Introduction

RESEARCH-TREAT-TBI will build up the knowledge base in the strategically important area of public health systems. In conformity with the call text, the research will focus on a specific health problem resulting from the war in the Balkan region: higher incidences of Traumatic Brain Injury victims. More specifically, it aims at the increased understanding of the post-conflict and post-trauma health problems, and will lead to the development of more effective treatment.

The project will contribute to the re-integration of the region. The project will encourage intensive networking among centers in 3 Balkan countries. Reference centers in the 3 Balkan countries dealing with Traumatic Brain Injuries, will meet each year at 4-day workshops to review and analyze results. The RESEARCH TREAT TBI website will include a blackboard for posting any notices, plus there will be chapter on the site unto which the latest scientific developments and links to relevant sites will be installed. The fourth 4-day workshop will take place in a EU member state.

Through the implementation of standard state-of-the-art methodologies, participating hospitals will be using standardized measures and disease classifications, facilitating present as well as future research. Post impact occurrences, so-called SBI - secondary brain injuries, have been shown to be a major cause of death or permanent disability. In hospitals where the guidelines have been implemented, significant reductions in mortality and disability have occurred. Best clinical practice involves all health workers, as the complex treatment system itself can be the cause of significant harm. RESEARCH-TREAT-TBI will uncover the factors leading to inequalities in treatments. An integral aim in all objectives of RESEARCH-TREAT-TBI is the improvement in preventative activities in health services.

The 'consumer' of public health policy - each tax-paying individual, deserves, and RESEARCH-TREAT-TBI will promote, timely and appropriate care. There is a moral imperative to save lives and reduce disability among victims to the minimum - the needs of the consumer of public services are paramount. Studies suggest that the tax burden on the consumer could be significantly reduced.

BALKANS

Number of death from injuries in the Balkan region as reported by WHO in 1998 is very high. Injuries rank number one, number two and number three killer in young population of the region (ages 5 to 44).

Leading Causes of Death, Both Sexes, 1998 (WHO)

Implementation of the Guidelines and the reduction of medical errors and omissions in the care of TBI patients would save approximately 50% of current deaths each year in the region and thousands more would be spared lifetime disabilities. Economically, the potential for savings on acute and long-term TBI care could run millions EUROs annually.

There is growing evidence of a strong negative relationship between economic development and exposure-adjusted traffic-related death rates . Cross-sectional data on road traffic-related deaths in 1990 were obtained from 83 countries. The former socialist East European countries had the highest road traffic-related mortality rates. The gross national product (GNP) per capita was positively correlated with traffic-related mortality/100,000 population/year (p = 0.01), but negatively correlated with traffic deaths/1000 registered vehicles (p < 0.0001). Increasing population density was associated with a proportionately greater number of traffic-related deaths in the young and the elderly (p = 0.036). Increasing GNP per capita and increased proportional spending on health care were associated with decreasing case-fatality rates among traffic-accident victims (p = 0.02 and 0.017, respectively). Middle-income countries appear to have, on average, the largest road-traffic mortality burden. After adjusting for motor vehicle numbers, however, the poorest countries show the highest road traffic-related mortality rates. Many industrialized countries would appear to have introduced interventions that reduce the incidence of road traffic injury and improve the survival rates of those injured. A major public health challenge is to utilize the experience of Western European nations to avoid the predicted increase in mortality in countries applying for EU membership.

The mortality rate of Traumatic Brain Injury patients in Eastern Europe is about 45 percent. The appropriate management of post-impact patients can significantly reduce the number of preventable deaths and limit the severity of Secondary Brain Insults. Due to the lack of rigorous evidence in treatment of Traumatic Brain Injury patients, hard evidence is lacking. What the true cost to society is at present unknown. Numerous studies of avoidable trauma deaths have suggested that in both the pre-hospital and hospital phases, a proportion of blunt road trauma deaths could be avoided with optimal care.

HEAD INJURY: "THE SILENT EPIDEMIC"

Until the last decade, most individuals who sustained severe head injuries died. Advances in trauma care and medical technology have resulted in significantly improved survival rates and improvements in the quality of patient outcomes (lower disability, lower brain damage). Many survivors have severe deficits. Mortality and the extent of disability have wide implications. Friends and family members must cope with a wide range of cognitive, behavioral, and emotional deficits. Mentally or physically disabled individuals incur high costs in qualitative as well as quantitative terms for immediate relatives, surroundings, and society as a whole. Of course, a very high psychic price is paid by the victim of a severe brain injury. It is imperative for health care consumers (everyone) to pay attention to the quality of care and the management of Traumatic Brain Injury patients (potentially everyone).

Worldwide in 1990 , about 5 million people died of injuries of all types, two-thirds of them men. Most of these deaths are heavily concentrated among young adults. In the 15-44 age group, road traffic accidents, suicide, war, fire and violence all figured within the ten leading causes of death. The significance of injuries has been largely overlooked by the health sector in many countries. Among adults aged 15-44 worldwide, road traffic accidents were the leading cause of death for men and the fifth most important for women. The burden of injury in 1990 was highest in the Formerly Socialist Economies of Europe, where almost 19 per cent of all burden was attributed to this group of causes. Even in the Established Market Economies, however, the burden of injuries-dominated by road traffic accidents-was almost 12 per cent of the burden.

Head injury is often referred to as "The Silent Epidemic". The annual incidence rate of hospital-referred head injury in one European country was 229/100,000 population with a male preponderance of 1.7:1.0. Causes were falls in 62%, traffic accident in 21%, and assault in 7% of the cases. In a 1998 World Health Organization paper, on a scale for Disability Adjusted Life Years, 16% is attributable to injuries; 12% to Neuropsychiatric conditions; 10% to Cardiovascular diseases; 6% to Cancer; and 56% to Other Diseases.

Trauma is the commonest cause of hospital admission in children. Head injuries are present in 75% of children with trauma and 70% of all traumatic deaths are due to the head injury . Often overlooked is the fact that brain damage or physical disability results from secondary ischaemic damage. Therapeutic interventions such as institution of adequate oxygen delivery and haemodynamic stability in the child at the earliest moment remains the most important intervention, and can significantly influence the outcome. Sharples et al examined the prevalence of avoidable complications contributing to the death of children with head injuries . For children who died in hospital there was a high prevalence of potentially avoidable factors, including delayed diagnosis of intracranial hemorrhage and intra-abdominal injury, inadequate airway management, and poor management of transfers between hospitals. The observed improvements in survival (in the UK) are attributed to better initial assessment and resuscitation in hospital and the provision of integrated management from the scene of the incident through to intensive care and definitive surgery.

There is little doubt that the combination of early surgery and good intensive care can result in a 10-20% improvement in outcome in severe head injury . However, variations in care were observed at centers regarded as representing best clinical practice in a recent survey in the UK. According to the authors, this has important implications. These variations are surprising due to the fact that there is no lack of consensus among experts in the specialty. Many studies have demonstrated the need to monitor and control intracranial and cerebral perfusion pressures in patients with severe head injury - there is a need to produce nationally accepted guidelines on minimum standards of care for patients with severe head injury . Such guidelines would also address the issues of referral from receiving hospitals and the necessary levels of care in neurosurgical units for individual patients, depending on the severity of their head injury. As it has been recently pointed out by Ghajar "the decrease in mortality and improved outcome for patients with severe traumatic brain injury over the past 25 years can be attributed to the approach of squeezing oxygenated blood through a swollen brain and quantification of cerebral perfusion by monitoring of intracranial pressure and treatment of cerebral hypoperfusion decrease secondary injury".

However, the aspects of intensive care found to be variable in the survey quoted in the above paragraph, have been subjected to rigorous analysis by a task force of the American Association of Neurological Surgeons and Joint Section in Neurotrauma and Critical Care, with support from the Brain Trauma Foundation. After consultation with the European Brain Injury Consortium (EBIC), however, Scientific Evidence Based Guidelines for the treatment of Traumatic Brain Injury patients and options for practice have already been formulated. The European Brain Injury Consortium paper points to the need for national guidelines to be produced as a basis for the formulation of local protocols. Without such guidelines, wide variations in approach are likely to continue.