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Objectives Prior studies of mortality following traumatic brain injury (TBI) have not focused specifically on older adults compared with a non-TBI trauma cohort or included specific causes of death. The objectives of this study were, among adults aged 65 years and older, to (1) generate standardized mortality ratios (SMRs) by cause of death for TBI and a non-TBI trauma cohort compared with a general population, and (2) assess risk of mortality associated with TBI compared with a non-TBI trauma cohort. Design Retrospective cohort study of adults aged 65 years and older who were treated at an urban trauma center from 1997 to 2008. Measurements Data from the trauma registry were linked to the National Death Index through 2008 to obtain date and cause of death. We identified individuals with TBI and non-TBI trauma and calculated age- and sex-adjusted SMRs by comparing with the state general population. We next compared time to mortality between individuals with TBI (n = 852) and non-TBI trauma (n = 1050), adjusting for potential confounders. Results Compared with the age- and sex-adjusted state general population, older adults with TBI (SMR = 8.1; 95% confidence interval [CI] = 7.4-9.0) and non-TBI trauma (SMR = 6.7; 95% CI = 6.1-7.4) were at a greatly increased risk of mortality. Highest SMRs in both cohorts were observed for accidents. In adjusted Cox regression models, TBI was not associated with increased risk of all-cause mortality (hazard ratio = 1.03; 95% CI = .87-1.23) compared with non-TBI trauma. Conclusion This study provides evidence that, over a 4-year follow-up of older adults, any moderate to severe injury is associated with increased mortality risk. Specifically, older injured adults are at high risk of death from accidental and therefore preventable causes, suggesting that intervention could reduce mortality. J Am Geriatr Soc 67:2382-2386, 2019.

INTRODUCTION: The COVID-19 pandemic presents a unique challenge to critical care teams during disaster surge scenarios due to the large number of highly trained personnel required to care for a potentially overwhelming number of critical ill patients Our hypothesis is that CRNAs possess a valuable skill set that can be effectively integrated into disaster ICU teams METHODS: Detailed medical planning factors were applied to specific personnel, equipment, and supply resources available at a Level 1 trauma center during the first surge period of the COVID-19 pandemic Regional modeling of COVID-19 cases was utilized to prepare a tiered staffing response Model included a variety of qualified specialties designed to complement each other on critical care teams Study team included anesthesiologists, CRNAs, and anesthesiology residents supervised by a surgical intensivist All CRNAs had recent exposure to critically ill patients in the perioperative period Clinical and didactic training program specific to COVID critical care was completed by all team members COVID specific web-based guidelines were developed by intensivists and practiced by all teams The State Governor expanded the disaster role for CRNAs RESULTS: The medical center is the major regional treatment center for the COVID-19 response The total number of COVID patients admitted to ICUs during the 10 weeks of peak surge -161: intubated-134, managed with NIV/HFNC-27 Number of intubated COVID patients in ICUs at peak of the surge (requiring CRNA utilization) was 41 COVID critical care patient-days provided by CRNA teams - 83 The CRNA pool trained to provide COVID critical care included 20 providers (27 CRNAs continued anesthesia/OR support) COVID ICU mortality was 38% (61/161, including CMO/DNR) Observed morbidity and mortality rates for CRNA teams was similar to other COVID ICU teams CONCLUSIONS: The COVID-19 pandemic requires an ?all hands-on deck? approach to maximize high quality, safe care for a high volume of critically ill patients The utilization of CRNAs has been demonstrated to provide effective, highly skilled critical care team augmentation during a disaster surge scenario Appropriate critical care team preparation and coordination, communication and training guidelines are essential during a disaster scenario

To determine the usefulness of S-100β, a marker for central nervous system damage, in the prediction of long-term outcomes after mild traumatic brain injury (MTBI) Hypothesis: Mid- and long-term outcomes of MTBI (i.e. 3, 6 and 12 months post-injury and return-to-work or school (RTWS)) may be predicted based on pre-injury and injury factors as well as S-100β.MTBI subjects without abnormal brain computed tomography requiring intervention, focal neurological deficits, seizures, amnesia 24 hours and severe or multiple injuries were recruited at a level I trauma centre. Admission S-100β measurements and baseline Concussion Symptom Checklist were obtained. Symptoms and RTWS were re-assessed at follow-up visits (3-10 days and 3, 6 and 12 months). Outcomes included number of symptoms and RTWS at follow-up. Chi-square tests, linear and logistic regression models were used and p 0.05 was considered statistically significant.One hundred and fifty of 180 study subjects had S-100β results. Eleven per cent were unable to RTWS at 12 months. S-100β levels were not associated with post-concussive symptomatology at follow-up. In addition, no association was found between S-100β levels and RTWS.Amongst MTBI patients, S-100β levels are not associated with prolonged post-concussive syndrome or the inability to RTWS.

BACKGROUND: : To examine the association of scene mobility status (SMS) and injury severity and mortality among motor vehicular crash (MVC) victims. METHODS: : Adult MVC victims transported to medical facilities between 1997 and 2008 and included in the National Automotive Sampling System were studied. SMS was classified as follows: "ejected," "self-exited," "exited with assistance," "removed from the vehicle with decreased mental status," "removed due to perceived serious injury," and "removed for other reasons." Associations of SMS with Injury Severity Score and death were studied with contingency tables and multiple logistic regression models. RESULTS: : A total of 62,634 cases representing 13,699,294 (weighted) cases were analyzed. Two percent of the cases were ejected, 38% self-exited, 18% exited with assistance, 4% removed with decreased mental status, 14% removed due to perceived serious injury, 1% other reasons, and 25% unknown. Mortality was highest among those ejected (8.7%). Those who self-exited and exited with assistance experienced a mortality of 0.02%. Injury Severity Score >8 occurred in 51% of those ejected, 37% of those removed with decreased mental status, 21% of those removed due to perceived serious injury, 4% of those who self-exited, and 5% of those exited with assistance. Multiple logistic regression revealed that those ejected, removed due to a low mental status or suspected injury, experienced higher adjusted odds ratios of dying than those who self-exited (odds ratio of 266 [69->999], 235 [61-903], and 66 (19-227), respectively). CONCLUSION: : MVC occupants who "self-exited" or "exited with assistance" experienced a very low injury severity and mortality. Further efforts are needed to decrease the overtriaging of these patients. Language: en

BACKGROUND: : Motor vehicle collisions (MVCs) are the leading cause of spine and spinal cord injuries in the United States. Traumatic cervical spine injuries (CSIs) result in significant morbidity and mortality. This study was designed to evaluate both the epidemiologic and biomechanical risk factors associated with CSI in MVCs by using a population-based database and to describe occupant and crashes characteristics for a subset of severe crashes in which a CSI was sustained as represented by the Crash Injury Research Engineering Network (CIREN) database. METHODS: : Prospectively collected CIREN data from the eight centers were used to identify all case occupants between 1996 and November 2009. Case occupants older than 14 years and case vehicles of the four most common vehicle types were included. The National Automotive Sampling System's Crashworthiness Data System, a probability sample of all police-reported MVCs in the United States, was queried using the same inclusion criteria between 1997 and 2008. Cervical spinal cord and spinal column injuries were identified using Abbreviated Injury Scale (AIS) score codes. Data were abstracted on all case occupants, biomechanical crash characteristics, and injuries sustained. Univariate analysis was performed using a χ analysis. Logistic regression was used to identify significant risk factors in a multivariate analysis to control for confounding associations. RESULTS: : CSIs were identified in 11.5% of CIREN case occupants. Case occupants aged 65 years or older and those occupants involved in rollover crashes were more likely to sustain a CSI. In univariate analysis of the subset of severe crashes represented by CIREN, the use of airbag and seat belt together (reference) were more protective than seat belt alone (odds ratio [OR] = 1.73, 95% confidence interval [CI] = 1.32-2.27) or the use of neither restraint system (OR = 1.45, 95% CI = 1.02-2.07). The most frequent injury sources in CIREN crashes were roof and its components (24.8%) and noncontact sources (15.5%). In multivariate analysis, age, rollover impact, and airbag-only restraint systems were associated with an increased odds of CSI. Using the population-based National Automotive Sampling System's Crashworthiness Data System data, 0.35% of occupants sustained a CSI. In univariate analysis, older age was noted to be a significant risk factor for CSI. Airbag-only restraint systems and both rollover and lateral crashes were also identified as risk factors for CSI. In addition, increasing delta v was highly associated with CSIs. In multivariate analysis, similar risk factors were noted. Of all the restraint systems, seat belt use without airbag deployment was found to be the most protective restraint system (OR = 0.29, 95% CI = 0.16-0.50), whereas airbag-only restraint was associated with the highest risk of CSI (OR = 3.54, 95% CI = 2.29-5.46). CONCLUSIONS: : Despite advances in automotive safety, CSIs sustained in MVC continue to occur too often. Older case occupants are at an increased risk of CSI. Rollover crashes and severe crashes led to a much higher risk of CSI than other types and severity of MVCs. Seat belt use is very effective in preventing CSI, whereas airbag deployment may increase the risk of occupants sustaining a CSI. More protection for older occupants is needed and protection in both rollover and lateral crashes should remain a focus of the automotive industry. The design of airbag restraint systems should be evaluated so that they are not causative of serious injury. In addition, engineers should continue to focus on improving automotive design to minimize the risk of spinal injury to occupants in high severity crashes. Language: en

The authors investigated whether impulsivity and depression affect the success of interventions to reduce alcohol use. Unadjusted and adjusted regression models were constructed to analyze the effect of impulsivity and depression on 12-month outcomes of participants of a trauma center based randomized trial of brief personalized motivational interventions versus information and advice. Of 497 problem drinkers enrolled in the program, 248 completed the 12-month follow-up. Impulsivity, male gender, being older than 35, and intentional mechanism of injury had a direct association with drinking. After interventions, a decrease in drinking was found that was unaffected by the presence of impulsivity or depression indicators.

BACKGROUND:: To study whether trauma center patients with positive toxicology findings for cocaine-positive (COC+) are at a higher risk for suicide, homicide, and unintentional injury death after discharge than cocaine-negative (COC+) trauma patients. METHODS:: Patients admitted between July 1983 and June 1995 and discharged alive from a level I trauma center were prospectively followed up for 1.5 years to 14.5 years. The occurrence of suicide, homicide, and unintentional injury death was explored in relation to COC+ status at admission using Cox proportional hazards methodology. Models included possible confounders. Interactions with each of the main effects were explored. RESULTS:: Of the 27,399 admissions, 21,500 had urine COC toxicology testing performed and were included in the study. COC was positive in 11.4% of the studied population. COC+ patients were significantly younger, with 72% of COC+ versus 43% of COC- in the 25 to 44 years age group. COC+ patients were more likely to be men, positive for alcohol, and intentional injury victims. COC+ status was not associated with subsequent suicide. Furthermore, the COC+ status association with subsequent homicide became nonsignificant after adjusting for confounders. Unadjusted COC+ status was associated with unintentional injury death (odds ratio = 1.65 [1.14-2.40]). Interactions were found in the association with unintentional injury death such that COC+ status tripled the odds of injury death (odds ratio = 2.75 [1.58-4.78]) among the alcohol-negative patients within the 25 to 45 years age group. CONCLUSION:: COC+ trauma patients are at an increased risk of subsequent unintentional injury death after discharge from a trauma center. Suicide and homicide occurrence seems to be unaffected. Language: en

Purpose: The purpose of this analysis was to determine which of the initial symptoms after mild traumatic brain injury (MTBI) can best predict the development of persistent postconcussive syndrome (PCS). Methods: One hundred eighty MTBI patients admitted to a level I trauma center were enrolled in a prospective study and 110 followed for 3 months. MTBI was defined as a Glasgow Coma Score of 13 to 15 with a transient loss of consciousness or report of being dazed or confused. PCS was defined as the persistence of four or more symptoms long term. Patients were screened at admission and at 3 days to 10 days and 3 months. Symptom checklists were administered to ascertain the presence of symptoms (cognitive, emotional, and physical) after concussion. For a subset of patients that were physically able, balance tests were also conducted. Stepwise logistic regression was used to identify which symptoms best predicted PCS. Results: The mean age of the subjects was 35 years, and 65% were men. Physical symptoms were the most prevalent in the 3 days to 10 days postinjury with most declining thereafter to baseline levels. Emotional and cognitive symptoms were less prevalent but more likely to remain elevated at 3 months; 41.8% of subjects reported PCS at 3 months. The strongest individual symptoms that predicted long-term PCS included anxiety, noise sensitivity (NS), and trouble thinking; reported by 49%, 27%, and 31% of the subjects at 3 days to 10 days, respectively. In multivariate regressions including age, gender, and early symptoms, only anxiety, NS and gender remained significant in the prediction of PCS. Interactions revealed that the effect of anxiety was seen primarily among women. NS had an odds ratio of 3.1 for PCS at 3 months. Conclusions: After MTBI, anxiety among women and NS are important predictors of PCS. Other physical symptoms, while more prevalent are poor predictors of PCS.

PURPOSE:: To investigate the association of history of school suspension (HSS) to risky behaviors and injury history. METHODS:: Adult patients admitted to a Level I trauma center (n = 774) were assessed for demographics, socioeconomic status, educational history, risky behaviors (infrequent seat belt use, drinking and driving, binge drinking, and speeding for a thrill), substance abuse disorders, and prior injury history. Student's t test and chi statistics were used to compare subjects with and without a HSS in relation to risky behaviors and injury history (alpha = 0.05). Logistic regression models were constructed with each risky behavior and injury history as the outcome adjusting for demographics, socioeconomic status, and substance abuse disorders. RESULTS:: Patients with HSS (n = 260) were significantly younger, more likely to be male, not married, low income, Black, unemployed, smokers, and alcohol and drug dependent than patients without such history (n = 514). They had higher rates of binge drinking (66% vs. 33%), infrequent seat belt use (50% vs. 26%), drinking and driving (24% vs. 12%), and driving fast for a thrill (21% vs. 8%). Similarly, they had more frequent previous history of vehicular injuries (44% vs. 31%) and assaults (36% vs. 16%). Multivariate models revealed school suspension to be associated with infrequent seat belt use (Odds ratio [OR] = 2.02 [1.44-2.83]), binge drinking (OR = 1.95 [1.25-3.04]), speeding for a thrill (OR = 1.83 [1.15-2.92]), prior vehicular injuries (OR = 1.46 [1.06-2.02]), and assaults (OR = 1.67 [1.13-2.47]). CONCLUSION:: HSS is associated with risky behaviors, and history of prior vehicular crashes and assaults. Language: en

Concerns regarding complications of cocaine use are frequently used to justify delaying procedures among patients with positive urine cocaine toxicology (UCT); however, there is no evidence to support this practice. We investigated whether UCT+ patients experience a worse outcome than UCT- patients when undergoing surgery on the first day after admission to a trauma center.Files of adult trauma patients undergoing surgery during the first 24 hours after admission were selected from a trauma database. Patients without UCT testing were excluded. UCT+ and UCT- patients were compared in relation to mortality; length of stay; and the development of cardiac, infectious, and neurologic complications. Possible confounders were analyzed. Student's t test, Pearson's chi2 test, and Wilcoxon's statistics were used for analysis (alpha = 0.05). Multiple logistic regression models and Cox proportional hazard methods were used to adjust for possible confounders.Of the 3,477 patients studied, 13% (n = 465) tested positive for cocaine. UCT+ patients had a different age distribution were more likely to be male and to have penetrating injury and had lower Injury Severity Scores than UCT- patients. Outcomes were similar for mortality (3% vs. 4%), for the development of infectious (18% and 19%) and neurologic (2% vs. 1%) complications, and median length of stay (5 days vs. 5 days). Cardiac complications were lower among the UCT+ patients (3% vs. 6%). Multiple logistic regression and Cox proportional hazard revealed results similar to those from the univariate analysis.Outcomes after surgery during the first 24 hours after admission are not negatively affected by the presence of UCT+. An apparent protective effect of UCT+ status in the development of cardiac complications needs to be explained.

Objectives: The objective of the current study was to examine trends in ankle/foot (A/F) injuries during the period 2001–2014, in order to determine whether the incidence of these injuries has changed and whether a previously identified difference in risk by gender still existed. In addition, other driver and crash-related risk factors were examined separately for men and women. Methods: Passenger vehicle drivers aged 16+ were identified from NASS-CDS; weighted data were analyzed for model years 2001–2014. Model years (MY) were grouped as 2001–2004 (older) vs. 2005–2014 (newer), and drivers in frontal crashes were included. Ankle injuries included fractures and dislocations to the malleolus and distal tibia/fibula. Foot injuries included fractures and dislocations of the talus, calcaneus, and tarsal/metatarsal bones. Logistic regression models were constructed to identify risk factors, including MY, age, belt use, toepan/instrument panel intrusion, and body mass index (BMI) separately for each gender using odds ratios. Results: The incidence of A/F injuries declined significantly between older and newer MY, especially for women. Whereas before MY 2005, ankle and foot injury risk was significantly higher for women than men, risks for ankle injury are now virtually the same for both genders, and women are only 1.2 times more likely than men to sustain a foot injury in a frontal crash. From multivariable regression models, however, it is apparent that there are different risk factors for A/F injuries for men vs. women. Body weight was a significant factor for both groups, but for men it was a risk only for those extremely obese, whereas for women those who were categorized as overweight were also at increased risk. Age greater than 55 was also found to be a risk factor for foot injuries among women but not men. For men and women, toepan intrusion remained the most important factor for both foot and ankle injuries, with significantly higher odds ratios noted for men. Foot pedals were a more likely injury source for women, whereas the toepan was more likely for men. In addition, belt use was protective for ankle injuries in women but not men. Conclusions: Significant declines in A/F injuries have been noted in recent years, especially for women, whose risks are now similar to those for men. However, significant risk factors remain for each gender, primarily related to body habitus (BMI) and toepan intrusion. Age was a risk factor for foot injuries among women, for whom the foot pedals were more likely to be an injury source. Toepan intrusion remains a major factor for both men and women, but, with the exception of 30+ cm of intrusion, odds ratios were primarily much higher for men in each category of intrusion.

Pedestrian injuries represent 11% of all motor vehicle related injuries in the USA. This study attempts to define the epidemiology of the pedestrian victim. Patients admitted to a regional adult trauma center were interviewed and evaluated for substance abuse. Pedestrians were compared with the remaining unintentional trauma patients with regard to demographics, socioeconomics, possession of a driver’s license, injury prone behaviors, risk taking dispositions, and BAC levels using the Student’s t-test and Pearson’s χ 2 statistic (α = 0.05). Multivariate logistic regression models were built with pedestrian mechanism as the outcome. When compared to the remaining unintentional trauma population (N = 661), pedestrians (N = 113) were significantly more likely to be black, not married, unemployed, binge drinkers, alcohol dependent, drug dependent, BAC+, to have a low income, low educational achievement, younger age, and to not have a driver license. Black race, unemployment of 1 year or more, never licensed, lapsed license, revoked license and BAC > 200 mg/dl showed statistical significance in the multiple logistic regression. Pedestrians represent a sub-population with a low socioeconomic status and high incidence of substance abuse. Unemployment, not having a driver’s license, black race, and a BAC > 200 mg/dl were strongly linked to being an injured pedestrian.

Numbers of crashes, rates of police-reported injury severity, and hospital admission rates were calculated for the ten year period between 2001 and 2010 in Maryland. Comparisons were made for two 5-year periods of 2001–2005 and 2006–2010. Crash characteristics remained similar for the two five-year periods, but there was a significant increase in occupant age. Declines in police-reported injury severity were noted for each of four age groups: 16–29, 30–54, 55–64, and 65+, with smaller declines among older occupants. In addition, there were significant declines in hospital admissions, comparing the two time periods. Although reductions in crashes may be attributable to various roadway, behavioral, and other safety improvement efforts, reductions in hospital admission rates most likely reflect major improvements in crashworthiness implemented during the past decade. For those admitted to hospitals, significant increases in injury severity were noted between the first and second time periods. There was an association between age and ISS, a measure of total bodily injury, with the highest ISS scores noted for the youngest and oldest groups (16–29 and 55+, respectively). In addition, there was a significant increase in the mean age over time, from 39 in 2001 to 43 in 2010, p

This study aimed to identify vehicular and crash factors associated with diaphragmatic injuries (DIs).DI presence was analyzed among Crash Injury Research and Engineering Network vehicular occupants (age ≥ 16 years) in relation to occupant and crash factors. Contact points (i.e., components in direct contact with occupants) involved in injury causation were analyzed. Cases with and without DI were compared in relation to mortality, Injury Severity Score (ISS) and the occurrence of injuries with a maximum Abbreviated Injury Scale (MAIS) score of 3+. Student's t test, Wilcoxon test, χ(2), and multiple logistic regression were used for statistical analysis.Of a total of 2,344 cases with complete data for analysis, 80 cases (3.4%) experienced DI. Multiple logistic regression analysis revealed a significant association with the occurrence of DI for near lateral impact (odds ratio, 7.71 [4.20-14.58]) and change in velocity (ΔV) of 40 km/h or greater (odds ratio 2.58 [1.29-5.24]). The seat belt and steering wheel were the most common contact points among frontal impact crashes, and the side interior surface and side hardware or armrest were the more common contact points among side impact crashes. DI cases experienced more MAIS3+ injuries in the head, chest and abdominal regions and exhibited higher median ISS (q1-q3) [42 (29-62.5) vs. 17 (10-27), p0.0001]. While mortality was higher among occupants with DI (48% vs. 14%), this effect disappeared when adjusted by ISS.DI are associated with lateral crashes and higher ΔV. Head, chest, and abdominal injuries occur more commonly among DI patients, and the presence of these injuries rather than the DI itself is responsible for the increased mortality in these patients.Epidemiologic study, level III.

Background: Early surgery for appendicitis is thought to avoid complications associated with appendiceal rupture. Aims: This study was to evaluate the effect of timing of surgery on complications, length of stay (LOS) and cost in patients undergoing appendectomy. Materials and Methods: Retrospective review of 396 patients with appendectomies from January 1, 2005 to December 31, 2007 was performed. Demographic data, time of presentation, physical findings, diagnostic data, operating room times, LOS, cost and complications were collected. Patients were divided into 4 groups based on time from presentation to appendectomy. Results: Pathology confirmed appendicitis in 354 (89%) patients. Most patients (90%) had surgery within 18 h of presentation. Timing of surgery did not affect the incidence of purulent peritonitis ( P = 0.883), abscess ( P = 0.841) or perforation ( P = 0.464). LOS was significantly shorter for patients with emergency department registration to operating room times less than 18 h ( P < 0.0001). Costs were significantly higher for patients with times to operating room greater than 18 h ( P < 0.001). Conclusion: Timing of surgery did not affect the incidence of complications or perforated appendicitis. However, delay in surgical consultation and surgery are associated with increased LOS and increased hospital costs. The optimal timing of appendectomy for uncomplicated acute appendicitis appears to be within 18 h of emergency department presentation.

Helicopter emergency medical systems (HEMS) have been reported to improve trauma survival. This study seeks to determine HEMS effect on survival across different subpopulations in relation to injury severity, degree of physiologic derangement, and transportation time (TT).The 2007 National Trauma Data Bank adult patients transported directly to hospitals by ground ambulance or HEMS were compared in relation to their survival with discharge and other possible confounders. Multivariate models were constructed to determine the adjusted odds ratios (OR) of survival for the entire cohort and across subpopulations stratified by different Injury Severity Score (ISS), hospital Revised Trauma Score (RTS), and TT.A total of 192,422 patients with complete data were analyzed. HEMS patients (15.3%) experienced lower survival rates than those transported by ground (93.8% vs. 96.1%, p0.001). Multivariate analysis revealed a survival advantage for HEMS in the entire cohort (OR, 1.78 [1.65-1.92]). Adding TT to the model did not affect HEMS effect on survival. HEMS effect was present across all ISS levels but was limited to those with RTS of less than 6 (n = 15,427; OR, 2.28 [2.10-2.49]). In contrast, those with RTS of 6 or greater experienced lower adjusted survival when transported by HEMS (n = 176,995; OR, 0.83 [0.74-0.94]). Stratification by RTS and ISS did not affect the results. Substratification by TT revealed no effect of HEMS on survival among patients with RTS of less than 6, ISS of less than 16, and TT of 60 minutes or greater. Remaining associations were not affected by TT substratification.HEMS beneficial effect on survival seems to be limited to patients with physiologic instability. Physiologically stable patients seem to have a worse outcome when transported by air.Epidemiologic/prognostic study, level III.

The occurrence of AI was studied in relation to vehicle model year (MY) among front seat vehicular occupants, age ≥ 16 in vehicles MY ≥ 1994, entered in the National Automotive Sampling System Crashworthiness Data System between 1997 and 2010 to determine whether newer vehicles, due to their crashworthiness improvements, are linked to a lower risk of aortic injuries (AI). MY was categorized as 1994–1997, 1998–2004, or 2005–2010 reflecting the introduction of newer occupant protection technology. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals for the association between AI and MY independent of possible confounders. Analysis was repeated, stratified by frontal and near lateral impacts. AI occurred in 19,187 (0.06%) of the 31,221,007 (weighted) cases, and contributed to 11% of all deaths. AIs were associated with advanced age, male gender, high BMI, near-side impact, rollover, ejection, collision against a fixed object, high ΔV, vehicle mismatch, unrestrained status, and forward track position. Among frontal crashes, MY 98–04 and MY 05–10 showed increased adjusted odds of AI when compared to MY 94–97 [OR 1.84 (1.02–3.32) and 1.99 (0.93–4.26), respectively]. In contrast, among near-side impact crashes, MY 98–04 and MY 05–10 showed decreased adjusted odds of AI [OR 0.50 (0.25–0.99) and 0.27 (0.06–1.31), respectively]. While occupants of newer vehicles experience lower odds of AI in near side impact crashes, a higher AI risk is present in frontal crashes.

Background: There are several commercially available neurotoxins to improve facial aesthetics, but few prospective, randomized trials have been conducted without commercial support to compare these agents. Objectives: The authors present the results of a study examining and comparing the effects of onabotulinumtoxinA (BoNT-ONA; Botox, Allergan, Inc., Irvine, California) and abobotulinumtoxinA (BoNT-ABO; Dysport, Ipsen Ltd, Slough, UK). Methods: The authors enrolled 53 patients in a prospective, randomized trial in which each patient received a dose of BoNT-ONA on one side of the upper face and BoNT-ABO on the other. The effects of each agent were monitored and recorded over 150 days according to each patient’s ability to elevate the brow, wrinkle count (as measured by the Visia system; Canfield Imaging Systems, Fairfield, New Jersey), and assessment of Fitzpatrick wrinkle scale rankings by blinded graders. Results: Results showed no statistically significant differences between the two agents. Both agents yielded measurable improvements on wrinkles of the upper face at 150 days. Conclusions: At the current pricing of the agents, BoNT-ABO offers a significant cost savings over BoNT-ONA, with a comparable efficacy. The effect of both drugs appears to be more prolonged than indicated in the current manufacturer guidelines. Level of Evidence: 2 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

to analyze the occurrence of severe injuries and deaths among crash victims transported to hospitals in relation to occupant and scene characteristics, including on-scene patient mobility, and their potential use in triaging patients to the appropriate level of care.the occurrence of death and ISS15 were studied in relation to occupant, crash and mobility data readily available to EMS at the scene, using weighted NASS-CDS data. Data set was randomly split in two for model development and evaluation. Characteristics were combined to develop new triage schemes. Overtriage and undertriage rates were calculated for the NASS-CDS case trauma center allocation and for the newly developed triage schemes.Compared to the NASS-CDS distribution, a scheme using patient mobility alone showed lower overtriage of those with ISS≤15 (38.8% vs. 55.5%) and lower undertriage of victims who died from their crash-related injuries (2.34% vs. 21.47%). Undertriage of injuries with ISS15 was similar (16.0 vs. 16.9). A scheme based on the presence of one of many scene risk factors (age55, GCS14, intrusion ≥18", near lateral impact, far lateral impact with intrusion ≥12", rollover or lack of restraint use) resulted in an undertriage of 0.86% (death) and 10.5% (ISS15) and an overtriage of 63.4%. The combination of at least one of the scene risk factors and mobility status greatly decreased overtriage of those with ISS15 (24.4%) with an increase in death undertriage (3.19%). Further combination of mobility and scene factors allowed for maintenance of a low undertriage (0.86%) as well as an acceptable overtriage (48%).Patient mobility data easily obtained at the scene of a crash allows triaging of injured patients to the appropriate facility with a high sensitivity and specificity. The addition of crash scene data to scene mobility allows further reductions on undertriaging or overtriaging.

To evaluate whether older injured motor vehicular crash (MVC) occupants' access to trauma centers (TC) reflects the lower threshold suggested in triaging recommendations.Adult front seat occupants of MVCs transported to a hospital from 1999 through 2006 included in the National Automotive Sampling System (NASS) were studied. Cases were classified by their age in years (≤60 years or60 years). Younger and older injured MVC occupants were compared in relation to their likelihood of being transported to a TC. Multiple logistic regression models were built to adjust for confounders.A total of 35,830 cases representing 7,894,940 cases after weighting were analyzed. Older occupants were less likely to be transported to a TC than younger ones (47% vs. 55%, p0.0001). Older individuals were more likely to be restrained, passengers, and seated on the impacted side of lateral crashes. Injury severity was higher among the older group (mean Injury Severity Score, 4.1 vs. 3.1; p0.0001) and so was the resulting mortality (1.7% vs. 0.6%, p0.0001). Multiple logistic regression models after adjusting for confounders (i.e., other triage criteria) revealed a lower likelihood of TC transport (odds ratio, 0.75 [0.57-0.98]) for the older group.In contrast to the American College of Surgeons triaging recommendations, injured MVC occupants older than 60 years are less likely to be transported to a TC than their younger counterparts. Further studies should establish whether the lower access to TC experienced by the older population is a function of geographical factors, emergency medical services unconscious bias, or other factors.

Background: The shortage of neurosurgeons is a problem in many US trauma centers. Most thoracolumbar spine fractures are treated conservatively, and at our institution, we found that most patients did not require surgery. We hypothesize that most spine fractures can be treated safely and effectively by the trauma team, without neurosurgical consultation, using a protocol to guide diagnosis and treatment. Methods: A treatment protocol was designed, which used radiologic criteria to screen for potentially stable fractures and guide their treatment by the trauma service without obtaining a spine consult. All patients meeting criteria were ambulated 1 day to 2 days after admission, either with or without a thoracolumbar support orthotic, depending on their level of spinal injury. All received a repeat spine computed tomographic (CT) scan after ambulation. Any change in the fractures on CT findings triggered neurosurgical consultation. Patients with no change in their fractures were discharged with outpatient neurosurgery follow-up and imaging. Results: Sixty-one patients were evaluated prospectively and 45 met inclusion criteria. Of the 45 patients, 39 were managed without the need for neurosurgical consult. Six patients had mild postambulation CT changes, triggering spine consultation, and all six were managed nonoperatively. All unstable fractures, cord injuries, or cases requiring surgery were identified during the initial trauma survey. One hundred fifty-two retrospective cases were then reviewed. Of these 152 patients, 85 met inclusion criteria. Overall, patients with postambulation CT changes were older (median age, 72 vs. 46 years). Of the 85 patients, none of the 9 patients who had postambulation CT changes required surgery. Hundred percent were managed with repeat CT scan and continued bracing. All operative or unstable fractures during the study period would have been effectively screened out by the protocol's radiologic criteria. Conclusions: The use of a treatment protocol for stable thoracolumbar fractures seems to be safe and is currently in clinical practice at our institution. Its use could conserve neurosurgical resources without sacrificing patient safety outcomes.

A study in the general population has shown a higher acute respiratory distress syndrome (ARDS) mortality among blacks. We studied whether black blunt-trauma patients experience different ARDS incidence, ARDS-associated mortality, or ARDS case fatality rates.National Trauma Data Bank (NTDB) extracts of blunt-trauma patients with Injury Severity Score (ISS) greater than 16 and length of stay greater than 3 days were used for this study. ARDS incidence, ARDS-associated mortality, and ARDS case fatality rates were calculated for Caucasians, blacks, and Hispanics, and compared using chi2. In order to adjust for confounders (age, gender, comorbidities, hypotension, and injury severity) multiple logistic regression models were built for the 3 outcomes. Odd ratios (ORs) and 95% confidence intervals (CIs) were calculated. A p.05 was used for all statistics.Among the 96350 patients studied, ARDS incidence, ARDS-associated mortality, and ARDS case fatality rates were 0.92%, 0.18%, and 19.1%, respectively. Differences among racial/ethnic groups were found between blacks and Caucasians for ARDS incidence (0.70% vs. 0.93%) and between Hispanic and Caucasians for ARDS-associated mortality (0.27% vs. 0.17%). Multiple logistic regression models adjusting for confounders, using Caucasian race/ethnicity as a reference, revealed a protective effect of black race/ethnicity for ARDS incidence (OR, 0.73; 95% CI, 0.58-0.91). Hispanics, but not blacks, experienced higher odds of adjusted ARDS-associated mortality (OR, 1.76; 95% CI, 1.15-2.62) and ARDS case fatality (OR, 1.92; 95% CI, 1.17-3.09).Black race/ethnicity is not associated with ARDS mortality among blunt-trauma patients. Black race/ethnicity seems to have a protective effect in relation to ARDS incidence. Hispanic ethnicity was associated with a higher mortality and case fatality rates for ARDS.

OBJECTIVE: To establish whether the Insurance Institute for Highway Safety (IIHS) offset crash test ratings are linked to different mortality rates in real world frontal crashes. METHODS: The study used Crash Injury Research Engineering Network drivers of age older than 15 years who were involved in frontal crashes. The Crash Injury Research Engineering Network is a convenience sample of persons injured in crashes with at least one Abbreviated Injury Scale score of 3+ injury or two Abbreviated Injury Scale score of 2+ injuries who were either treated at a Level I trauma center or died. Cases were grouped by IIHS crash test ratings (i.e., good, acceptable, marginal, poor, and not rated). Those rated marginal were excluded because of their small numbers. Mortality rates experienced by these ratings-based groups were compared using the Mantel-Haenszel chi test. Multiple logistic regression models were built to adjust for confounders (i.e., occupant, vehicular, and crash factors). RESULTS: A total of 1,226 cases were distributed within not rated (59%), poor (12%), average (16%), and good (14%) categories. Those rated good and average experienced a lower unadjusted mortality rate. After adjustment by confounders, those in vehicles rated good experienced a lower risk of death (adjusted OR 0.38 [0.16-0.90]) than those in vehicles rated poor. There was no significant effect for "acceptable" rating. Other factors influencing the occurrence of death were age, DeltaV >or=70 km/h, high body mass index, and lack of restraint use. CONCLUSION: After adjusting for occupant, vehicular, and crash factors, drivers of vehicles rated good by the IIHS experienced a lower risk of death in frontal crashes. Language: en

To quantify the effect of model year (MY) on the occurrence of severe injuries and death after involvement in motor vehicle crashes.Cases involving adult front seat occupants of vehicles MYor = 1994 equipped with frontal airbags were selected from the Crash Injury Research and Engineering Network (CIREN) database. Cases were grouped by MY: 1994-1997, 1998-2004, and 2005-2007 (MY groups [MYG] 1, 2, and 3, respectively. MYGs were compared in relation to mortality, Injury Severity Score (ISS), and the occurrence of Abbreviated Injury Severity score (AIS) 3+ and AIS4+ injuries to each body region using Mantel Haenszel chi-square, Kruskal-Wallis, and Bonferroni corrected t test. To adjust for confounders, multiple logistic regression models were built to explore the association of MYG with death. Covariates included age, BMI, delta v, principal direction of force (PDOF), restraint use, and vehicle type.A total of 1888 cases was distributed within MYG1 (34%), MYG2 (62%), and MYG (34%). Age, gender, BMI, and PDOF distribution did not differ among MYGs. Though ISS distribution was not different, a decrease in the occurrence of AIS4+ of the thorax and spine regions was noted over time. Mortality also decreased over time (18, 9, and 4% MYG 1, 2, and 3, respectively). Multivariate analysis revealed a protective effect of MYG2 and MGY3 (odds ratio [OR], 0.57 [0.44-0.75] and 0.22 [0.07-0.50], respectively) in relation to death.Front seat occupants of later MY vehicles injured during crashes experience a decreased likelihood of very severe thoracic injuries, spinal injuries, and death.

OBJECTIVE: To compare injury patterns and outcomes of near- and far-side collisions. METHODS: Near- and far-side occupants in the Crash Injury Research and Engineering Network (CIREN) were compared for mortality and the occurrence of severe injuries (maximum abbreviated injury scale [MAIS] 3+). Regression models, adjusting for confounders, examined death and MAIS 3+ injuries as outcomes and near- or far-side position as an independent variable. CIREN findings were compared with those of the Crash Outcome Data Evaluation System (CODES), and the Maryland Automated Accident Reporting System. RESULTS: Of the 380 cases, 72% were in the near and 28% in the far position. Mortality was similar between groups within CIREN. Near-side occupants experienced a higher frequency of MAIS 3+ injuries for the thorax, abdomen, and lower extremities, and fewer MAIS 3+ head injuries than far-side occupants (35% vs. 46%, p = 0.06). Regression models revealed similar risk of MAIS 3+ head injuries among near- and far-side occupants. The most common structures contacting the head in far-side crashes (N = 62) were opposite side structures (52%) and other occupants (13%). Similar risks of head injuries among near- and far-side occupants were observed for the CODES data; however, lower risks of death were present among far-side drivers involved in crashes, based on CODES and Maryland Automated Accident Reporting System. CONCLUSIONS: Despite a lower incidence of thoracic, abdominal, and lower extremity injuries, far-side occupants experienced a similar risk of head injuries to that of near-side occupants. Contact patterns suggest that restraint systems fail to keep far-side occupants' heads from striking opposite side structures or other occupants. Language: en

BACKGROUND: This study investigates the influence of overweight and obesity on outcome from vehicular trauma. METHODS: All Crash Injury Research and Engineering Network patients older than 16 years involved in frontal and lateral crashes between 2000 and 2005 in vehicles with front airbags were included (n = 1,615). Obese, overweight, and normal-weight patients were compared in relation to injury severity score (ISS) and mortality using the Bonferroni method for multiple comparisons and the chi test. Control variables included patient factors (gender, age, and height) and crash factors (curb weight, change in velocity [DeltaV], principal direction of force, and restraint use). Multivariate analysis was performed for both ISS and mortality using linear and logistic regression, respectively. An alpha value of 0.05 was used for all statistics. RESULTS: Univariate analysis showed no difference in ISSs between groups based on body mass index. Mortality was higher for obese and overweight than for normal-weight patients (20.5%, 16.2%, and 9.4%, respectively). Multiple linear regression revealed a positive association of ISS with overweight (parameter estimate 2.44, p = 0.009) but not with obese patients. Crash factor adjusted odds of dying were 2.08 (CI 1.43-3.04) for overweight and 3.17 (CI 2.14-4.72) for obese patients. Injury-severity-adjusted odds of dying were 1.87 (CI 1.17-3.01) for overweight and 3.89 (CI 2.38-6.45) for obese patients. CONCLUSION: After adjusting for age, gender, and crash factors, overweight patients (but not obese patients) experienced more severe injuries. Obese and overweight patients experience higher unadjusted and adjusted mortality rates. Language: en

To measure the combined contribution of change in velocity (Deltav), principal direction of force (PDOF), and restraint use on mortality after vehicular trauma.The Crash Injury Research and Engineering Network population includes patients8 years old with one injury with an Abbreviated Injury Scale scoreor=3 or with two injuries with an Abbreviated Injury Scale scoreor=2, who were occupants of a vehicle. Patients 15 years or younger; in rear collisions; back seat occupants; in crashes with Deltav80 km/h, unknown Deltav, or unknown PDOF; or in vehicles without airbags were excluded. Mortality was analyzed in relation to Deltav (km/h), restraint use, and PDOF using chi2. Multiple logistic regression models were built, including possible confounders (body mass index, age, gender) and interactions were explored. An [alpha] = 0.05 was used for all statistics.A total of 1,261 cases were included. Mortality was higher for unrestrained than for restrained patients (17% vs. 9%) and was higher for lateral than for frontal impact patients (17% vs. 11%). Higher mortality rates were also observed for Deltav 40-80 km/h than for Deltav40 km/h (17% vs. 9%). Multiple logistic regression findings, after adjusting for age, gender, and body mass index, revealed significant effects of lateral PDOF (odds ratio [OR] 3.06 [2.03-4.61]), unrestrained status (OR 2.95 [2.01-4.38]), and Deltav 40-80 km/h (OR 3.65 [2.44-5.44]). Effect modification was found between PDOF and Deltav.A Deltav 40 km/h to 80 km/h, lack of restraint use, and lateral impact significantly affects mortality. A synergistic effect was found between Deltav 40-80 km/h and lateral PDOF.

Smoking has been linked to disease and injury. The purpose of this study is to investigate the smoking habits of motor vehicular driver trauma center patients and their association with previous injury history and risky behaviors.The studied population included 323 motor vehicular driver injury patients (123 smokers and 200 non-smokers) interviewed as part of a larger study of psychoactive substance use disorders at an adult Level I trauma center. Patients with head injuries, hospital stays of less than two days, and diminished cognition were excluded. Interviews included demographics (age, gender, race, marital status), socioeconomic status (SES; income, education, employment), risky behaviors (seatbelt non-use, drinking and driving, riding with drunk driver, binge drinking), and trauma history information (vehicular, assault, and other injuries). Substance abuse (alcohol and drug dependence) was evaluated in depth using DSM III-R criteria. Smokers and non-smokers were compared in relation to control and dependent variables using student's t test and chi-square (alpha = 0.05). Outcome variables included previous trauma history and risky behaviors. Multiple logistic regression models using step-down selection methods (alpha = 0.05) were constructed with risky behaviors and trauma history as dependent variables including demographics, SES and substance as independent variables.Smokers represented 38 percent of the 323 patients studied. Smokers (n = 123) were younger (34 vs. 43 years), more likely to be male (72 percent vs. 50 percent), not married (72 percent vs. 56 percent), and had higher rates of alcohol (29 percent vs. 9 percent) and drug dependence (14 percent vs. 3 percent) than non-smokers (n = 200). Educational achievement (20 percent vs. 15 percent less than high school) and income level (24 percent vs. 23 percent with less than $15,000 of yearly income) were not different between smokers and non-smokers. Smokers were more likely than non-smokers to have a history of prior vehicular trauma (48 percent vs. 26 percent), assault (25 percent vs. 9 percent), or other injury (50 percent vs 37 percent). The following injury-prone behaviors were also more common among the smokers than non-smokers: seatbelt non-use (49 percent vs. 29 percent), drinking and driving (38 percent vs. 15 percent), riding with drunk driver (38 percent vs. 13 percent), and binge drinking (68 percent vs. 26 percent). In multiple logistic regression models adjusting for demographics, SES, and substance abuse, smoking revealed significantly higher odds ratios (OR) for the following dependent variables: seatbelt non-use (OR = 2.9), riding with drunk driver (OR = 2.2), binge drinking (OR = 2.4), previous vehicular (OR = 2.0), and assault injuries (OR = 2.5). Smoking did not reach significance for drinking and driving and other (non-vehicular and non-assault) injury.Smoking is independently associated with risky behaviors and repeated history of vehicular or assault injury within the vehicular trauma population.

Background: Suicide risk after discharge among trauma patients could be influenced by multiple factors. The aim of this study is to establish whether patients discharged from a trauma center experience an increased suicide rate and whether this can be explained by defined demographic, injury, or alcohol abuse risk factors. Methods: Patients admitted between July 1, 1983, and June 30, 1995, and discharged alive from a Level I trauma center (n = 27,399) were followed for 1.5 to 14.5 years to determine whether they had died. Death determination was made by an epidemiologic support service, which had created a repository of death certificates. Variables used in the analyses included age, gender, race, Injury Severity Score, discharge disposition, mechanism of injury, and alcohol toxicology. General and trauma populations were compared using standard mortality rates. Risk factors for suicide within the trauma population were explored using Pearson's Χ 2 , Mantel-Haenszel Χ 2 , Cox proportional hazards, and Mantel-Cox log-rank methodology. Results: Suicide was more common in the trauma than in the general population (standard mortality rate = 1.71). This difference may be attributed primarily to alcohol use problems. Suicide risk in the trauma population increased with age from 25 to 44 years, male gender, Caucasian race, and positive alcohol toxicology. Disability (as measured by discharge disposition), but not injury severity, also seemed to have an influence on suicide rates. Conclusion: Interventions that address modifiable risk factors for suicide (substance abuse, psychiatric disorders, hopelessness, and social isolation) could benefit trauma patients known to be at higher risk for suicide, particularly those abusing alcohol.

In recent years there has been a significant increase in mortality among motorcyclists, especially older riders (40+ years). However, few studies have compared the nature and severity of injuries sustained by older vs. younger cyclists. The purpose of this analysis was to determine differences, if any, in injury patterns to older vs. younger motorcyclists and to explore rider, vehicle, and environmental factors associated with these differences. Older riders were found to have a significantly higher incidence of thoracic injury, especially multiple thoracic injuries, and specifically multiple rib fractures. Older motorcyclists were also more likely to ride larger motorcycles, and were more involved in collisions involving overturning or striking highway structures. Large engine sizes were associated with increased risk of head and thoracic injuries, but not abdominal injuries. The magnitude of increased risks related to 1000+ cc engine size was higher among older motorcyclists than younger motorcyclists.

Alcohol dependence has been associated with behavioral risk factors and risk-taking tendencies. We investigated whether past alcohol dependent trauma center patients (n=42) retain the characteristics of current alcohol dependent patients (n=67) or whether they resemble patients without history of alcohol dependence (n=262). We found that past alcohol dependence patients retain some of the risk-taking tendencies (impulsivity and sensation seeking) and risk-taking behaviors (drinking and driving, riding with a drunk driver, binge drinking, speeding for the thrill) common to current alcohol dependent patients and they remain at a higher injury risk than the non alcohol dependent population.

Low risk perception and high impulsivity, in conjunction with substance abuse disorders, are associated with the occurrence of injury in the general population. The study described in this article investigated the association of risk perception and impulsivity with risky behaviors (infrequent seat belt use, drinking and driving, riding with a drunk driver, binge drinking, and speeding for the thrill) among adults with unintentional blunt trauma. Patients (N = 756) were assessed for substance abuse disorders and participation in risky behaviors. Risk perception and impulsivity were measured by questionnaire. Pearson's chi-square statistic was used to investigate risk perception, impulsivity, substance abuse, and possible confounders relative to risky behaviors. Odds ratios were calculated using logistic regression methodology. Univariate results indicated that low risk perception and high impulsivity were significant risk factors for risky behaviors. After adjustment for confounding factors, low risk perception and high impulsivity remained significantly associated with risky behaviors in the trauma patient population.

OBJECTIVE: To assess the utility of laboratory markers of severe alcoholism in a cross-sectional population of male trauma center patients, who have a high rate of current alcohol dependence (CAD). METHODS: A total of 684 men were assessed for CAD by using standard criteria, all of whom had complete laboratory data. The ability of tests to predict CAD was ascertained by using Student's t test, sensitivity, specificity, and area under the curve (AUC) of receiver operating characteristic curves. RESULTS: Mean values of five tests were individually associated with a CAD diagnosis. Gamma-glutamyltransferase, aspartate aminotransferase, and mean corpuscular volume had sensitivities less than or equal to 0.51 and AUC less than or equal to 0.67. Blood alcohol concentration (BAC) and serum osmolality had sensitivities of 0.64 and 0.74 and AUC of 0.74 and 0.76, respectively. Each marker, when combined with BAC, showed little improvement in AUC over BAC alone. CONCLUSIONS: Laboratory tests are not highly predictive of CAD in male trauma patients. A combination of BAC tests and interview screens is suggested for use in this patient population.

Introduction: Acute spinal cord injury is associated with significant morbidity and mortality. Spinal cord injury patients often develop neurogenic shock (NS). Our objective is to determine whether the development of NS has any impact on the outcome of SCI patients. Methods: SCI patients admitted to