Changing speed limit leads to proportional changes in average speeds which may affect the number of traffic accident occurrences. It is however critical and challenging to evaluate the impact of a speed limit alteration on the number and severity of accidents due primarily to the unavailability of adequate data and the inherent limitations of existing approaches. Although speed is regarded as one of the main contributory factors in traffic accident occurrences, research findings are inconsistent. Independent of the robustness of their statistical approaches, accident frequency models typically use accident grouping concepts based on spatial criteria (e.g. accident counts by link termed as a link-based approach). In the link-based approach, the variability of accidents is explained by highly aggregated average measures of explanatory variables that may be inappropriate, especially for time-varying variables such as speed and volume. This thesis re-examines accident-speed relationships by developing a new accident data aggregation method that enables improved representation of the road conditions just before accident occurrences in order to evaluate the impact of a potential speed limit increase on the UK motorways (e.g. from 70 mph to 80 mph). In this work, accidents are aggregated according to the similarity of their pre-accident traffic and geometric conditions, forming an alternative accident count dataset termed as the condition-based approach. Accident-speed relationships are separately developed and compared for both approaches (i.e. link-based and condition-based) by employing the reported annual accidents that occurred on the Strategic Road Network of England in 2012 along with traffic and geometric variables. Accident locations were refined using a fuzzy-logic-based algorithm designed for the study area with 98.9% estimated accuracy. The datasets were modelled by injury severity (i.e. fatal and serious or slight) and by number of vehicles involved (i.e. single-vehicle and multiple-vehicle) using the multivariate Poisson lognormal regression, with spatial effects for the link-based model under a full Bayesian inference method. The results of the condition-based models imply that single-vehicle accidents of all severities and multiple-vehicle accidents with fatal or serious injuries increase at higher speed conditions, particularly when these are combined with lower volumes. Multiple-vehicle slight injury accidents were not found to be related with higher speeds, but instead with congested traffic. The outcomes of the link-based model were almost the opposite; suggesting that the speed-accident relationship is negative. The differences between the results reveal that data aggregation may be crucial, yet so far overlooked in the methodological aspect of accident data analyses. By employing the speed elasticity of motorway accidents that was derived from the calibrated condition-based models it has been found that a 10 mph increase in UK motorway speed limit (i.e. from 70 mph to 80 mph) would result in a 6-12% increase in fatal and serious injury accidents and 1-3% increase in slight injury accidents.

Doctor of Philosophy / Department of Civil Engineering / Sunanda Dissanayake / Young drivers have elevated motor vehicle crash rates compared to other drivers. This dissertation investigated characteristics, contributory causes, and factors which increase the injury severity of young driver crashes in Kansas by comparing them with more experienced drivers. Crash data were obtained from the Kansas Department of Transportation. Young drivers were divided into two groups: 15-19 years (teen) and 20-24 years (young adult) for a detailed investigation. Using data from 2006 to 2009, frequencies, percentages, and crash rates were calculated for each characteristic and contributory cause. Contingency table analysis and odds ratios (OR) analysis were carried out to identify overly represented factors of young-driver crashes compared to experienced drivers. Young drivers were more likely to be involved in crashes due to failure to yield-right-of way, disregarding traffic signs/signals, turning, or lane changing, compared to experienced drivers. Ordered logistic regression models were developed to identify severity affecting factors in young driver crashes. According to model results, factors that decreased injury severity of the driver were seat belt use, driving at low speeds, driving newer vehicles, and driving with an adult passenger. The models also showed that alcohol involvement, driving on high-posted-speed-limit roadways, ejection at the time of crash, and trapping at the time of crash can increase young drivers’ injury severity. Based on identified critical factors, countermeasure ideas were suggested to improve the safety of young drivers. It is important for teen drivers and parents/guardians to gain better understanding about these critical factors that are helpful in preventing crashes and minimizing driving risk. Parents/guardians can consider high-risk conditions such as driving during dark, during weekends, on rural roads, on wet road surfaces, and on roadways with high speed limits, for planning teen driving. Protective devices, crash-worthy cars, and safer road infrastructures, such as rumble strips, and forgiving roadsides, will particularly reduce young drivers’ risk. Predictable traffic situations and low complexity resulting from improved road infrastructure are beneficial for young drivers. The effectiveness of Kansas Graduated Driver Licensing (GDL) system needs to be investigated in the future.

Clostridium difficile est responsable de 15 à 25% des cas de diarrhées post-antibiotiques (ATB) et de plus de 95% des cas de colite pseudomembraneuse. Depuis 2003 et suite à l'émergence du clone 027, les ICD sont devenues plus fréquentes et plus sévères. Compte tenu des conséquences, il a été décidé d'explorer en détail et prospectivement cette maladie au Groupement Hospitalier Edouard Herriot L'inclusion des patients a débuté fin février 2011 et devrait s'arrêter fin février 2014. Dans une méta-analyse, nous avons montré que l'ICD communautaire est associée à l'exposition aux mêmes ATB qu'une ICD nosocomiale. Une analyse de la littérature, en utilisant la grille ORION comme outil, nous a permis de synthétiser les connaissances sur la prévention et le contrôle d'ICD en milieu hospitalier. Par la suite sur la base d'une étude rétrospective, le sexe, la CRP et l'exposition aux fluoroquinolones ont été identifiés comme associés à une ICD sévère chez les patients hospitalisés en réanimation. Entre 2011 et 2013, 430 patients ont été inclus dans notre cohorte. L'analyse des données de la prise en charge thérapeutique de 118 cas d'ICD a montré un niveau insuffisant de la connaissance des recommandations actuelles concernant le traitement de cette infection. L'analyse pronostique a montré un taux de mortalité de 19,5% dans les 30 jours qui suivent le diagnostic. L'ICD était indiquée comme une cause principale ou contributive de décès dans quinze cas (65,7% des décédés). Les analyses multivariées ont montré que les facteurs associés au décès sont différents entre les patients avec une ICD et les patients présentant une diarrhée non liée au Clostridium difficile / Clostridium difficile is responsible for almost all cases of pseudomembranous colitis and for 15%-25% of cases of post-antibiotic (ATB) diarrhea. Since 2003 and the emergence of 027 strain, CDI epidemiology is changing, with evidence of rising incidence and severity. In response to the alarming situation we decided to conduct a prospective study at Eduard Herriot Hospital to explore in details this infection. Patient’s inclusion has started in February 2011 and will end in February 2014. In a meta-analysis we found that the risk profiles for antimicrobial classes as risk factors for community-acquired CDI are similar to those described for nosocomial CDI. We used the ORION statement (Outbreak Reports and Intervention Studies Of Nosocomial infection) to synthesize knowledge of interventions to reduce and to control CDI in hospitals. Then in a retrospective study, we found that male gender, rising serum C-reactive protein level, and previous exposure to fluoroquinolones were independently associated with severe CDI in ICU. Between 2011 and 2013, 430 patients were included in our prospective cohort study. Data analysis of 118 cases of CDI showed an inefficient knowledge of current recommendations of CDI treatment. The crude mortality rate within 30 days after CDI diagnosis was 19.5%, with 15 deaths (65.7% of deceased patients) related to CDI. In a multivariate cox regression model, gender, serum albumin, antidiarrheal medications, cephalosporins, peritonitis and septic shock were independently associated with mortality in CDI patients. When diarrhea was not related to C. difficile, mortality was rather associated with cancer and high WBC level

Drooling management in the neurologically impaired pediatric population is a challenge. Surgery is considered an invasive procedure, while behaviour modification techniques, correction of situational factors and oral-motor therapy do not always produce sustained improvement. In recent years Botox® has been investigated. This study comprised analyses of clinical data obtained from a Drooling Treatment Project (DTP) conducted at a school for special needs children in South Africa. The aims of the DTP were to establish the response of drooling in a number of different contexts, following bilateral submandibular salivary gland injections of Botox®. Two groups of children were involved, 7 children with cerebral palsy and 2 children with operculum syndrome. Drooling was assessed in 5 different situations and at different time points pre- and post Botox® injection up to 6 months. Parents’/primary caregivers’ perceptions of drooling and treatment with Botox® were also measured using an interview form and a quality of life questionnaire. Results showed that drooling was reduced in all situations, with significant reductions in the general and communicating situations. These results indicate that the context in which drooling occurs is an important factor and suggest the value of considering the situational context when making drooling judgements. Further, there was a difference in the pattern of response between the 2 groups. This finding has implications, not only for future research, but also for models of explanation of the effects of Botox®. Most parents/primary caregivers felt their children’s lives and their own had improved following the Botox® injection and would repeat the treatment. Clinical and research implications are discussed, with reference to the South African context.

O tratamento de sementes tem como objetivo tradicional erradicar ou reduzir os fungos associados às sementes, além de protegê-las de patógenos presentes no solo. Algumas doenças que ocorrem na parte área das plantas podem ser manejadas através do tratamento das sementes com produtos sistêmicos. Essa forma de controle tem sido utilizada há muitos anos, visando o controle de fungos biotróficos em arroz e trigo. A ferrugem asiática da soja é a principal doença que ataca a cultura, a qual necessita de ferramentas eficientes para seu manejo. O objetivo desta dissertação foi verificar a contribuição do tratamento de sementes de soja com produtos fitossanitários no manejo da ferrugem asiática. Desta forma, produtos fitossanitários foram aplicados às sementes de soja em diferentes doses, a fim de se verificar os efeitos fitotóxicos sobre sementes e plântulas que eventualmente fossem causados pelos mesmos. As maiores doses não fitotóxicas de cada tratamento foram selecionadas, novamente aplicadas às sementes e distribuídas em campo experimental, onde se verificou o efeito do tratamento das sementes isoladamente ou com a aplicação foliar de fungicidas foliares, no manejo da ferrugem asiática da soja. Ciproconazol + azoxistrobina (10,0 + 25,0g i.a./100kg de sementes), difenoconazol (50,0), epoxiconazol (2,5), fluquinconazol (50,0), flutriafol (10,0), flutriafol TS (5,0), flutriafol + tiofanato metílico (10,0 + 50,0), tebuconazol (10,0), tebuconazol + trifloxistrobina (10,0 + 5,0), tetraconazol (10,0), triticonazol (25,0), acibenzolar-S-methyl (50,0) e pó de rocha (2,0) não apresentaram fitotoxicidade e foram comparados em campo. Ciproconazol + azoxistrobina (25,0 + 10,0g i.a./100kg de sementes) e epoxiconazol (2,5) diminuíram a emergência das plântulas de soja em campo. No ensaio somente com tratamento de sementes, sem aplicação de fungicida foliar, tebuconazol e tebuconazol + trifloxistrobina diminuíram a ferrugem asiática em plantas de soja. Quando se integrou a pulverização foliar de fungicidas, fluquinconazol, tebuconazol e tebuconazol + trifloxistrobina, diminuíram a severidade da ferrugem asiática da soja. Apesar de não aumentar o rendimento da cultura, o tratamento de sementes pode contribuir no manejo da ferrugem asiática da soja, mantendo a segurança e o rendimento do produtor. / Seed treatment has as traditional objective to eradicate or to reduce fungi associated with seeds and to protect them from soilborne pathogens. Some diseases that occur in the aerial part of plants may be managed through seed treatment with systemic products. This kind of control has been used for many years, aiming the control of biotrophic fungi in rice and wheat. Soybean\'s asian rust is the main disease that attacks the culture, which needs efficient tools for its management. The objective of this study was to verify the contribution of soybean seed treatment with phytosanitary products in the management of asian rust. In this case, phytosanitary products were applied to soybean seeds in different doses, aiming to verify the phytotoxicity effects onto seeds and seedlings that eventually would be caused by these products. The highest non phytotoxic doses of each treatment were selected, applied again to seeds and these were distributed on experimental field, where it was verified the effect of each seed treatment with and without foliar application of fungicides, in the management of soybean\'s asian rust. Ciproconazol + azoxystrobin (10,0 + 25,0g a.i./100kg of seeds), difenoconazol (50,0), epoxiconazol (2,5), fluquinconazole (50,0), flutriafol (10,0), flutriafol TS (5,0), flutriafol + thiophanate-methyl (10,0 + 50,0), tebuconazole (10,0), tebuconazole + trifloxystrobin (10,0 + 5,0), tetraconazole (10,0), triticonazole (25,0), acibenzolar-S-methyl (50,0) and rock powder (2,0) did not present phytotoxicity and were compared in field. Ciproconazol + azoxystrobin (25,0 + 10,0g a.i./100kg of seeds) and epoxiconazol (2,5) decreased the seedling\'s emergency in field. In the experiment with only seed treatment, with no foliar fungicide application, tebuconazole and tebuconazole + trifloxystrobin decreased asian rust in soybean plants. When the application of foliar fungicide was integrated, fluquinconazole, tebuconazole and tebuconazole + trifloxystrobin the asian rust severity decreased. Despite there was no increase in the culture yield, seed treatment can contribute in asian rust´s management, increasing the safety an the revenue of the producer.

Introdução: O transplante de células-tronco hematopoiéticas (TCTH) tornou-se um procedimento terapêutico mundialmente aceito sobretudo pelo impacto positivo na sobrevida e na qualidade de vida dos pacientes com doenças onco-hematológicas. No entanto, a mortalidade ainda é alta e influenciada por fatores de natureza individual e terapêutica. Objetivo: Analisar a mortalidade relacionada ao transplante (MRT) nos pacientes submetidos ao TCTH e seus fatores associados. Método: Coorte prospectiva realizada com 60 pacientes internados na unidade de TCTH do Hospital de Clínicas da Universidade Estadual de Campinas. Os dados foram obtidos pela análise diária dos prontuários. A variável dependente foi a MRT e as variáveis independentes foram demográficas e de evolução clínicas, incluindo escore de risco pré-TCTH (EBMT) e o SAPS II. Na análise dos dados foram utilizados os testes Qui-quadrado, Exato de Fisher, o teste t de Student e Mann-Whitney. Na análise da MRT utilizou-se o método de kaplan-Meier e o Modelo de Cox. Considerou-se nível de significância igual a 5%. Resultados: A MRT foi de 15% aos cem dias do TCTH, de 18,9% no grupo de pacientes de TCTH alogênico e de 8,7% para os de TCTH autólogo. A infecção foi a principal causa de óbito. Na amostra, o tempo médio de sobrevida dos pacientes foi de 83,2 dias (DP 32,7). No grupo de pacientes não sobreviventes a maioria pertencia ao sexo masculino, com média de idade de 48,7 anos e diagnóstico principal de leucemia. Quanto à gravidade destes pacientes, o escore de risco pré-TCTH (EBMT) foi de 4,1 pontos e do SAPS II geral foi de 52,6 pontos, o que correspondeu a um risco médio de morte de de 38,4%. Os fatores associados à MRT, em cem dias, foram faixa etária (p=0,0306), presença de infecção (p=0,0216), número de infecções (p=0,0386), ocorrência de enxertia (p<0,0001), uso de ventilação mecânica (p<0,0001) e de drogas vasoativas (p<0,0001). O índice de gravidade SAPS II foi fator preditor para MRT (p=0,0001). Conclusão: O índice de gravidade SAPS II, preditor para MRT em cem dias, mostrou que o paciente submetido ao TCTH é grave e necessita de cuidado especializado e intensivo. / Hematopoietic stem cells transplantation (HSCT) has become a therapeutic procedure accepted worldwide, particularly because of its positive impact on survival and quality of life of patients with onco-hematological diseases. However, the mortality is still high and it is influenced by factors of individual and therapeutic kinds. Objective: To analyze the transplant-related mortality (TRM) on patients submitted to HSCT and its associated factors. Methodology: Prospective cohort study with 60 patients hospitalized in the HSTC unit of the Clinical Hospital of the State University of Campinas (Unicamp). Data was obtained by daily analysis of the medical records. The dependent variable was the TRM and the independent variables were demographic and clinical development, including pre-HSCT risk score (EBMT) and SAPS II. For data analysis were used the Chi-square, Fishers exact tests, Students t-test, Mann-Whitney. On TRM analysis were used Kaplan-Meier and Cox Model method. It was considered a significance level of 5%. Results: The TRM was 15% to a hundred days of HSCT, 18,9% to allogeneic HSCT patients and 8,7% to autologous HSCT. Infection was the main cause of death. In the sample, the median survival time of the patients was 83,2 days (DP 32,7). In the group of non-surviving patients the most were male, with an average age of 48,7 years and the main diagnosis was leukemia. Regarding to the severity of these patients, the pre-HSCT risk score (EBMT) was 4,1 points and general SAPS II was 52,6 points, which corresponds to an average death risk of 38,4%. The TRM associated factors on a hundred days were age (p=0,0306), presence of infection (p=0,0216), number of infections (p=0,0386), occurrence of grafting (p<0,0001), mechanical ventilation use (p<0,0001) and vasoactive drugs (p<0,0001). The severity rate SAPS II was a predictive factor for TRM (p=0,0001). Conclusion: The severity rate SAPS II was predictive for TRM on a hundred days and showed that the patient submitted to HSCT is severe and demands specialized and intensive care.

As intoxicações decorrentes do uso de drogas de abuso representam atualmente um grave problema para a saúde pública. Dentre os principais agentes envolvidos, destaca-se a cocaína. Ela se tornou uma das drogas mais consumidas ao redor do mundo, sendo um dos principais motivos de atendimentos em pronto-socorro (PS) devido ao uso de substâncias ilícitas. Seu uso ocorre principalmente em associação com bebida alcóolica. Existem poucos estudos realizados que relacionem a concentração sanguínea de cocaína e a gravidade das manifestações clínicas em populações que a utilizam como droga de abuso, e que envolvam pacientes atendidos em PS. O objetivo do presente estudo foi verificar a possível relação entre concentração sanguínea de cocaína e cocaetileno (produto da interação de cocaína com etanol) com a gravidade das manifestações clínicas apresentadas por pacientes com hipótese diagnóstica de intoxicação por cocaína. As concentrações sanguíneas foram determinadas por cromatografia líquida de alta eficiência (HPLC) e a gravidade das manifestações clínicas foi avaliada através do Stimulant Intoxication Score (SIS). Dos 81 pacientes incluídos no estudo 77,8% são homens com idade média de 32,5 anos ± 8,5 e SIS médio de 3,4 ± 2,5. Do total de pacientes incluídos no estudo 20 (24,7%) tiveram resultados positivos em sangue para os analitos de interesse, sendo a concentração sanguínea média de cocaína igual a 0,34 &#181;g/mL ± 0,45 e de cocaetileno igual a 0,38 &#181;g/mL ± 0,34. A concentração sanguínea de cocaína e cocaetileno não se mostrou informação útil para tratamento e prognóstico dos pacientes, porém a detecção no sangue destas substâncias no momento do atendimento, independentemente de sua concentração, pode ser um indicador de gravidade, mostrando que quaisquer concentrações destas substâncias devem ser consideradas potencialmente tóxicas. A aplicação do score SIS revelou-se como importante alternativa capaz de predizer a gravidade dos pacientes atendidos devido a intoxicação por cocaína de maneira rápida e simplificada. / Currently, poisoning resulting from the abuse of drug represents a serious problem for public health. Among the main agents involved, cocaine stands out. It became one of the most abused drugs around the world, being one of the main reasons for visits to the emergency room due to the use of illicit substances. The use of cocaine is primarily in combination with alcoholic beverages. There are few studies that relate cocaine blood concentration and the severity of its clinical manifestations in patients attended in the Emergency Room. The aim of the present study was to verify the possible relationship between the blood concentration of cocaine and cocaethylene (product of the interaction of cocaine with ethanol) with the severity of the clinical manifestations presented by patients with cocaine intoxication. Blood levels were measured by high-performance liquid chromatography (HPLC) and the severity of clinical manifestations was assessed using the Stimulant Intoxication Score (SIS). Of the 81 patients included in the study, 77.8% were men with a mean age of 32.5 years ± 8.5 and mean of SIS 3.4 ± 2.5. From the total of patients included in the study 20 (24.7%) had positive blood results for the analytes of interest, being the mean blood concentration of cocaine equal to 0,34 &#181;g/mL ± 0,45 and of cocaethylene equal to 0,38 &#181;g/mL ± 0,34. The blood concentration of cocaine and cocaethylene has not been shown to be useful information for the treatment and prognosis of patients, but blood levels of these substances at the time of treatment, regardless of their concentration, may be an indicator of severity, showing that any concentrations of these substances should be considered as potentially toxic. The application of the SIS score proved to be an important alternative capable of predicting the severity of the patients attended due to cocaine intoxication in a fast and simplified way.

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.

O trauma hoje é considerado a epidemia do século XXI, representando a principal causa de morte nas primeiras quatro décadas de vida. Na pesquisa atual, foram consideradas para análise as vítimas de traumas decorrentes de acidentes de transporte por considerar a relevância do tema no cenário da saúde nacional e internacional. Os objetivos foram: caracterizar a gravidade das vítimas de acidentes de transporte que foram atendidas em uma unidade de Centro Cirúrgico de um Hospital de referência no atendimento ao trauma no Município de São Paulo; caracterizar a amostra do estudo quanto aos dados sociodemográficos, tipo de colisão e atendimento pré-hospitalar; descrever a gravidade da lesão, segundo a região corpórea pelo score AIS e MAIS; descrever a gravidade global das vítimas, segundo o score ISS; caracterizar as condições clínicas das vítimas nos períodos pré, trans e pós-operatórios, verificar a relação existente entre os dados sociodemográficos, tipo de colisão, atendimento pré-hospitalar, os escores AIS, MAIS, ISS, as características clínicas e a ocorrência de óbito e sequela. Trata-se de uma pesquisa exploratória, descritiva, retrospectiva, de abordagem quantitativa, realizada por meio da análise retrospectiva dos prontuários de todos os pacientes vítimas de acidente de trânsito que foram admitidos no Centro Cirúrgico do ICHC-FMUSP no período de 1 de janeiro a 31 de dezembro de 2008. Concluiu-se estatisticamente que, os pacientes de maior gravidade cirúrgica, eram jovens, vítimas de acidente motociclístico ou pedestres, que chegaram à instituição, utilizando-se de dispositivos para a permeabilidade das vias aéreas (máscara de oxigênio ou cânula de intubação orotraqueal), com sinais vitais instáveis, que apresentavam lesões de abdome e conteúdo pélvico ou de extremidades e cintura pélvica, como fraturas, grandes hemorragias ou lesões abdominais. Eram também os que seriam submetidos em sua maioria, à cirurgia geral e cirurgia ortopédica, procedimentos de grande porte com grande probabilidade de gerarem algum tipo de sequela temporária ou permanente. Em razão dessa gravidade, há necessidade de infusão de volume seja hemoconcentrado, hemoderivado ou solução coloide, objetivando sempre a manutenção da homeostase, primordial para a manutenção da boa condição clínica desses pacientes. A pesquisa indicou que os pacientes que chegaram com maior gravidade à unidade de Centro Cirúrgico, têm maior risco de óbito ou sequela. / Trauma is now considered an epidemic of the century, representing the leading cause of death in the first four decades of life. In the current study, were considered for analysis the victims of injuries from traffic accidents by considering the relevance of the theme in the health service nationally and internationally. The aim of this study was to characterize the severity of traffic accident victims who were treated in Surgical Ward of a referral hospital in trauma care in São Paulo. The study sample was characterized by using demographic data; type of collision and use of pre-hospital service; severity of injury according to the body region using AIS and MAIS score; overall severity of the victims using ISS score; clinical condition of the victims before, during and after surgery; and the relationship between demographic data; type of collision and use of pre-hospital service; the AIS, MAIS and ISS score; the clinical features and occurrence of death and disability. This is an exploratory, descriptive, retrospective, quantitative approach study, carried out by retrospective chart review of all patients victims of traffic accidents who were admitted to the Surgical Ward of ICHC-FMUSP during the period January 1st to December 31th, 2008. It was concluded that statistically patients with more severe surgery were young, victims of motorcycle accidents or pedestrians, who came to the institution, using devices for airway permeability (oxygen mask or orotracheal tube) with unstable vital signs, patients with abdomen and pelvic contents lesions or extremities and pelvis lesions such as fractures, abdominal injuries or major bleeding. They were also to be submitted in most cases to general surgery and orthopedic surgery, major procedures most likely to generate some kind of temporary or permanent disability. Because of this seriousness, volume infusion were needed using blood product or colloid solutions aiming always to maintain homeostasis, essential for maintaining good clinical condition of these patients. The survey indicated that patients who arrived at the Surgical Ward with greater gravity have a higher risk of death or disability.

Objetivos: Descrever o comportamento da Doença Meningocócica (DM) focalizando aspectos clínicos e seus desfechos, analisar o possível impacto da descentralização da assistência hospitalar, investigando também fatores associados à sua gravidade no município de São Paulo (SP), de 1986 a 2004. Metodologia: Trata-se de um estudo de corte transversal com componente descritivo e analítico, abrangendo o período de 1986 a 2004. A população de estudo abrange pacientes de DM, residentes no município de SP, notificados à vigilância. Os dados foram obtidos junto à vigilância passiva da DM e ao Instituto Adolfo Lutz de São Paulo. A descrição da doença foi efetuada segundo aspectos relativos ao tempo, espaço e pessoa. Para a investigação dos fatores associados à gravidade da DM tomou-se como variável dependente o óbito por DM e como variável independente, as exposições de interesse. Elas foram investigadas por meio das estimativas das odds ratio não ajustadas e ajustadas pela regressão logística não condicional, com os respectivos intervalos de confiança de 95 por cento. Resultados: Foram confirmados 10.087 casos de DM no município de São Paulo, durante o período de interesse. No pico epidêmico de 1995, a taxa de incidência média da DM foi de 8,1 casos/100.000 habitantes (hab), a mortalidade de 1,8 casos/hab/ano e letalidade média de 22 por cento. Crianças menores de quatro anos foram as mais atingidas, constituindo 54 por cento dos casos, principalmente entre os menores de um ano, com taxa de incidência média de 60,1/100000 casos/hab. Em 1986, o Hospital Especializado atendia 83 por cento dos casos e os Assistenciais apenas 12 por cento. No final do período estudado (2004), com a descentralização do serviço, o Hospital Especializado passou a atendeu 22 por cento dos casos e 71 por cento dos casos os Assistenciais. O Hospital Especializado manteve a letalidade anual dos casos de DM constante durante todo período, em torno de 11 por cento. A letalidade 15 dos Hospitais Assistenciais foi diminuindo gradativamente ao longo do período, inicialmente com 60 por cento e terminando com 16 por cento. Conclusão: A identificação de fatores associados à gravidade da DM e a repercussão da assistência hospital podem contribuir na melhoria das condutas clínicas, e subsidiar políticas públicas e intervenções de saúde pública / Objectives: To describe the behavior of meningococcal disease (MD) focusing on clinical features and outcomes, analyze the potential impacts of decentralization of hospital care, also investigating factors associated with the severity of MD in São Paulo (SP) city, from 1986 to 2004. Methods: This is a cross-sectional study with descriptive and analytical component covering the period 1986 to 2004. The population of the study was inhabitants in SP city, registered in the surveillance system. The data were obtained from the surveillance system of the DM MD and the Adolfo Lutz Institute of São Paulo. The descriptive analysis was presented by aspects of the time, space and person. The investigation of factors associated with the severity of the MD, it was considered as dependent variable death, and as independent variable, the exposure of interest. They were investigated by unadjusted and adjusted odds ratios by unconditional logistic regression, with their confidence intervals of 95 per cent. Results: There were 10,087 confirmed cases of MD in SP city, from 1986 to 2004. In epidemic peak (1995), the average rate of incidence of MD was 8.1 cases/100000 inhabitants (inhabit), the mortality rate was 1.8 cases/inhab/year and average case fatality rate (CFR) was of 22 per cent. Children under four years were the highest risk, representing 54 per cent of cases, especially among children under one year with average incidence rate of 60.1/100000 cases/inhab. In 1986, the specialized hospital cared 83 per cent of cases and non-specialized hospital only 12 per cent. At the end of the period studied (2004), with the decentralization of service, the specialized hospital has attended 22 per cent and 71 per cent of cases by the non-specialized. The referential hospital represented an annual CFR of MD constant in over time, around 11 per cent. The CFR of non-specialized hospital has been decreasing gradually 17 over the period, initially with 60 per cent and ending with 16 per cent. Conclusion: The identification of factors associated with the severity of DM and the impact of decentralization of the hospitals care can help in improving the clinical procedures, and support public policies and public health interventions