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Association of persistent hyperglycemia with outcome of severe traumatic brain injury in pediatric population
Abstract and Figures
Hyperglycemia is a common secondary insult associated with an increased risk of mortality and poor outcome in traumatic brain injury (TBI), but the effect of hyperglycemia on outcomes of severe TBI in children and adolescents is less apparent. The aim of this study was to evaluate the association of hyperglycemia with mortality in pediatric patients with severe TBI.
In this cross-sectional study, data of all children and adolescents with severe TBI admitted to Poursina Hospital in Rasht, including age, gender, Glasgow Coma Scale (GCS) upon admission, mortality rate, hospital length of stay, and serial blood glucose during the first three consecutive ICU days following admission, were reviewed from April 2007 to May 2011. After univariate analysis and adjustment for related covariates, logistic regression model was established to determine the association between persistent hyperglycemia and outcome.
One-hundred and twenty-two children were included with a median admission GCS of 6 (interquartile range (IQR) 5-7) and a median age of 13 years (IQR 7.75-17). Among them, 91 were boys (74.6 %) and 31 were girls (26.6 %); the overall mortality was 40.2 % (n = 49). Patients who died had a significantly greater blood glucose levels than survivors for the first 3 days of admission (P = 0.003, P < 0.001, P = 0.001, respectively). Moreover, persistent hyperglycemia during the first 3 days of admission had an adjusted odds ratio of 11.11 for mortality (P < 0.001).
Early hyperglycemia is associated with poor outcome, and persistent hyperglycemia is a powerful and independent predictor of mortality in children and adolescents with severe TBI.
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... Hyperglycemia is a commonly observed response to the stress of critical illness, which is mediated by alterations in glucose metabolism that are caused by increases in pro-inflammatory and counter-regulatory hormones, such as cortisol and epinephrine (50). This stress hyperglycemia (SH) represents a common secondary insult to the brain after sTBI (51), and has been associated with increased morbidity and mortality in adult and pediatric patients (52)(53)(54)(55)(56). Studies examining the effect of tight glycemic control in PICU patients have yielded inconsistent results, with most studies showing no benefit or concern for harm from severe hypoglycemia (57)(58)(59). ...
In critically ill children with severe traumatic brain injury (sTBI), nutrition may help facilitate optimal recovery. There is ongoing research regarding nutritional practices in the pediatric intensive care unit (PICU). These are focused on identifying a patient's most appropriate energy goal, the mode and timing of nutrient delivery that results in improved outcomes, as well as balancing these goals against inherent risks associated with nutrition therapy. Within the PICU population, children with sTBI experience complex physiologic derangements in the acute post-injury period that may alter metabolic demand, leading to nutritional needs that may differ from those in other critically ill patients. Currently, there are relatively few studies examining nutrition practices in PICU patients, and even fewer studies that focus on pediatric sTBI patients. Available data suggest that contemporary neurocritical care practices may largely blunt the expected hypermetabolic state after sTBI, and that early enteral nutrition may be associated with lower morbidity and mortality. In concordance with these data, the most recent guidelines for the management of pediatric sTBI released by the Brain Trauma Foundation recommend initiation of enteral nutrition within 72 h to improve outcome (Level 3 evidence). In this review, we will summarize available literature on nutrition therapy for children with sTBI and identify gaps for future research.
Objective
To review the influence of metabolic dysfunction of glucose after traumatic brain injury on patient mortality.
Materials and methods
We searched PubMed, Scopus, EBSCOhost, Medline, and Embase electronic databases, involving publications from 1980 to August 2017 in English and Spanish.
Results
The glucose metabolism in brain involved in brain signal conduction, neurotransmission, synaptic plasticity, and cognitive function. Insulin levels traverse the blood–brain barrier by utilizing an insulin receptor protein as a carrier, playing a pivotal role in various cognitive functions while also regulating energy metabolism. TBI causes elevated blood glucose levels. Hyperglycemia is attributed to an acute sympatho-adrenomedullary response, resulting in elevated catecholamines, increased levels of cortisol, and IL-6. Moreover, there is a potential association with hypothalamic involvement. Additionally, hyperglycemia is linked to lactic acidosis at the tissue level, ultimately contributing to higher mortality rates.
Conclusions
The monitoring and control of glucose should be an important part of multimodal monitoring in patients with moderate to severe traumatic brain injury managed in neurocritical care units. A management protocol should ensure normoglycemia and early detection and correction of glucose abnormalities since it improves patients' clinical outcomes.
Objective:
The aim: Traumatic Brain Injury (TBI) remains a significant health burden worldwide. This study aimed to describe, determine and recommendation concerning the impact of hyperglycemia on pediatric TBI.
Patients and methods:
Materials and methods: Paediatric trauma patients with severe TBI event were identified and admitted to our Dr. Soetomo General Hospital, Surabaya, the regional Trauma Center of East Java, Indonesia between calendar year of 2017 and 2022. Our institutions trauma database was utilized to select the patient included in this study. Patients with GCS ≤ 8 who underwent neurosurgical interventions were included to the study. Neurosurgical interventions are craniotomy for clot evacuation and decompressive craniectomy. We excluded patients with GCS > 8 and/or treated with conservative therapy (no surgery needed). Data collected for analysis as independent variables included patient age, admission GCS score and admission serum glucose score, mechanism of injury, type of intracranial lesion and type of surgery. Outcome of the patients included was examined at discharge which sub-grouped by Glasgow Outcomes Scale (GOS) score. Independent variables were entered into the logistic model in a stepwise fashion with a significant cutoff of p< 0,05.
Results:
Results: Patients with worse neurological outcomes (GOS score 1-2) had a mean serum glucose value of over 200 mg/dL. Patients who died (GOS score of 1) had higher mean admission glucose values (226.44 ± 62,00) than the patients who had survived with a GOS score of 3 (139.80 ± 10.87), 4 (87), or 5 (134). Patients who resulted in a vegetative state (GOS score of 2) had higher mean admission serum glucose values than patients who were discharged with a GOS score of 5 (205.14 ± 36.17 vs. 134; p = 0.003).
Conclusion:
Conclusions: Hyperglycaemia in pediatric TBI patients that underwent neurosurgical intervention is associated with worse outcomes, even mortality. We believe that prospective evaluation of glucose normalization in the context of acute management of pediatric head injuries is both appropriate and necessary for the next study.
Acute neurologic injuries represent a common cause of morbidity and mortality in children presenting to the pediatric intensive care unit. After primary neurologic insults, there may be cerebral brain tissue that remains at risk of secondary insults, which can lead to worsening neurologic injury and unfavorable outcomes. A fundamental goal of pediatric neurocritical care is to mitigate the impact of secondary neurologic injury and improve neurologic outcomes for critically ill children. This review describes the physiologic framework by which strategies in pediatric neurocritical care are designed to reduce the impact of secondary brain injury and improve functional outcomes. Here, we present current and emerging strategies for optimizing neuroprotective strategies in critically ill children.
Background:
To study the association in moderate and severe pediatric traumatic brain injury (TBI) between hyperglycemia, hyperlactatemia, acidosis and unfavorable outcome, as assessed by Pediatric Cerebral Performance Category (PCPC) on discharge from the pediatric intensive care unit (PICU).
Methods:
Children <16 years old with TBI and Glasgow Coma Scale (GCS) ≤13 in an Asian multi-center PICU TBI cohort from January 2014 to October 2017 were included in this study. We defined unfavorable outcome as PCPC ≥3-moderate disability, severe disability, vegetative state, and death. We performed logistic regression to investigate the association between metabolic changes with unfavorable outcome. We divided hyperglycemia (glucose >11.1 mmol/L) during PICU admission into early-onset (within 24 h), late-onset (beyond 48 h) and persistent (throughout first 72 h).
Results:
Among the 305 children analyzed, 136 (44.6%) had unfavorable outcome. Children with unfavorable outcome were more likely to have early hyperglycemia (75/136, 55.1% vs. 33/169, 19.5%; P<0.001), high lactate levels >2.0 mmol/L (74/136, 54.4% vs. 56/169, 32.5%; P<0.001) and initial acidosis (85/136, 62.5% vs. 78/169, 56.1%; P=0.003) compared to those with favorable outcome. After adjusting for gender, GCS ≤8 and presence of polytrauma, early hyperglycemia [adjusted odds ratio (aOR) =3.68, 95% CI: 2.12-6.39, P<0.001] and late hyperglycemia (aOR =13.30, 95% CI: 1.64-107.8, P=0.015] were independently associated with unfavorable outcome. All children with persistent hyperglycemia died.
Conclusions:
We described unfavorable outcome in pediatric TBI especially with persistent hyperglycemia. Future trials should investigate the causal relationship between glycemic trends, early intervention and outcome in this cohort.
Introduction/Aim: Recently, hemoglobin A1c (HbA1c) has been suggested as a predictor of mortality and poor clinical outcome in patients with trauma. The aim of this study was to evaluate the relationship between HbA1c values and clinical outcome in patients with traumatic brain injury (TBI). Methods: In a cross-sectional study, a total of 133 TBI patients referred to the emergency department of Imam Khomeini Hospital in Sari, Mazandaran, Iran were evaluated. After transferring the patients to the neurosurgery ward, their HbA1c, fasting blood glucose (FBG) and postprandial glucose (PPG) were measured. Also, patients' Glasgow Coma Scale (GCS) score was recorded at the time of admission, 24 hours after admission and at the time of discharge from the hospital. Results: The mean of GCS score of patients at the time of admission, 24 hours after admission, and at the time of discharge were 9.02 (2.09), 10.07 (2.16), and 12.98 (1.82), respectively. The mean GCS score of patients with HbA1c < 5.7% was significantly lower than of patients with HbA1c = 5.7 - 6.5% at the time of admission (p < 0.05). At 24 hours after admission, the mean GCS score of patients with HbA1c < 5.7% was significantly lower than in other groups (p < 0.05). However, at the time of discharge, the mean GCS score of patients with HbA1c > 6.5% was significantly lower than in patients with HbA1c = 5.7 - 6.5% (p < 0.05). Over time, the mean of GCS scores in all patients significantly increased (p < 0.001). Conclusion: According to the results of this study it seems that HbA1c measurements cannot provide clear information about the clinical outcome of patients with TBI.
Objective
To identify early prognostic factors that lead to an increased risk of unfavorable prognosis.
Design
Observational cohort study from October 2002 to October 2017.
Setting and patients
Patients with severe TBI admitted to intensive care were included.
Variables and interventions
Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS less than or equal to 3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis.
Results
98 patients were included, 61.2% males, median age 6.4 years (IQR 2.49–11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients.
Conclusions
it is possible to identify prognostic factors of poor evolution in the first 24 h after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families.
Introduction
Severe traumatic brain injury (sTBI) is a leading cause of mortality in children. As clinical prognostication is important in guiding optimal care and decision making, our goal was to create a highly discriminative sTBI outcome prediction model for mortality.
Methods
Machine learning and advanced analytics were applied to the patient admission variables obtained from a comprehensive pediatric sTBI database. Demographic and clinical data, head CT imaging abnormalities and blood biochemical data from 196 children and adolescents admitted to a tertiary pediatric intensive care unit (PICU) with sTBI were integrated using feature ranking by way of a forest of randomized decision trees, and a model was generated from a reduced number of admission variables with maximal ability to discriminate outcome.
Results
In total, 36 admission variables were analyzed using feature ranking with variable weighting to determine their predictive importance for mortality following sTBI. Reduction analysis utilizing Borata feature selection resulted in a parsimonious six-variable model with a mortality classification accuracy of 82%. The final admission variables that predicted mortality were: partial thromboplastin time (22%); motor Glasgow Coma Scale (21%); serum glucose (16%); fixed pupil(s) (16%); platelet count (13%) and creatinine (12%). Using only these six admission variables, a t-distributed stochastic nearest neighbor embedding algorithm plot demonstrated visual separation of sTBI patients that lived or died, with high mortality predictive ability of this model on the validation dataset (AUC=0.90) which was confirmed with a conventional area-under-the-curve statistical approach on the total dataset (AUC=0.91; P<0.001).
Conclusions
Machine learning-based modeling identified the most clinically important prognostic factors resulting in a pragmatic, high performing prognostic tool for pediatric sTBI with excellent discrimination ability to predict mortality risk with 82% classification accuracy (AUC=0.90). After external multicenter validation, our prognostic model might help to guide treatment decisions, aggressiveness of therapy and prepare family members and caregivers for timely end-of-life discussions and decision making.
Level of Evidence: III; Prognostic
Patients with diseases involving the nervous system often require anesthesia for diagnostic imaging, sample collection, or treatment of the disease pathology. Understanding the physiology and pathology of the nervous system is important when considering an anesthetic plan during which the goal should be optimization of cerebral blood flow (CBF) and perfusion and prevention of increases in intracranial pressure (ICP). Certain neurologic conditions may affect ventilatory centers; therefore, adequate oxygenation and ventilation must also be a priority. Opioids are an acceptable choice for premedication and analgesia in neurologic patients, as they have minimal direct effects on CBF and ICP. Intervertebral disc disease and vertebral trauma leading to spinal cord dysfunction are major causes of neurologic injury in smallanimal patients. The goals of anesthetic management should focus on using a balanced, multimodal approach while providing adequate analgesia. Dysautonomia is a rare idiopathic condition characterized by degeneration of neurons in the autonomic nervous system ganglia.
Resumen
Objetivo
Identificar factores pronósticos precoces que conduzcan a un mayor riesgo de pronóstico desfavorable.
Diseño
Estudio de cohortes observacional de octubre de 2002 a octubre de 2017.
Pacientes y ámbito
Se incluyeron pacientes menores de 18 años con TCE grave ingresados en cuidados intensivos (UCIP).
Variables e intervenciones
Se recogieron variables epidemiológicas, clínico-analíticas y terapéuticas. Se valoró la capacidad funcional del paciente a los 6 meses mediante la Glasgow Outcome Scale (GOS). Se consideró pronóstico desfavorable un GOS ≤ 3. Se realizó un análisis univariante para comparar grupos de buen y mal pronóstico y su relación con las diferentes variables. Se realizó un análisis multivariante para predecir el pronóstico del paciente.
Resultados
Se incluyeron 98 pacientes, 61,2% varones, mediana de edad 6,4 años (RIQ 2,49-11,23). El 84,7% fueron atendidos por los servicios de emergencias extrahospitalarios. A los 6 meses, el 51% presentaban recuperación satisfactoria, el 26,5% secuelas moderadas, el 6,1% secuelas graves y el 2% estado vegetativo. Fallecieron el 14,3%. Hubo significación estadística entre la puntuación en la Escala de Coma de Glasgow (ECG) prehospitalaria, reactividad pupilar, hipotensión arterial, hipoxia, ciertas alteraciones analíticas y radiológicas (compresión de las cisternas basales), con pronóstico desfavorable. El análisis multivariante demostró que es posible realizar modelos predictores de la evolución de los pacientes.
Conclusiones
Es posible identificar factores pronósticos de mala evolución en las primeras 24 h postraumatismo. Su conocimiento puede ayudar a la toma de decisiones clínicas y ofrecer una mejor información a las familias.
Hyperglycemia in the acute phase after trauma could adversely affect outcome in children with severe traumatic brain injury (TBI). The goal of this study was to identify the relationship between acute spontaneous hyperglycemia and outcome in children with severe TBI at hospital discharge and 6 months later.
A retrospective analysis of blood glucose levels in children with severe TBI at a Pediatric level I Trauma Center, between January 2000 and December 2005. Hyperglycemia was considered for a cut-off value of 11.1 mmol/l (200 mg/dl). Outcome was measured with Glasgow Outcome Scale (GOS) at hospital discharge and at 6 months. A multiple logistic regression analysis, the Student's t test and the chi (2) test were done.
Hyperglycemia was noted within the first 48 h in 34% of the patients. Mortality (70% vs 14%, p < 10(-5)) was more frequent in hyperglycemic children and bad outcome upon hospital discharge in those who remained hyperglycemic during the first 48 h of hospitalization. GOS after 6 months demonstrated that those normoglycemic children had a better outcome (95%) than those who developed hyperglycemia during the first 48 h (83%, p = 0.01) after trauma.
Hyperglycemia could be considered as a marker of brain injury and when present upon admission, could reflect extensive brain damage with frequently associated mortality and bad outcome. The inability to maintain normal blood glucose levels during the first 48 h could be a predictive factor of bad outcome. Avoiding hyperglycemia in the initial phase could be a major issue in children with severe TBI.
To verify the prevalence of acute hyperglycemia in children with head trauma stratified by the Glasgow coma scale (GCS).
A prospective cross-sectional study carried out with information from medical records of pediatric patients presenting with head injury in the emergency room of a referral emergency hospital during a one year period. We considered the cut-off value of 150 mg/dL to define hyperglycemia.
A total of 340 children were included and 60 (17.6%) had admission hyperglycemia. Hyperglycemia was present in 9% of mild head trauma cases; 30.4% of those with moderate head trauma and 49% of severe head trauma. We observed that among children with higher blood glucose levels, 85% had abnormal findings on cranial computed tomography scans.
Hyperglycemia was more prevalent in patients with severe head trauma (GCS <8), regardless if they had or not multiple traumas and in children with abnormal findings on head computed tomography scans.
Traumatic Brain Injury (TBI) in children has been poorly studied, and the literature is limited. We evaluated 146 children with severe TBI (coma score less than 8) in an attempt to establish the prognostic factors of severe TBI in children.
The severity of TBI was assessed via modified Glasgow Coma Score for those more than 3 years old and via Children Coma Score for those under 3 years old. Clinical presentations, laboratory parameters and features of Computerised Tomography brain scans were analyzed. Outcomes were assessed at 6 months with the Pediatric Cerebral Performance Categories Scale; the outcomes were categorised as good or poor outcomes. Correlations with outcome were evaluated using univariate and multivariate logistic models.
A low coma score upon admission was independently associated with poor outcome. The presence of diabetes insipidus within 3 days post-TBI (OR: 1.9), hyperglycaemia (OR: 1.2), prolonged PT ratio (OR: 2.3) and leukocytosis (OR: 1.1) were associated with poorer outcome.
Knowledge of these prognostic factors helps neurosurgeons and neurocritical care specialists to manage and improve outcome in severe TBI in children.
To identify the relationship between admission hyperglycemia and outcome in children with severe brain injury at hospital discharge and 6 months later.
A retrospective analysis of blood glucose levels was conducted in 61 children with severe brain injury admitted to the Pediatric Intensive Care Unit between November 1, 2005 and October 30, 2009. Hyperglycemia was considered for a cut off value of > 150 mg/dL, based on literature. Outcome was measured with the Glasgow Outcome Scale at hospital discharge and 6 months after discharge. Death was also analyzed as an outcome measure.
Mean admission blood glucose of the patients was 251 mg/dL (68-791). Hyperglycemia was noted on admission in 51 (83.6%) patients. A moderately significant positive correlation was found between admission blood glucose and severity of head trauma according to Abbreviated Injury Score (r = 0.46). Mean admission glucose level of non-survivors was significantly higher (207 mg/dL vs. 455 mg/dL, p < 0.001). Mean blood glucose level of the patients in bad outcome group was found significantly higher compared to that of the patients in good outcome group at hospital discharge and 6 months after discharge (185 mg/dL vs. 262 mg/dL, p < 0.15 and 184 mg/dL vs. 346 mg/dL, p < 0.04, respectively).
Hyperglycemia could be considered as a marker of brain injury and, when present upon admission, could reflect extensive brain damage, frequently associated with mortality and bad outcome. Further studies are needed to investigate the effect of strict glycemic control on mortality and outcomes.
Recent literature demonstrates hyperglycemia to be common in patients with trauma and associated with poor outcome in patients with traumatic brain injury and critically ill patients. The goal of this study was to analyze the impact of admission blood glucose on the outcome of surviving patients with multiple injuries.
Patients' charts (age >16) admitted to the emergency room of the University Hospital of Berne, Switzerland, between January 1, 2002, and December 31, 2004, with an Injury Severity Score >or=17 and more than one severely injured organ system were reviewed retrospectively. Outcome measurements included morbidity, intensive care unit, and hospital length of stay.
The inclusion criteria were met by 555 patients, of which 108 (19.5%) patients died. After multiple regression analysis, admission blood glucose proved to be an independent predictor of posttraumatic morbidity (p < 0.0001), intensive care unit, and hospital length of stay (p < 0.0001), despite intensified insulin therapy on the intensive care unit.
In this population of patients with multiple injuries, hyperglycemia on admission was strongly associated with increased morbidity, especially infections, prolonged intensive care unit, and hospital length of stay independent of injury severity, gender, age, and various biochemical parameters.
The optimal glucose range in patients with severe traumatic brain injury (TBI) remains unclear. The goal of this study was to examine the association of serum glucose levels on mortality in patients with severe TBI. As a secondary endpoint, we determined the risk of hyperglycemic and hypoglycemic events, and their association with mortality.
We conducted a retrospective cohort study of patients admitted to the ICU between May 2000 and March 2006 with severe TBI (Glasgow Coma Scale ≤ 8) who survived at least 12 h. Average daily morning glucose levels for the first 10 days of admission were calculated and divided into quintiles.
A total of 170 patients were included in the analysis. We found no association between quintiles of mean daily morning glucose and hospital mortality. Episodes of hyperglycemia ( ≥ 11.1 mmol/l or 200 mg/dl) during the first 10 days occurred in 65% of patients (5.4% of all glucose measurements). Using multivariable regression, a single episode of hyperglycemia was associated with 3.6-fold increased risk of hospital mortality (95%CI: 1.2-11.2, P = 0.02). Hypoglycemia ( ≤ 4.4 mmol/l or 80 mg/dl) was present in 48% of patients (4.3% of all glucose measurements), and was not associated with mortality.
Any episode of hyperglycemia ( ≥ 11.1 mmol/l or 200 mg/dl) was associated with 3.6-fold increased risk of hospital mortality in patients with severe TBI and thus, should be avoided. Maintaining serum glucose ≤ 10 mmol/l appears to be a reasonable balance to avoid extremes of glucose control, but further studies are needed to determine the optimal glucose range.
In patients with severe traumatic brain injury (TBI), admission hyperglycemia is associated with poor outcome. The effect of persistent hyperglycemia (PH) on outcome in severe TBI, however, remains unknown. We performed a retrospective review of all blunt trauma patients with severe TBI (head Abbreviated Injury Score > or = 3) admitted to the intensive care unit at a Level I trauma center from January 1998 through December 2005. Admission and daily intensive care unit blood glucose levels up to the end of the first week were measured. PH was defined as an average daily blood glucose > or = 150 mg/dL on all days for the first week of the hospital stay. TBI patients with and without PH were compared with respect to baseline demographics, injury characteristics, and outcomes. Independent risk factors for mortality were identified using logistic regression analysis. One hundred and five (12.6%) out of 834 severe TBI patients had PH. Patients with PH were older, more severely injured, and had worse head injury compared with patients without PH. After adjusting for significant risk factors, PH was identified as an independent risk factor for mortality (odds ratio (OR): 4.91 [95% confidence interval (CI), 2.88-8.56, P < 0.0001]). PH is associated with significantly higher mortality rates in severe TBI patients.
Hyperglycemia among adult trauma patients with head injuries is a recognized phenomenon which has been shown to be associated with a poor prognosis when it takes the form of nonketotic hyperosmolar hyperglycemia. It is not known to what extent a similar phenomenon occurs in pediatric patients, although it is known that a child's physiologic response to injury, particularly to neurologic injury, is often different than an adult's. This study was undertaken to characterize the hyperglycemic response of children with closed head injury compared to children with a non-head injury, and to measure the extent to which the presence of hyperglycemia is associated with a poor outcome among children with severe head injury. Records for all children ages 2 to 12 years admitted to a major regional trauma center with closed head injury over a 6-year period were compared to the records of a control group of children hospitalized for a non-head injury. The hyperglycemic response was more common among those with head trauma, occurring in 40% compared to 5% of the controls (p less than 0.001); however, the level of hyperglycemia could not be associated with any indicator of outcome. The entity known as nonketotic hyperosmolar hyperglycemia did not occur in any of these patients. Apparently, the hyperglycemia associated with closed head injury in children is transient, does not need to be treated with insulin therapy, and in contrast to what has been demonstrated in adult trauma patients, does not predict patient outcome.
The traditional view of injuries as "accidents", or random events, has resulted in the historical neglect of this area of public health. However, the most recent estimates show that injuries are among the leading causes of death and disability in the world. They affect all populations, regardless of age, sex, income, or geographic region. In 1998, about 5.8 million people (97.9 per 100,000 population) died of injuries worldwide, and injuries caused 16% of the global burden of disease. Road traffic injuries are the 10th leading cause of death and the 9th leading cause of the burden of disease; self-inflicted injuries, falls, and interpersonal violence follow closely. Injuries affect mostly young people, often causing long-term disability. Decreasing the burden of injuries is among the main challenges for public health in the next century--injuries are preventable, and many effective strategies are available. Public health officials must gain a better understanding of the magnitude and characteristics of the problem, contribute to the development and evaluation of injury prevention programs, and develop the best possible prehospital and hospital care and rehabilitation for injured persons.