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Introduction: Readmissions after a traumatic brain injury (TBI) can have severe impacts on long-term health outcomes as well as rehabilitation. The aim of this descriptive study was to analyze the Nationwide Readmissions Database to determine possible risk factors associated with readmission for patients who previously sustained a TBI., Methods: This retrospective study used data from the Nationwide Readmissions Database to explore gender, age, injury severity score, comorbidities, index admission hospital size, discharge disposition of the patient, and cause for readmission for adults admitted with a TBI. Multivariable logistic regression was used to assess likelihood of readmission., Results: There was a readmission rate of 28.7% (n = 31,757) among the study population. The primary cause of readmission was either subsequent injury or sequelae of the original injury (n = 8825; 29%) followed by circulatory (n = 5894; 19%) and nervous system issues (n = 2904; 9%). There was a significantly higher risk of being readmitted in males (Female odds ratio: 0.87; confidence interval [0.851-0.922), older patients (65-79: 32.3%; > 80: 37.1%), patients with three or more comorbidities (≥ 3: 32.9%), or in patients discharged to a skilled nursing facility/intermediate care facility/rehab (SNF/ICF/Rehab odds ratio: 1.55; confidence interval [0.234-0.262])., Conclusions: This study demonstrates a large proportion of patients are readmitted after sustaining a TBI. A significant number of patients are readmitted for subsequent injuries, circulatory issues, nervous system problems, and infections. Although readmissions cannot be completely avoided, defining at-risk populations is the first step of understanding how to reduce readmissions., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Calcium is required for coagulation, cardiac output, and peripheral vascular resistance. Between 85% and 94% of trauma patients treated with massive blood transfusion develop hypocalcemia. 1 The aim of this study is to evaluate the relationship between increased intravenous calcium administration during massive transfusion and improved survival of trauma patients., Methods: We performed a retrospective analysis of trauma patients who received massive transfusion over a 2-y period. Doses of elemental calcium administered per unit of blood product transfused were calculated by calcium to blood product ratio (CBR). Chi-square test evaluated association between coagulopathy and 30-d mortality. Two-sample t-test evaluated association between CBR and coagulopathy. Bivariate regression analysis evaluated association between CBR and blood products transfused per patient. Multivariable logistic regression analysis, controlling for age, sex, coagulopathy, and Injury Severity Score evaluated the association between CBR and mortality., Results: The study included 77 patients. Coagulopathy was associated with increased 30-d mortality (P < 0.05). Patients who survived had higher CBR than those who died (P < 0.05). CBR was associated with a significant reduction in total blood products transfused per patient (P < 0.05). CBR was not associated with coagulopathy (P = 0.24). Multivariable logistic regression analysis demonstrated that Injury Severity Score ≥16, coagulopathy and decreased CBR were significant predictors of mortality (P < 0.05). CBR above 50 mg was a predictor of survival (P < 0.05)., Conclusions: Higher doses of calcium given per blood product transfused were associated with improved 30-d survival and decreased blood product transfusions., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Traumatic injury is a leading cause of death and disability among US workers. Severe injuries are less subject to systematic ascertainment bias related to factors such as reporting barriers, inpatient admission criteria, and workers' compensation coverage. A state-based occupational health indicator (OHI #22) was initiated in 2012 to track work-related severe traumatic injury hospitalizations. After 2015, OHI #22 was reformulated to account for the transition from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. This study describes rates and trends in OHI #22, alongside corresponding metrics for all work-related hospitalizations., Methods: Seventeen states used hospital discharge data to calculate estimates for calendar years 2012-2019. State-panel fixed-effects regression was used to model linear trends in annual work-related hospitalization rates, OHI #22 rates, and the proportion of work-related hospitalizations resulting from severe injuries. Models included calendar year and pre- to post-ICD-10-CM transition., Results: Work-related hospitalization rates showed a decreasing monotonic trend, with no significant change associated with the ICD-10-CM transition. In contrast, OHI #22 rates showed a monotonic increasing trend from 2012 to 2014, then a significant 50% drop, returning to a near-monotonic increasing trend from 2016 to 2019. On average, OHI #22 accounted for 12.9% of work-related hospitalizations before the ICD-10-CM transition, versus 9.1% post-transition., Conclusions: Although hospital discharge data suggest decreasing work-related hospitalizations over time, work-related severe traumatic injury hospitalizations are apparently increasing. OHI #22 contributes meaningfully to state occupational health surveillance efforts by reducing the impact of factors that differentially obscure minor injuries; however, OHI #22 trend estimates must account for the ICD-10-CM transition-associated structural break in 2015., (© 2023 Wiley Periodicals LLC.)

Introduction: The Arkansas Trauma System was established by law more than a dozen years ago, and all participating trauma centers are required to maintain red blood cells. Since then, there has been a paradigm shift in resuscitating exsanguinating trauma patients. Damage Control Resuscitation with balanced blood products (or whole blood) and minimal crystalloid is now the standard of care. This project aimed to determine access to balanced blood products in our state's Trauma System (TS)., Methods: A survey of all trauma centers in the Arkansas TS was conducted, and geospatial analysis was performed. Immediately Available Balanced Blood (IABB) was defined as at least 2 units (U) of thawed plasma (TP) or never frozen plasma (NFP), 4 units of red blood cells (RBCs), 2 units of fresh frozen plasma (FFP), and 1 unit of platelets or 2 units of whole blood (WB)., Results: All 64 trauma centers in the state TS completed the survey. All level I, II, and III Trauma Centers (TCs) maintain RBC, plasma, and platelets, but only half of the level II and 16% of the level III TCs have thawed or never frozen plasma. A third of level IV TCs maintain only RBCs, while only 1 had platelets, and none had thawed plasma. 85% of people in our state are within 30 min of RBCs, almost two-thirds are within 30 min of plasma (TP, NFP, or FFP) and platelets, while only a third are within 30 min of IABB. More than 90% are within an hour of plasma and platelets, while only 60% are within that time from an IABB. The median drive times for Arkansas from RBC, plasma (TP, NFP, or FFP), platelets, and an immediately available and balanced blood bank are 19, 21, 32, and 59 minutes, respectively. A lack of thawed or non-frozen plasma and platelets are the most common limitations of IABB. One level III TC in the state maintains WB, which would alleviate the limited access to IABB., Conclusion: Only 16% of the trauma centers in Arkansas can provide IABB, and only 61% of the population can reach IABB within 60 minutes. Opportunities exist to reduce the time to balanced blood products by selectively distributing WB, TP, or NFP to hospitals in our state trauma system.

Background: While it is assumed adolescents receive comparable trauma care at pediatric trauma centers (PTC), adult trauma centers (ATC), and combined facilities (MTC), this remains understudied., Methods: We conducted a retrospective cohort study through the NTDB evaluating patients 14-18 years of age who presented to an ACS-verified level 1 or 2 trauma facility between 1/1/2016 and 12/31/2019. Multiple logistic regression analyses were performed to compare mortality risk among trauma facility verification types., Results: 91,881 adolescents presented after trauma over the four-years. Hypotension, severe TBI, firearm mechanism, and ISS >15 were associated with increased mortality. Compared to PTCs, the odds of trauma-related mortality were statistically higher at MTCs (OR 1.82, p = 0.004) and ATCs (OR 1.89-2.05, p = 0.001-0.002)., Conclusions: Injured adolescents receiving care at ATCs and MTCs have higher mortality risk than those cared for at PTCs. Further evaluation of factors associated with this observed difference is warranted and may help identify opportunities to improve outcomes in injured adolescents., (Published by Elsevier Inc.)

Background: The SARS-Cov-2 coronavirus has varying clinical effects-from asymptomatic patients to life-threatening illness and death. At the only Level 1 Trauma Center in a rural state, outcomes appeared worse in trauma patients who tested positive for COVID despite these patients presumably being asymptomatic or only mildly affected before their traumatic event. This study compares all trauma admissions that were COVID-positive to those who were not., Methods: The institutional database was queried for all level 1 and 2 trauma activations from March 2020-July 2021. The analysis consisted of a multivariate regression between COVID-negative and the COVID-positive group controlling for age, injury severity score (ISS), and Glasgow Coma Score (GCS). Outcomes compared were hospital length-of-stay (LOS), ICU LOS, ventilator days, days to discharge to a facility, and in-hospital mortality., Results: Hospital LOS was 2.7 days longer in the COVID-positive group ( P < .0005). ICU LOS was 2.9 days longer for patients admitted to the ICU in the COVID positive-group ( P = .017). Ventilator days were 4.7 days longer for patients requiring mechanical ventilation in the COVID-positive group ( P = .002). Discharge to a post-acute facility required 6.1 more days in the COVID-positive group ( P = .005)., Conclusion: Trauma patients presenting positive for COVID-19 are presumed to be asymptomatic before their traumatic event. Despite this, the physiologic toll of trauma combined with the COVID infection causes significantly worse clinical outcomes, including increasing hospital days in this patient population, which continues to tax the already burdened healthcare system.

In trauma care and trauma care research there exists an implementation gap regarding a consistent controlled vocabulary to describe organizational aspects of trauma centers and trauma systems. This paper describes the development and evaluation of a controlled vocabulary for trauma care organizations. We give a detailed description of the involvement of domain experts in the domain analysis workflow and the authoring of definitions and additional term descriptions. Finally, the paper details the evaluation methodology to assess the initial version of the controlled vocabulary. The results of the evaluation show that our development process yields terms most of which find approval from domain experts not involved in the development. In addition, our evaluation tools resulted in valuable domain expert input to optimize the controlled vocabulary.

Objectives: All-terrain vehicle (ATV) crashes have been responsible for significant injuries among children, despite public education efforts. Our study examined pediatric ATV injury patterns in US emergency departments (EDs) compared with injuries after motor vehicle crash (MVC) and sports activities., Methods: We studied 2006 to 2011 data from the Nationwide Emergency Department Sample. Children younger than 18 years and involved in ATV crashes, MVC, or sports activities were included. The primary outcome analyzed was a constructed binary measure identifying severe trauma, defined as injury severity score greater than 15. Logistic regression models were fit to determine the association between mechanism of injury and severe trauma., Results: A total of 6,004,953 ED visits were identified. Of these, ATV crashes accounted for 3.4%, MVC accounted for 44.7%, and sports activities accounted for 51.9%. Emergency department visits after ATV crashes were more likely to result in admission (8%) and incur higher median charges ($1263) compared with visits after sports activities (1%, $1013). Visits after sports activities were 90% less likely to result in severe trauma when compared with ATV crash visits. Emergency department visits after ATV crashes result in severe injuries similar to those sustained in MVC (odds ratio, 1.03; P = 0.626)., Conclusions: Pediatric ED visits after ATV crashes result in significant injuries and charges. Public health interventions such as education, legislation, and engineering are needed to reduce injuries among children and the subsequent ED visits for care. The impact of proven interventions may be greatest for children living in rural areas and among older children, 10 to 17 years old.

Objective: To describe characteristics of industrial injury hospitalizations, and to test the hypothesis that industrial injuries were increasingly billed to non-workers' compensation (WC) payers over time., Data Sources: Hospitalization data for 1998-2009 from State Inpatient Databases, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality., Study Design: Retrospective secondary analyses described the distribution of payer, age, gender, race/ethnicity, and injury severity for injuries identified using industrial place of occurrence codes. Logistic regression models estimated trends in expected payer., Principal Findings: There was a significant increase over time in the odds of an industrial injury not being billed to WC in California and Colorado, but a significant decrease in New York. These states had markedly different WC policy histories. Industrial injuries among older workers were more often billed to a non-WC payer, primarily Medicare., Conclusions: Findings suggest potentially dramatic cost shifting from WC to Medicare. This study adds to limited, but mounting evidence that, in at least some states, the burden on non-WC payers to cover health care for industrial injuries is growing, even while WC-related employer costs are decreasing-an area that warrants further research., (© Health Research and Educational Trust.)

Objectives: Work-related traumatic injury is a leading cause of death and disability among US workers. Occupational injury surveillance is necessary for effective prevention planning and assessing progress toward Healthy People 2020 objectives. Our objectives were to (1) describe the Washington State Trauma Registry (WTR) as a resource for occupational injury surveillance and research, (2) compare the WTR with 2 population-based data sources more widely used for these purposes, and (3) compare the number of injuries ascertained by the WTR with other data sources., Methods: We linked WTR records to hospital discharge records in the Comprehensive Hospital Abstract Reporting System for 2009 and to workers' compensation claims from the Washington State Department of Labor and Industries for 1998 to 2008. We assessed the 3 data sources for overlap, concordance, and case ascertainment., Results: Of 9185 work-related injuries in the WTR, 3380 (37%) did not link to workers' compensation claims. Use of payer information in hospital discharge records along with the WTR work-relatedness field identified 20% more linked injuries as work related (n = 720) than did use of payer information alone (n = 602). The WTR identified substantial numbers of work-related injuries that were not identified through workers' compensation or hospital discharge records., Conclusions: Workers' compensation and hospital discharge databases are important but incomplete data sources for work-related injuries; many work-related injuries are not billed to, reported to, or covered by workers' compensation. Trauma registries are well positioned to capture severe work-related injuries and should be included in comprehensive injury surveillance efforts., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Organizational structures of healthcare organizations has increasingly become a focus of medical research. In the CAFÉ project we aim to provide a web-service enabling ontology-driven comparison of the organizational characteristics of trauma centers and trauma systems. Trauma remains one of the biggest challenges to healthcare systems worldwide. Research has demonstrated that coordinated efforts like trauma systems and trauma centers are key components of addressing this challenge. Evaluation and comparison of these organizations is essential. However, this research challenge is frequently compounded by the lack of a shared terminology and the lack of effective information technology solutions for assessing and comparing these organizations. In this paper we present the Ontology of Organizational Structures of Trauma systems and Trauma centers (OOSTT) that provides the ontological foundation to CAFÉ's web-based questionnaire infrastructure. We present the usage of the ontology in relation to the questionnaire and provide the methods that were used to create the ontology.

Background: Hospital discharge data are used for occupational injury surveillance, but observed hospitalisation trends are affected by trends in healthcare practices and workers' compensation coverage that may increasingly impair ascertainment of minor injuries relative to severe injuries. The objectives of this study were to (1) describe the development of a severe injury definition for surveillance purposes and (2) assess the impact of imposing a severity threshold on estimated occupational and non-occupational injury trends., Methods: Three independent methods were used to estimate injury severity for the severe injury definition. 10 population-based hospital discharge databases were used to estimate trends (1998-2009), including the National Hospital Discharge Survey (NHDS) and State Inpatient Databases (SID) from the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality. Negative binomial regression was used to model injury trends with and without severity restriction and to test trend divergence by severity., Results: Trend estimates for occupational injuries were biased downwards in the absence of severity restriction, more so than for non-occupational injuries. Imposing a severity threshold resulted in a markedly different historical picture., Conclusions: Severity restriction can be used as an injury surveillance methodology to increase the accuracy of trend estimates, which can then be used by occupational health researchers, practitioners and policy-makers to identify prevention opportunities and to support state and national investments in occupational injury prevention efforts. The newly adopted state-based occupational health indicator, 'Work-Related Severe Traumatic Injury Hospitalizations', incorporates a severity threshold that will reduce temporal ascertainment threats to accurate trend estimates., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Purpose: Acute work-related trauma is a leading cause of death and disability among U.S. workers. Existing methods to estimate injury severity have important limitations. This study assessed a severe injury indicator constructed from a list of severe traumatic injury diagnosis codes previously developed for surveillance purposes. Study objectives were to: (1) describe the degree to which the severe injury indicator predicts work disability and medical cost outcomes; (2) assess whether this indicator adequately substitutes for estimating Abbreviated Injury Scale (AIS)-based injury severity from workers' compensation (WC) billing data; and (3) assess concordance between indicators constructed from Washington State Trauma Registry (WTR) and WC data., Methods: WC claims for workers injured in Washington State from 1998 to 2008 were linked to WTR records. Competing risks survival analysis was used to model work disability outcomes. Adjusted total medical costs were modeled using linear regression. Information content of the severe injury indicator and AIS-based injury severity measures were compared using Akaike Information Criterion and R(2)., Results: Of 208,522 eligible WC claims, 5 % were classified as severe. Among WC claims linked to the WTR, there was substantial agreement between WC-based and WTR-based indicators (kappa = 0.75). Information content of the severe injury indicator was similar to some AIS-based measures. The severe injury indicator was a significant predictor of WTR inclusion, early hospitalization, compensated time loss, total permanent disability, and total medical costs., Conclusions: Severe traumatic injuries can be directly identified when diagnosis codes are available. This method provides a simple and transparent alternative to AIS-based injury severity estimation.

Background: Achievement of health equity and elimination of disparities are overarching goals of Healthy People 2020, yet there is a paucity of population-based data regarding race/ethnicity-based disparities in occupational injuries., Methods: Hospital discharge data for five states (Arizona, California, Florida, New Jersey, and New York) were obtained from the Healthcare Cost & Utilization Project (HCUP) for 2003-2009. Age-adjusted rates and trends for work-related injury hospitalizations were calculated using negative binomial regression (reference category: non-Latino white)., Results: Latinos were significantly more likely to have a work-related traumatic injury hospitalization. The disparity for Latinos was greatest for machinery-related hospitalizations. Latinos were also more likely to have a fall-related hospitalization. African-Americans were more likely to have an occupational assault-related hospitalization, but less likely to have a fall-related hospitalization., Conclusions: We found evidence of substantial multistate disparities in occupational injury-related hospitalizations. Enhanced surveillance and further research are needed to identify and address underlying causes., (© 2015 Wiley Periodicals, Inc.)

Objective: The suitability of the Washington State Trauma Registry (WTR) for occupational injury surveillance was assessed via comparing estimated rates and trends with those derived from state hospital discharge data., Methods: Descriptive methods and negative binomial regression were used to model occupational injury trends (1998 to 2009)., Results: Nonlinear trends based on WTR data closely tracked those based on hospital discharge data, beginning about 2002. Rate estimates differed somewhat by data source and were most similar when a severity threshold was applied. Conclusions regarding temporal trends in work-related injury rates were the same using either data source., Conclusions: This study found substantial similarity between occupational injury trends estimated using either WTR or hospital discharge data. We conclude that a mature state trauma registry with mandatory reporting requirements can be used for surveillance of severe work-related traumatic injuries.

Objective: Occupational injury researchers typically use payer to identify work-related injuries in hospital discharge records. Many trauma registries contain a work-related field, independent of payer. Linked trauma registry and hospital discharge records were used to assess data field concordance and to assess the validity of using payer or external cause of injury (E-codes) to identify work-related injuries., Methods: Washington State Trauma Registry records were linked to hospital discharges (year 2009)., Results: There was substantial agreement between Washington State Trauma Registry and hospital discharge records for workers' compensation as primary payer. E-code based methods of identifying occupational injuries had high specificity (more than 99%) but low sensitivity (less than 14%). Payer was 76% sensitive and 98% specific., Conclusions: This study found substantial agreement for data fields key to occupational injury surveillance and research. Nevertheless, many work-related injuries could not be identified using hospital discharge records.

Background: Hospitalization-based estimates of trends in injury incidence are also affected by trends in health care practices and payer coverage that may differentially impact minor injuries. This study assessed whether implementing a severity threshold would improve occupational injury surveillance., Methods: Hospital discharge data from four states and a national survey were used to identify traumatic injuries (1998-2009). Negative binomial regression was used to model injury trends with/without severity restriction, and to test trend divergence by severity., Results: Trend estimates were generally biased downward in the absence of severity restriction, more so for occupational than non-occupational injuries. Restriction to severe injuries provided a markedly different overall picture of trends., Conclusions: Severity restriction may improve occupational injury trend estimates by reducing temporal biases such as increasingly restrictive hospital admission practices, constricting workers' compensation coverage, and decreasing identification/reporting of minor work-related injuries. Injury severity measures should be developed for occupational injury surveillance systems., (© 2014 Wiley Periodicals, Inc.)

Background: Acute work-related trauma is a leading cause of death and disability for U.S. workers but it is difficult to obtain information about injured workers not covered by workers' compensation (WC). This study aimed to: (1) describe trends in expected payer and linkage to WC claims, (2) compare characteristics of injured workers who did and did not have a linked WC claim, and (3) describe variation in expected payer and linkage to WC claims by ethnicity and injury severity., Methods: Data for injuries occurring from 1998 through 2008 were obtained from the Washington State Trauma Registry and linked to WC claims., Results: We found that 27% of work-related traumatic injuries did not have WC listed as a payer, while 37% did not link to a WC claim. Among those with WC listed as a payer, the odds of having a linked WC claim were 57% lower for workers with other non-WC insurance compared with the otherwise uninsured. Latinos were more likely to have a linked WC claim compared with non-Latinos, but there was no significant difference after partially controlling for WC-covered employment and other insurance., Conclusions: This study demonstrated the importance of considering differential access to other insurance coverage and adaptation by health care settings to financial pressures when assessing trends in occupational injury incidence and reporting, especially when using WC as a proxy for work-relatedness. The addition of occupation, industry, and work status to trauma registries and hospital discharge databases would improve surveillance, research, policy and prevention efforts., (Copyright © 2013 Wiley Periodicals, Inc.)

Purpose: Acute work-related trauma is a leading cause of death and disability among US workers. The research objectives were to assess: (1) the feasibility of estimating Abbreviated Injury Scale-based injury severity scores (ISS) from ICD-9-CM codes available in workers' compensation (WC) medical billing data, (2) whether ISS predicts work-related disability and medical cost outcomes, (3) whether ISS adds value over other injury severity proxies, and (4) whether the utility of ISS differs for an all-injury sample compared with three specific injury samples (amputations, extremity fractures, traumatic brain injury)., Methods: ISS was estimated from ICD-9-CM codes using Stata's user-written -icdpic- program for 208,522 compensable nonfatal WC claims for workers injured in Washington State from 1998 to 2008. The Akaike Information Criterion and R(2) were used to compare severity measures. Competing risks survival analysis was used to evaluate work disability outcomes. Adjusted total medical costs were modeled using linear regression., Results: Work disability and medical costs increased monotonically with injury severity. For a subset of 4,301 claims linked to the Washington State Trauma Registry (WTR), there was moderate agreement between WC-based ISS and WTR-based ISS. Including ISS together with an early hospitalization indicator resulted in the most informative models; however, early hospitalization is a more downstream measure., Conclusions: ISS was significantly associated with work disability and medical cost outcomes for work-related injuries. Injury severity should be considered as a potential confounder for occupational injury intervention, program evaluation, or outcome studies, and can be estimated using existing software when ICD-9-CM codes are available.

Objective: Disproportionate occupational injury rates for Latinos are well documented, but there is limited information about whether disparity is increasing over time. This study describes trends in the burden of work-related traumatic injuries sustained by Latinos in Washington State., Methods: Washington State Trauma Registry data from 1998 to 2008 were used to model annual change in the odds that a work-related traumatic injury was sustained by a Latino, controlling for demographics, injury-related factors, and Latino representation in the underlying labor force., Results: We found a 5% mean annual increase in the odds that a comparable work-related traumatic injury was sustained by a Latino (P = 0.007). Falls in industrial/mine/quarry locations were the strongest contributor to increasing disparity., Conclusions: Latinos bear an increasingly disproportionate burden of occupational injuries and are less likely to have health insurance coverage aside from workers' compensation.

Objective: Many state trauma registries contain work-related information but are underutilized for occupational injury research/surveillance. We assessed three methods of identifying work-related injuries in the Washington State Trauma Registry (WTR)., Methods: State-designated trauma facilities report traumatic injuries meeting specific inclusion criteria to the WTR. The WTR reports from 1998 to 2008 were linked to workers' compensation claims to generate sensitivity estimates., Results: The sensitivity of the WTR work-related indicator was 87%, varying significantly by injury mechanism/location. Sensitivity was 89% for payer and 60% for an indicator based on International Classification of Diseases-9th Revision-Clinical Modification external cause codes., Conclusions: The WTR work-related indicator is highly sensitive and may identify injuries that occur in the course of exempt/excluded employment, are not reported to workers' compensation, and/or are work-related using definitions that go beyond WC coverage. Judicious use of external cause codes may identify additional work-related injuries.

Objectives: Given that the news media shape our understanding of health issues, a study was undertaken to examine the use by the US media of the expression 'freak accident' in relation to injury events. This analysis is intended to contribute to the ongoing consideration of lay conceptualisation of injuries as 'accidents'., Methods: LexisNexis Academic was used to search three purposively selected US news sources (Associated Press, New York Times and Philadelphia Inquirer) for the expression 'freak accident' over 5 years (2005-9). Textual analysis included both structured and open coding. Coding included measures for who used the expression within the story, the nature of the injury event and the injured person(s) being reported upon, incorporation of prevention information within the story and finally a phenomenological consideration of the uses and meanings of the expression within the story context. Results The search yielded a dataset of 250 human injury stories incorporating the term 'freak accident'. Injuries sustained by professional athletes dominated coverage (61%). Fewer than 10% of stories provided a clear and explicit injury prevention message. Stories in which journalists employed the expression 'freak accident' were less likely to include prevention information than stories in which the expression was used by people quoted in the story., Conclusions: Journalists who frame injury events as freak accidents may be an appropriate focus for advocacy efforts. Effective prevention messages should be developed and disseminated to accompany injury reporting in order to educate and protect the public.

To identify age and gender differences among teen drivers in fatal crashes, we analyzed FARS data for 14,026crashes during 2007-2009. Compared with female teenagers, crashes of male teenagers were significantly more likely to involve BACs of 0.08% or more (21% vs. 12%), speeding (38% vs. 25%), reckless driving (17% vs. 14%), night driving (41% vs. 36%) and felony crashes (hit-and-run, homicide, or manslaughter) (8% vs. 6%) (all χ(2) p<0.001). Conversely, crashes of female teenagers were more likely to involve right angle ("t-bone") crashes (23% vs. 17%). Some crash characteristics associated with males and known to play a major role in crash causation also are more common in the youngest teenagers; for example, crashes of drivers age 15 or 16 were more likely than crashes of older teens to involve speeding or reckless driving. Crashes of drivers with BACs of 0.08% or higher increased with age in both genders. Some age effects differed by gender: for example, the proportion of crashes of female teens that involved speeding dropped from 38% to 22% between ages 15 and 19, while for males about 38% of crashes at each age involved speeding. The gender and age differences observed in teen drivers suggest opportunities for targeted driver training - for example, simulator training modules specifically tailored for male or female teenagers. Technology-based tools could also be developed to help parents to focus on the reckless driving tendencies of their sons. Insurance companies should consider ways to incentivize young males to drive more responsibly.

Objective: Traumatic injuries are a leading cause of death and disability among US workers, yet state trauma registries are rarely used for occupational research. Many, including the Washington State Trauma Registry, include information about work-relatedness. The objective is to explore and document the Washington State Trauma Registry as a resource for occupational injury surveillance and research., Methods: State-designated trauma facilities report traumatic injuries meeting specific inclusion criteria to the Washington State Trauma Registry. This study included 16+ year-olds injured in Washington during 1998 to 2008., Results: Of 125,625 injuries, 7.3% were work related. We found no evidence of downward trends in traumatic occupational injuries (2003 to 2008)., Conclusions: Capturing industry and occupation would enhance utility for occupational injury surveillance and research. Trauma registry data could contribute to prevention planning/evaluation, improve case ascertainment for severe occupational injuries, and aid identification of high-risk populations and emerging trends.

Background: In the United States, burns are the third leading cause of unintentional injury death in children aged 1-14 years, accounting for more than 600 deaths per year in children aged 0-19 years., Objective: To describe trends in paediatric burn hospitalisations in the United States and provide national benchmarks for state and regional comparisons., Methods: Analysis of existing data (1993-2006) from the Nationwide Inpatient Sample-the largest, longitudinal, all-payer inpatient care database in the United States. Children aged 0-19 years were included., Main Outcome Measures: Estimated national annual rates of burn-related hospitalisations, stratified by age, gender, and in-hospital mortality., Results: From 1993 to 2006, the estimated annual incidence rate of paediatric hospitalisations associated with burns declined 40% from 27.3 (1993-94) to 16.1 per 100,000 (p<0.001). The rates declined for all age groups and for both boys and girls. Boys were consistently more likely to be hospitalised than girls (20.3 vs 11.7 hospitalisations per 100,000 during 2004-06, p<0.001). For children less than 5 years of age, burn hospitalisations decreased 46% from 65.2 per 100,000 in 1993-94 to 35.1 per 100,000 in 2004-06 (p<0.001). Fatal hospitalisation rates also declined from 0.3 deaths per 100,000 in 1993-94 to 0.1 in 2004-06 (p<0.001)., Conclusion: Paediatric hospitalisation rates for burns have decreased over the past 14 years. The study also provides national estimates of paediatric burn hospitalisations that can be used as benchmarks to further injury prevention effectiveness through targeting of effective strategies.

Background: Although nonoperative management is the standard of care for hemodynamically stable children with blunt splenic trauma, significant variation in practice exists. Little attention has been given to physician factors associated with management differences., Design: Nationally representative mail survey conducted in June 2008., Setting: United States., Participants: Ten percent random sample of active, dues-paying fellows in the American College of Surgeons., Main Outcome Measures: Knowledge, attitudes, and beliefs toward pediatric splenic injury management, including the role of clinical practice guidelines., Results: Almost all of the 375 responding surgeons (97.4%) agreed that surgical intervention is not immediately necessary for hemodynamically stable children. However, surgeons reported significant disagreement regarding whether blood should be administered before operative intervention for hemodynamically unstable children and whether explorative surgery is needed for stable patients with evidence of contrast extravasation on computed tomography. Only 18.7% of surgeons reported being very familiar with the clinical practice guidelines for the management of pediatric blunt splenic trauma from either the Eastern Association for the Surgery of Trauma or the American Pediatric Surgical Association. Surgeons who were very familiar with either guideline were significantly more likely to rate the guidelines as beneficial (90.0% vs 72.8%, P = .002)., Conclusions: General surgeons reported varying degrees of familiarity with and use of clinical practice guidelines for pediatric splenic injury management. Limited pediatric experience and lack of pediatric hospital resources may limit more widespread adoption of nonoperative management. Targeted educational interventions may help increase surgeon knowledge of guidelines and best practices.

Uncuffed endotracheal tubes traditionally have been preferred over cuffed endotracheal tubes in young pediatric patients. However, recent evidence in elective pediatric surgical populations suggests otherwise. Because young pediatric burn patients can pose unique airway and ventilation challenges, we reviewed adverse events associated with the perioperative use of cuffed and uncuffed endotracheal tubes. We retrospectively reviewed 327 cases of operating room endotracheal intubation for general anesthesia in burned children 0-10 years of age over a 10-year period. Clinical airway outcomes were compared using multivariable logistic regression, controlling for relevant patient and injury characteristics. Compared to those receiving cuffed tubes, children receiving uncuffed tubes were significantly more likely to demonstrate clinically significant loss of tidal volume (odds ratio 10.62, 95% confidence interval 2.2-50.5) and require immediate reintubation to change tube size/type (odds ratio 5.54, 95% confidence interval 2.1-13.6). No significant differences were noted for rates of post-extubation stridor. Our data suggest that operating room use of uncuffed endotracheal tubes in such patients is associated with increased rates of tidal volume loss and reintubation. Due to the frequent challenge of airway management in this population, strategies should emphasize cuffed endotracheal tube use that is associated with lower rates of airway manipulation., (2009 Elsevier Ltd and ISBI. All rights reserved.)

Purpose: Controlling for injury and patient characteristics, one would expect comparable in-hospital outcomes for injured patients with and without epilepsy. The historical stigma associated with epilepsy is well-documented, yet potential disparities in injury care for people with epilepsy/seizures have not been examined. We compared in-hospital outcomes of injured patients with epilepsy/seizures with patients without epilepsy/seizures and tested the hypothesis that injured people with epilepsy have worse outcomes., Methods: Existing data were analyzed from the Nationwide Inpatient Sample-the largest, longitudinal, all-payer inpatient care database in the United States. Injured patients of all ages were included. Multivariable logistic regression was used to control for patient and hospital characteristics., Main Outcome Measure: In-hospital mortality., Results: When controlling for patient and injury characteristics, our results show that people with epilepsy/seizures were more likely to die in-hospital than people without epilepsy [odds ratio (OR) 1.17, p < 0.001]. People with epilepsy were significantly more likely to have a traumatic brain injury diagnosis than similar individuals without epilepsy (unintentional injuries OR 2.81, p < 0.001; interpersonal violence OR 6.0, p < 0.001). By mechanism of injury, significantly increased risk of death was observed for injuries from falls (OR 1.21, p < 0.001), other transport injuries (OR 2.04, p = 0.01), struck by/against (OR 1.85, p = 0.02), and suffocation (OR 10.93, p = 0.009). People with epilepsy/seizures receiving firearm injuries were less likely to die in-hospital (OR 0.25, p < 0.001)., Discussion: Disparities in hospital outcomes for people with epilepsy deserve further attention. Identifying the underlying causes of these disparities will allow for the development of targeted prevention interventions.

Objective: Wide variation has been reported in the proportion of injury deaths occurring during the prehospital phase. Potential disparities in where injured people with epilepsy and seizure disorders die have not been examined. We compared location of death between injured patients with epilepsy and seizure disorders and similar patients without epilepsy/seizures and tested the hypothesis that injured people with epilepsy/seizures are more likely to die outside of a hospital or health care setting., Methods: U.S. vital statistics (mortality) data from the multiple cause of death files of the National Center for Health Statistics were analyzed. Patients less than 65 years of age at death who had injury as the underlying cause of death were included. Multinomial logistic regression was used to assess location of death, controlling for patient and injury characteristics., Results: Controlling for potential confounders, people with epilepsy/seizures were more likely to die at home from unintentional injuries (relative risk ratio [RRR]=1.51, P<0.001) and less likely to die in public places (RRR=0.27, P<0.001). People with epilepsy/seizures were less likely to die at home or in public places from suicide, but significantly more likely to die at home from homicide (RRR=2.29, P<0.001). By mechanism of injury, people with epilepsy/seizures were more likely to die at home from drowning (RRR=2.35, P<0.001)., Discussion: Disparities in where injured people with epilepsy/seizures die deserve further attention. Identifying the underlying causes of these disparities will allow for the development of targeted prevention interventions., ((c) 2009 Elsevier Inc. All rights reserved.)

Objectives: The goals were to describe trends in pediatric traumatic brain injury hospitalizations in the United States and to provide national benchmarks for state and regional comparisons., Methods: Analysis of existing data (1991-2005) from the Nationwide Inpatient Sample, the largest longitudinal, all-payer, inpatient care database in the United States, was performed. Children 0 to 19 years of age were included. Annual rates of traumatic brain injury-related hospitalizations, stratified according to age, gender, severity of traumatic brain injury, and outcome, were determined., Results: From 1991 to 2005, the estimated annual incidence rate of pediatric hospitalizations associated with traumatic brain injury decreased 39%, from 119.4 to 72.7 hospitalizations per 100,000. The rates decreased for all age groups and for both boys and girls, although the rate for boys remained consistently higher at each time point. Fatal hospitalization rates decreased from 3.5 deaths per 100,000 in 1991-1993 to 2.8 deaths per 100,000 in 2003-2005. The rate of mild traumatic brain injury hospitalizations accounted for most of the overall decrease, whereas nonfatal hospitalization rates for moderate and severe traumatic brain injuries remained relatively unchanged., Conclusions: Although pediatric hospitalization rates for mild traumatic brain injuries have decreased over the past 15 years, rates for moderate and severe traumatic brain injuries are relatively unchanged. Our study provides national estimates of pediatric traumatic brain injury hospitalizations that can be used as benchmarks to increase injury prevention effectiveness through targeting of effective strategies.

Context: While trauma designation has been associated with lower risk of death in large urban settings, relatively little attention has been given to this issue in small rural hospitals., Purpose: To examine factors related to in-hospital mortality and delayed transfer in small rural hospitals with and without trauma designation., Methods: Analysis of data from the Nationwide Inpatient Sample for discharges between 1998 and 2003 of patients hospitalized with moderate to major traumatic injury in nonfederal, short-stay rural hospitals with annual discharges of 1,500 or fewer patients (N = 9,590). Logistic regression was used to control for patient and hospital characteristics, stratifying by hospital volume. Main outcome measures were in-hospital death and transfer to another acute care facility after initial admission., Findings: A total of 333 patients (3.5%) died in-hospital. After adjusting for patient, injury and hospital characteristics, in-hospital death was more likely among patients treated at the non-designated hospitals with fewer than 500 discharges per year (OR 2.35; 95% CI 1.25-4.41) than among patients treated at similar trauma-designated hospitals. Patients admitted to non-designated hospitals were more likely to be transferred after admission, although this finding was significant only in the larger-volume hospitals with discharges of 500-1,500 per year (OR 1.41, 95% CI 1.08-1.83)., Conclusions: Associations between trauma designation and outcomes in rural hospitals warrant further study to determine whether expanding designation to more rural hospitals might lead to further improvement in trauma outcomes.

Background: Evidence suggests that over 90% of pediatric splenic injuries can be successfully managed nonoperatively. Although pediatric hospitals have rapidly adopted nonoperative management, variability exists among other types of hospitals., Objectives: We tested 2 a priori hypotheses: (1) spleen-injured children are more likely to receive splenectomy in for-profit hospitals than in not-for-profit hospitals; and (2) hospital charges for spleen cases are greater in for-profit hospital than in not-for-profit hospitals., Research Design: Multivariable regression was performed with data from the Kid's Inpatient Database (KID) for years 2000 and 2003, controlling for patient and hospital characteristics. Children (0-18 years) hospitalized with a blunt traumatic (noniatrogenic) spleen injury in any of the states participating in KID (N = 5061), including adult and pediatric hospitals. Main outcome measures were splenectomy and hospital charges., Results: A total of 756 children (14.9%) received splenectomies within 1 day of arrival. Splenectomy was found to be more likely among children treated at for-profit hospitals [odds ratio (OR), 1.75; 95% confidence interval (CI), 1.14-2.67] than among children treated in not-for-profit general hospitals. Splenectomies were much less common in children's hospitals (OR, 0.14; 95% CI, 0.05-0.41) than in not-for-profit general hospitals. Hospital charges for all spleen-injured children (regardless of treatment) were significantly greater in for-profit hospitals than in not-for-profit hospitals., Conclusions: For-profit hospitals seem to be trailing not-for-profit hospitals in the adoption of spleen-conserving management practices. The cost of caring for a child with a splenic injury also seems greater at for-profit hospitals, regardless of management path (ie, splenectomy vs. nonoperative management).

Crash data from 2001-2005 was linked to hospital discharge data to determine the impact of safety restraint use on crashed-related hospital charges and use for 4013 hospitalizations. Safety restraint use, year of hospitalization and age group affected the hospital charges and length of stay after a crash. Mean hospital charges were 44% greater for unrestrained patients ($44,736 versus $30,990); mean length of stay was 23% longer for the unrestrained (9.2 days versus 7.5 days). Lack of safety restraint use was associated with greater use of hospital resources. Prevention efforts should focus on increasing compliance.

Background: Although racial differences in hospital outcomes are well known for medical conditions (eg, cardiovascular disease), it is unknown whether differences exist for patients with traumatic brain injury (TBI)., Research Design: Using the National Trauma Data Bank, we examined racial and ethnic differences in hospital outcomes of 56,482 patients with moderate to severe TBI who were hospitalized in level I or II trauma-designated hospitals between 2000 and 2003. We examined racial and ethnic disparities in in-hospital mortality and the likelihood of survivors receiving postacute care at a rehabilitation center., Results: After multivariable adjustment, compared with whites, we observed increased in-hospital mortality for blacks (odds ratio [OR] = 1.19, P = 0.026) and Asians (OR = 1.41, P = 0.005). We observed a trend toward significance for Hispanics (OR = 1.41, P = 0.077), but not for other races. For survivors, compared with whites, blacks and Hispanics were less likely to be discharged to a rehabilitation center (OR = 0.68, P < 0.001, and OR = 0.67, P = 0.002, respectively)., Conclusions: Racial and ethnic disparities exist both in mortality and in discharge to postacute rehabilitation centers among persons with TBI.

Context: Despite evidence that more than 90% of children with traumatic injuries to the spleen can be successfully managed nonoperatively, there is significant variation in the use of splenectomy. As asplenic children are at increased risk of overwhelming postsplenectomy infection, nonoperative management may be considered a quality of care indicator., Objective: To test the hypothesis that children are more likely to undergo splenectomy in general hospitals than in children's hospitals., Design: Retrospective cohort study using data from the Kid's Inpatient Database (KID) for the year 2000. Multivariable regression was used to control for patient and hospital characteristics., Setting and Participants: All children aged 0 to 16 years who were hospitalized with a traumatic (noniatrogenic) spleen injury in nonfederal short-stay hospitals in any of the 27 states participating in KID (N = 2851)., Main Outcome Measure: Splenectomy performed within 1 day of arrival., Results: A total of 11 children (3%) with splenic injuries receiving care at children's hospitals underwent splenectomy compared with 383 children (15.4%) cared for at general hospitals (P<.001). After adjusting for patient characteristics, injury severity, and hospital characteristics, splenectomy was more likely among children treated at general hospitals (odds ratio, 5.01; 95% confidence interval, 2.21-11.36) than among children treated at children's hospitals., Conclusions: There is considerable variation in the management of pediatric splenic injuries, with significantly lower rates of splenectomy at designated children's hospitals. Quality improvement interventions, including increased education and training for physicians in general hospitals, may be needed to increase the use of spleen-conserving management practices.

In a study of primary (methyl to butyl) amines as nucleophiles for cyano-induced cleavage of cysteinyl proteins, methylamine was found to be superior to ammonia for cyanylation (CN)-based disulfide mass mapping methodology. Reaction conditions such as nucleophile concentration, temperature, and reaction time were systematically studied using ribonuclease A as a model protein. The CN-induced cleavage products were monitored using reverse-phase chromatography and matrix-assisted laser desorption ionization mass spectrometry. Results showed that low temperature, short reaction time, and high nucleophile concentration optimize the cleavage reaction and minimize side reactions. These conditions shorten the analysis time and substantially improve the yield of cleavage products. Further, the concurrent use of homologous nucleophiles (e.g., ammonia and methylamine) facilitates recognition and identification of cleavage products.