Analysis statement on the electronic databases Cochrane, PsycArticles, Psychology and Behavioral Sciences Collection, PsycInfo, PubMed, ScienceDirect and Scopus with « early maladaptive schemas » AND « bipolar disorder » as keywords. Only studies meeting eligibility criteria concerning publication status, language, population and outcomes were included after several screenings on basis of title, abstract and full-text. Then, we carried out data extraction in accordance with criteria defined in principle (about characteristics of participants, objectives, materiel and methods, principle results and bias).

RESULTS

Among 39 records identified, a total of 10 studies met eligibility criteria for inclusion in this review. Synthesizing findings across the studies revealed three important topics. First, early maladaptive schemas appear as potential cognitive characteristics that clinicians have to investigate in clinical practice. Indeed, patients with bipolar disorders present greater activation of the early maladaptive schemas in comparison with people who have no disorder. This point supports the first part of Ball's theoretical model that considers schemas as a vulnerability to bipolarity. Secondly, early maladaptive schemas are relevant to distinguish bipolar disorders from unipolar depression and borderline personality disorder. A greater and a lower activation are respectively identified among bipolar disorders. Thirdly, supporting the second part of Ball's model, early maladaptive schemas play a key role in recovery regarding their impact on the course of bipolarity, in particular on suicidality and functional impairment. Finally, these dysfunctional schemas allow us to understand the clinical heterogeneity of bipolar disorder, and among others, about the type of bipolarity. These results have several implications, but there are some limits in this systematic review. First, no French study has been done. Then, reduced sample sizes in these studies increased the risk to conclude wrongly to an activation difference between groups. Furthermore, probably due to the variety of methods and populations, we could not identify an homogeneous pattern of early activated maladaptive schemas. Overall, scientific approaches used in these studies are based on statistical models using mean and standard deviation. These types of statistical analyses are the main limit because they cannot represent the heterogeneity of early maladaptive schemas profiles.

CONCLUSIONS

Schema theory proves to be a relevant approach in bipolar disorders, and early maladaptive schemas appear to be important to take into account in clinical practice. Nevertheless, in order to propose schemas therapy appropriately, it is necessary to specify if early maladaptive schemas are activated and to specify therapeutic indications because of clinical heterogeneity. Moreover, data do not yet allow us to understand the disparity of profiles during the inter-episode period. Indeed, a French research perspective is being considered that will prefer a person-oriented approach.

French migration to the Americas in the 19th and 20th centuries as a historical problem

"How do we account for the fact that so little is known of the patterns of French emigration to, and settlement in the Americas?... If the silence of the historians cannot be adequately and simply explained by the modesty of the flow, it becomes necessary to delve deeper into the reasons which account for this silence....I suggest that a reconceptualization of French emigration along the lines of a transatlantic, comparative analysis will not only enlighten the history of the migrants themselves...but will also enrich our vision of the social history of France and of the receiving countries."

The broadened framework of compulsory interventions in the new Israeli law. Their practical consequences

Improved treatment efficacy and prognosis in modern psychiatry have mandated changes in the Israeli Mental Health Law. Since 1991, the conditions for compulsory intervention have broadened, beyond that of immediate physical danger. Concurrently, checks and balances over this process have increased. No compulsory treatment decisions are taken without a recent psychiatric examination by a specialist, and the uncooperative patient can be compelled to undergo such an examination. The overriding principle of least restrictive alliterative, coupled with the use of depot-neuroleptics, have led to the implementation of commitment to out-patient treatment. Detailed statistics related to uncooperative patients during 1994 reveal that a significant proportion of such patients become cooperative once the process is activated. Thus, changes in the law permit maximal exploitation of modem therapeutic improvements and permit earlier intervention. The number of compulsory hospitalizations has not, however, increased, thus indicating that an appropriate balance between the patient's right to treatment and right to decide has been achieved.

The right of the mental patient to be medically informed

Parallel to changes in the nature of the relationship between the physician and his or her patient, have been shifts in the mode of transmission of information to the patient concerning his or her illness. Historically, the therapist-patient bond was based on a complementarity of status: For the patient, ignorance and anxiety drew him or her to seek the help of a therapist for whom rationality and scientific knowledge were the basis of his or her response. In the more recent past, the patient's active involvement in the therapeutic process has been intensified. Medical paternalism has been progressively rejected. Treatment could thus be initiated only after informed consent was given, in the context of verbal transmission of information by the therapist to the patient and the patient's right to consult 'his or her own' medical records evolved. This article details the risks of such a right--especially in psychiatry--for the patient himself or herself, for the collateral sources who have transmitted confidential information to the therapist, and for the therapist-patient relationship.

Ethical and moral dilemmas in the treatment of an abusive parent--the occupational therapy perspective

Treating patients who physically abuse their children creates in the therapist moral and ethical dilemmas which challenge his or her ability to maintain a professional conduct and attitude. In such cases the therapist usually finds himself or herself confronted with the following dilemmas: (a) treatment of a patient who experiences therapy as a no-choice situation; (b) treatment of a patient whose conduct is in conflict with the moral values of the therapist; (c) the obligation of the therapist to report the abusive acts to the authorities versus his or her duty to protect the patient's right to confidentiality; and (d) the therapist's loyalty to the patient's welfare, when it is in conflict with the abused person's welfare. These issues are illustrated through the following case study examined in the context of occupational therapy (OT): A 26-year-old married woman, mother to a four-month-old infant was referred to therapy after causing severe burns to her daughter's hands. As a child the patient experienced physical abuse by her parents. The patient viewed treatment as her only possible means of keeping her child. On the other hand, she was suspicious of verbal therapy, as she assumed that the contents might incriminate her. Occupational therapy was therefore a major therapeutic modality used to assess and improve her disturbed psychosocial occupational performances. The article describes the way in which the OT approach helped overcome and resolve the moral and ethical dilemmas raised in the case.

Releasing the treating psychiatrist from confidentiality

Confidentiality is one of the oldest and most universal traditions of medicine. This rule is beneficial to the patient, who can disclose his or her secrets to his or her therapist without reluctance, to the physician, who enjoys a privileged relationships with his or her patient and to society at large, interested in public health and unrestricted access of all citizens to treatment. Nevertheless, each one of these beneficiaries claims the right to break this rule. The patient considers that the confidence is his or hers and may be disposed of at his or her discretion. The psychiatrist claims that he or she cannot remain silent and passive when the absence or delay of treatment of a reluctant patient can result in a disaster. Finally, society advocates the existence of a hierarchy which places the protection of society above the interests of the individual. Originally, breaches in confidentiality allowed by the legislator were chiefly intended to enable the patient to enjoy his or her rights or to facilitate treatment. Moreover the physician was encouraged to limit released data to those which were necessary for the purpose stated in the request for information. Unfortunately, the extent of the breaches is increasing. Some of the exceptions, like the obligation to report child abuse or imminent danger to others (Tarasoff) are usually readily accepted. This article details cases which give concern inasmuch as the disclosure of information exposes the patient to diverse restrictions. For example the right to confidence is waived by the patient under external pressure as a condition to obtain employment, access to military service or a driver's licence.(ABSTRACT TRUNCATED AT 250 WORDS)