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Introduction: The aim is comparing the quality of care at a typical American trauma center (USC) vs. an equivalent European referral center in Spain (SRC), through the analysis of preventable and potentially preventable deaths., Methods: Comparative study that evaluated trauma patients older than 16 years old who died during their hospitalization. We cross-referenced these deaths and extracted all deaths that were classified as potentially preventable or preventable. All errors identified were then classified using the JC taxonomy., Results: The rate of preventable and potentially preventable mortality was 7.7% and 13.8% in the USC and SRC respectively. According to the JC taxonomy, the main error type was clinical in both centers, due to errors in intervention (treatment). Errors occurred mostly in the emergency department and were caused by physicians. In the USC, 73% of errors were therapeutic as compared to 59% in the SRC (P=.06). The SRC had a 41% of diagnosis errors vs just 18% in the USC (P = .001). In both centers, the main cause of error was human. At the USC, the most frequent human cause was 'knowledge-based' (44%). In contrast, at the SRC center the most common errors were 'rule-based' (58%) (P<.001)., Conclusions: The use of a common language of errors among centers is key in establishing benchmarking standards. Comparing the quality of care of an American trauma center and a Spanish referral center, we have detected remarkably similar avoidable errors. More diagnostic and 'ruled-based' errors have been found in the Spanish center., (Copyright © 2017. Publicado por Elsevier España, S.L.U.)

Purpose: To describe the injuries due to fireworks use in Colombia during the period 2008-2013 and to identify factors associated with hospitalization and death due to this cause., Methods: A descriptive study from surveillance data was carried out. Incidence rates and relative risks were calculated. The incidence rate trend was modeled with a joint point regression model. Multivariate logistical models were implemented to identify the associated factors with hospitalization and mortality due to firework injuries., Results: A total of 6585 people were reported to be injured by fireworks during the 2008-2013 period. An upward trend in the incidence rate during this period was observed, with an annual percentage of change of 28% (95% CI 27.7-28.3) during 2008-2011 and 3.5% (95% CI 3.0-3.9) during 2011-2013. The factors associated with hospitalization were injury occurrence at the workplace (odds ratio (OR) 2.62, 95% CI 1.97-3.47), storage (OR 2.40, 95% CI 1.54-3.73), transport (OR 1.63, 95% CI 1.20-2.21), multiple trauma (OR 1.49, 95% CI 1.31-1.70), and injury occurrence at home (OR 1.26, 95% CI 1.07-1.50). The factors associated with mortality were storage (OR 19.52, 95% CI 4.62-82.44), transport (OR 13.37, 95% CI 3.29-54.3), injury occurrence at the workplace (OR 4.88, 95% CI 1.69-14.13), and ethnicity (OR 3.37, 95% CI 1.12-10.12)., Conclusion: These results provided information for revising the public policies and intersectorial interventions to reduce the avoidable burden due to firework injuries at all times and not just during the high injury occurrence season., (Copyright © 2016 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: The incidence of ladder-related falls is increasing, and this represents a disturbing trend, particularly in the context of increased life expectancy and the impending retirement of the populous 'baby-boomer' generation. To date, there have been no critical illness-focused studies reporting on the incidence, severity and outcomes of severe ladder-related injuries requiring ICU management., Methods: Major trauma patients admitted to ICU over a 5year period to June 2011 after ladder falls >1m were identified from prospectively collected trauma data at a Level 1 trauma service. Demographic and ICU clinical management data were collected and non-parametric statistical analyses were used to explore the relationships between variables in hospital mortality/survival., Results: There were 584 ladder fall admissions, including 194 major trauma cases, of whom 29.9% (n=58) fell >1m and were admitted to ICU. Hospital mortality was 26%, and fatal cases were almost entirely older males in domestic falls of ≤3m who died as a result of traumatic brain injury. Non-survivors had lower GCS at the scene (p=0.02), higher AIS head code (p=0.01), higher heart rate and lower mean arterial pressure (p<0.01) in the initial 24h period in ICU, and were ≥55years of age (p=0.05). Only 46% of patients available for follow-up were living at home at 12months without requiring additional care., Conclusions: The incidence of ladder falls requiring ICU management is increasing, and severe traumatic brain injury was responsible for the majority of deaths and for poor outcomes in survivors. In-hospital costs attributable to the care of these patients are high, and fewer than half were living independently at home at 12months post-fall. A concerted public health campaign is required to alert the community to the potential consequences of this mechanism of injury. The use of helmets for ladder users in domestic settings, where occupational health and safety regulations are less likely to be applied, is strongly recommended to mitigate the risk of severe brain injury. The benefits of this simple strategy far outweigh any mild inconvenience for the wearer, and may prevent catastrophic injury., (Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.)

Objective: To quantify unintentional injuries associated with housing elements among children less than 18 years old treated in US hospital emergency departments., Methods: The National Electronic Injury Surveillance System (NEISS) coding manual was reviewed, and all product codes that identified products permanently affixed to a home (housing elements) were identified. A query of the 2008 NEISS data for children under 18 determined the numbers of cases by severity code for each identified housing element. Housing elements were then tabulated by the number of cases for each severity code. The top 10 cases by severity code, (1) hospitalised or (2) treated in emergency departments, were included in a case review. Ten per cent of all cases or a minimum of 100 cases were randomly selected for review for each of the identified housing elements to assess if the case description could inform prevention efforts., Results: Twelve housing elements (bathtub, cabinet, carpet, ceiling/wall, counter, door, fence, floor, nail, porch, stairs and window) were identified as the leading causes of injuries resulting in hospitalisations or emergency department visits. A list of potential interventions was generated based on the review of the case histories. Suggested changes for NEISS coding are also offered to enhance future prevention research., Conclusions: NEISS is a valuable tool to identify home injury risks and inform design decisions for housing elements. Improved understanding of housing elements associated with injuries has the potential to enhance home inspection forms. However, interpretation of NEISS results is limited by lack of clarity about how the housing element was involved in the injury event., (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/)

Background: Martial arts such as judo, taekwondo and wrestling are regulated, usually athletic duels. The aim is to score better than your opponent or to win. As with any type of sport, athletes in martial arts sustain minor and major injuries, which may have many negative consequences. In addition, sports injuries and their rehabilitation generate high costs to the healthcare system. In contrast to the FIFA 11+ warm-up program, no preventive programs have been postulated for injury prevention in these martial arts. Therefore, the aim of this systematic review was to summarise the latest research findings and to evaluate whether initial recommendations can be given for the reduction of injuries in the martial arts judo, wrestling and taekwondo., Methods: To gain an overview of the latest research findings, we searched for systematic reviews in PEDro, PubMed, Cochrane and the internet search engine Google Scholar. The methodological quality of these reviews was assessed using the Critical Appraisal Tool for a Systematic Review (CASP), and data was extracted on the risk of injury, injury location and injury type., Results: It was found that all three review articles are of low to moderate methodological quality. Regarding injury location, it became evident that the extremities are particularly vulnerable to injury in all three martial arts. Effusion was observed to be the most common type of injury., Conclusion: Due to the moderate methodological quality and the injury type of effusion, it is not possible to formulate recommendations for injury prevention. Moreover, uniform definitions should be developed to describe sports injuries., (© Georg Thieme Verlag KG Stuttgart · New York.)

To prevention death and serious injuries personnel must be equipped with war materiel collective and individual antimine defence. The experience gained in the establishment of protective equipment shows that modern technology can prevent serious injuries and moderately severe blast injuries in the members of the crew an ensure injury prevention not less than 95%. The solution to this problem is achieved by exception of conditions for spinal compression fractures, ankle and foot fractures, severe and moderately severe brain contusions and eardrum ruptures. Anti-mine defence effectiveness test should be carried in situ and in semi natural environment using as an analogue of the human body a biomorphic model and recording parameters and traumatic factors in the following mathematical simulation of the reaction of the human body on the effect of these factors.

Introduction: Pregnancy associated osteoporosis (PAO) was first reported almost half a century ago. The most common symptom is acute lower back pain due to vertebral fractures in the last trimester or immediately after birth., Patient: We present a case involving a female patient born in 1971 (gravida II, para I) with a history of PAO. In April 2000 at the age of 28 years, she delivered a son and breastfed him for 4 months. A first magnetic resonance tomography (MRT) screening in June 2000 showed osteoporotic fractures at lumbar vertebra 1-4. Therefore, the patient received oral alendronate therapy. In May 2001, a second MRT exhibited burst fracture of thoracic 8, end-plate fracture of thoracic 11, 12, lumbar 2-5 and compression fracture of lumbar 1. The oral therapy was switched to ibandronate (3 mg) intravenously every 3 months. An X-ray in December 2002 showed 3 new additional end-plate fractures at thoracic 4, 6 and 7. Ibandronate was discontinued in September 2004 and the patient received daily subcutaneous (s. c.) injections of 1-34 PTH in September 2005., Results: After starting 1-34 PTH treatment for 18 months, a further increase in bone mineral density (BMD) was achieved without any further fracture., Conclusion: We presented for the first time a case of severe PAO with 11 spine fractures. We observed an unsatisfactory effect of oral and i. v. bisphosphonates in combination with adequate calcium and vitamin D supplementation. The treatment with 1-34 PTH showed an increase in BMD with no further fractures., (© Georg Thieme Verlag KG Stuttgart · New York.)

Unlabelled: Rollover car crashes (ROCs) are serious public safety concerns worldwide., Objective: To determine the incidence and outcomes of ROCs with or without ejection of occupants in the State of Qatar., Methods: A retrospective study of all patients involved in ROCs admitted to Level I trauma center in Qatar (2011-2012). Patients were divided into Group I (ROC with ejection) and Group II (ROC without ejection)., Results: A total of 719 patients were evaluated (237 in Group I and 482 in Group II). The mean age in Group I was lower than in Group II (24.3 ± 10.3 versus 29 ± 12.2; P = 0.001). Group I had higher injury severity score and sustained significantly more head, chest, and abdominal injuries in comparison to Group II. The mortality rate was higher in Group I (25% versus 7%; P = 0.001). Group I patients required higher ICU admission rate (P = 0.001). Patients in Group I had a 5-fold increased risk for age-adjusted mortality (OR 5.43; 95% CI 3.11-9.49), P = 0.001)., Conclusion: ROCs with ejection are associated with higher rate of morbidity and mortality compared to ROCs without ejection. As an increased number of young Qatari males sustain ROCs with ejection, these findings highlight the need for research-based injury prevention initiatives in the country.

Alpine skiing is the most popular winter sport discipline in Germany and is performed by more than 4 million recreational sportsmen and ski racing athletes. Compared to other sports, however, the injury rate in alpine skiing is quite high. Especially the knee joint is the most commonly injured area of the musculoskeletal system. Knee injuries are classified as severe in a high percentage of cases. In this review article, epidemiologic data and typical injury patterns in recreational alpine skiing and in competitive alpine ski racing are compared. In addition, the potentials of preventive methods in alpine skiing are presented and evaluated with a special focus on orthotic devices and protection wear as injury prevention equipment.

The purpose of this study was to elucidate the role of alpha-tocopherol succinate (TS)- and AMD3100-mobilized progenitors in mitigating combined injury associated with acute radiation exposure in combination with secondary physical wounding. CD2F1 mice were exposed to high doses of cobalt-60 gamma-radiation and then transfused intravenously with 5 million peripheral blood mononuclear cells (PBMCs) from TS- and AMD3100-injected mice after irradiation. Within 1 h after irradiation, mice were exposed to secondary wounding. Mice were observed for 30 d after irradiation and cytokine analysis was conducted by multiplex Luminex assay at various time-points after irradiation and wounding. Our results initially demonstrated that transfusion of TS-mobilized progenitors from normal mice enhanced survival of acutely irradiated mice exposed 24 h prior to transfusion to supralethal doses (11.5-12.5 Gy) of (60)Co gamma-radiation. Subsequently, comparable transfusions of TS-mobilized progenitors were shown to significantly mitigate severe combined injuries in acutely irradiated mice. TS administered 24 h before irradiation was able to protect mice against combined injury as well. Cytokine results demonstrated that wounding modulates irradiation-induced cytokines. This study further supports the conclusion that the infusion of TS-mobilized progenitor-containing PBMCs acts as a bridging therapy in radiation-combined-injury mice. We suggest that this novel bridging therapeutic approach involving the infusion of TS-mobilized hematopoietic progenitors following acute radiation exposure or combined injury might be applicable to humans.

With the incidence of work-related injuries decreasing, we continue to observe an unchanged trend in leisure-related accidents. As in any other hobby, model flying devices bear the risk for accidents among builders and flyers ranging from skin lacerations to complicated and even life-threatening injuries. The fast-moving razor-sharp propeller blades predominantly cause trauma to the hands and fingers resulting in typical multiple parallel skin injuries also affecting structures deep to the dermis (e. g., tendons, vessels and nerves). The resultant clinical management involves complex reconstructive surgical procedures and prolonged rehabilitative follow-up. Improving the legal framework (e. g., warnings by the manufacturer) on the one hand, providing informative action and sensitising those affected on the other, should form a basis for an altered prevention strategy to reduce model flying device-related injuries in the future., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To assess whether the Brazilian Driving Dry Law reached its goal after the three years following its enactment., Methods: We conducted a retrospective study of patients with craniofacial fractures who underwent surgery at a university hospital in two periods: before the Law (2005 to 2008) and after the Law (2008 to 2011)., Results: 265 patients (220 men and 45 women) were operated on during this period, 149 (56%) before and 116 (44%) after the Law, which indicates a reduction in the number of traumatisms (p=0.04). The age range between 19 and 40 years predominated in both periods. The main causes of traumas were car accidents, physical aggression and falls. Alcohol abuse was identified in 15.4% patients before and 19% patients after the enactment. The jaw and the maxillo-zygomatic complex were the most affected bones., Conclusion: The drop in the number of polytraumatized patients operated on at this institution in the three years following the Driving Dry Law was 22%, which is below the expected and desired percentage. These results must be compared to those of different services offering the same attendance type in order to compile data and enlarge statistics. The low index of reduction in the number of traumatisms and the report of alcohol abuse by several patients at the moment of trauma, even after the law, evidence the need of adopting stricter measures to control and punish violators.

Background: Despite the benefit of safety vests to the reduction of torso injuries in children and adolescents is unclear, its' use is recommended. The aim of the present study is to determine the effectiveness of safety vests actually used in pediatric equestrian activities., Patients and Method: In this case-control-study, we analyzed the accidents of 92 riders aged 18 or younger who fell off a horse onto his/her torso during a period of 18 months. Data were gathered from the clinical records. Additionally, a questionnaire was administered on the day of trauma by the patients and/or their parents., Results: The cases comprised 31 patients who sustained torso injuries. The controls were 61 riders with injuries of other body parts than to the torso. Safety vest use was not associated with a lower risk of torso injuries (OR=1.18, 95% CI (0.50, 2.81), p=0.707). Post hoc power analysis revealed that within such a setting an odds ratio of 0.266 could be found with a power of 80%., Conclusion: This study is not able to show an association between wearing a torso protector and protection from torso injuries, probably due to confounding. We did not detect a high effect of safety vest usage in our study population. Whether the development of a new generation of safety vests might be more effective remains unclear. An effective vest should be adapted to the requirements of children and adolescents and should protect the thorax and abdomen, but also the cervical and the lumbar spine., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To examine injuries sustained in noncombat motor vehicle accidents (MVAs) during Operation Iraqi Freedom by injury type, site, and severity., Methods: Three hundred and forty-eight military personnel injured in noncombat MVAs from March 2004-June 2007 were identified from clinical records completed near the point of injury., Results: On average, personnel suffered two injuries per accident. The most frequent MVA mechanism was non-collision due to loss of control (30%). Overall, 16% were injured in a collision accident and 19% in a rollover accident. Rollovers were associated with more severe injuries. A greater proportion of drivers sustained head/neck/face injuries, whereas gunners and pedestrians had higher percents of extremity injuries., Conclusions: This analysis provides a thorough overview of injuries incurred in nonbattle MVAs in the combat environment. Future research should combine injury data with accident reports to elucidate areas for improvements in vehicle safety., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background and Purpose: Adjacent VCF frequently occurs after percutaneous vertebroplasty. Our aim was to evaluate PrVP in the prevention of PVNO-adjacent VCF., Materials and Methods: Radiographs of 68 patients who initially presented with a single-level unhealed fracture and underwent vertebroplasty were retrospectively reviewed for the occurrence of PVNO fracture. Patients in the nonpreventive group (n = 33) underwent TVP only for a vertebra with an unhealed fracture. The preventive group (n = 35) underwent PrVP combined with TVP. We injected bone cement into the caudal part of the superior adjacent vertebra and the cephalic part of the inferior adjacent vertebra to perform PrVP., Results: The incidences of PVNO fracture in adjacent vertebra next to a vertebra cemented at the patient's first vertebroplasty (within 6 months: 24% versus 3%, P = .012; within 1 year: 30% versus 3%, P = .006; >4 years: 39% versus 3%, P = .006) markedly decreased in the preventive group compared with the nonpreventive group. PVNO fracture was found in 26% of vertebrae adjacent to the first TVP level in the nonpreventive group and in 2% of vertebrae adjacent to a PrVP level in the preventive group after inclusion of all PrVP procedures. Approximately 33% of patients in the nonpreventive group underwent repeat vertebroplasty, mainly due to adjacent fractures. Only 3% of patients in the preventive group underwent repeated procedures. None of the vertebrae cemented for PrVP or TVP developed PVNO refracture., Conclusions: Preventive vertebroplasty for the adjacent vertebra combined with TVP for the fractured vertebra is effective in the prevention of propagation of PVNO adjacent fractures, thus reducing the necessity of multiple repeat vertebroplasty procedures.

We analyzed an incident of exposure to pepper spray 35 persons, including 29 children. Medical procedures were difficult because of the lack of reliable information about the nature of exposure, lack of hospital action plan for chemical accidents and established principles of cooperation with poison control center, as well as the need of extensive medical documentation for each patient.

Background: Domestic accidents (DA) are preventable and untoward events occurring in a house, pool or garage. Those events constitute a major issue in the context of public health. The objective of this study was to highlight the characteristics of female involvement in DA and their level of knowledge regarding first aid., Methods: Adult female relatives of patients presenting at the university-based emergency department within the six-month study period comprised the study sample. They were asked to answer a 23-item self-reported questionnaire, and the responses were analyzed., Results: A total of 1017 women (mean age: 29.2±11.1 years) were enrolled in the study. Hand lacerations (n=924, 90.8%), sprain and contusions (n=904, 88.8%) and burns (n=803, 78.9%) were the most commonly reported types of DA. The children were reported to suffer mostly from hits, sprains and contusions (n=478, 91.7%), followed by falls and slipping (n=452, 86.7%). The telephone number of emergency medical services was recalled most frequently (n=871, 85.6%), while that of the poison control center was known least commonly (n=48, 4.7%). The group with the highest level of education had a significantly higher mean number of correct answers than that of the group with the lowest level of education (p=0.001). The knowledge level of the women who worked was significantly lower than that of the unemployed women (p=0.02)., Conclusion: Extensive training of women on DA should be undertaken and the mass media should be utilized to achieve this goal.

Background: The purpose of this study was to define the epidemiologic properties and correlation of physiological and anatomical risk factors with the mortality rate among patients with thorax trauma and to ensure early prediction of severe trauma., Methods: Files of 371 cases were retrospectively examined. Their initial state in the emergency department was analyzed in terms of mortality development. Age, gender, trauma mechanism, systolic blood pressure and respiration type on admission, accompanying injuries, thorax pathology, trauma scores, and treatment approaches in exitus and surviving cases were compared. Survival probabilities and unexpected mortality rates were computed using the Trauma Revised Score-Injury Severity Score (TRISS)., Results: Age, hypotension, pathologic respiration, blunt injury, accompanying injury, abdominal trauma, high Injury Severity Score (ISS), and low Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), and TRISS were the factors affecting mortality, and presence of blunt injuries, TRISS <85, ISS >22 and GCS <13 were found to be independent prognostic factors. The strongest factor indicating mortality was TRISS. Thirty-four of 307 cases with survival probability of over 50% died., Conclusion: In the presence of factors affecting mortality, patients with thorax trauma should be evaluated as being in a high-risk group and treatment strategies must be aggressive. Case analysis based on the TRISS model would further reveal the mistakes and may improve patient care.

Introduction: The success of traffic safety improvement strategies is based on documentation. Analysis and remedy of accident black spots in addition to improvements in automobile production involve the work of traffic engineers, politicians, traffic regulations, police, and medical care. To create priorities, the traffic statistics differentiate accidents in a 3-class system in relation to severe accidents: slightly injured, severely injured and fatally injured (death). This study assesses the validity of the existing classification of "severely injured" compared with the actual injury severity., Material and Method: We analysed accidents resulting in 182 "severely injured" people in one year in a city model. A synchronisation of anonymous police documentation with the medical notes of admitted casualties which were validated by established trauma scores and medical classification was undertaken. A correlation analysis of length of stay should give indications of the actual injury severity., Results: The study group showed a ubiquitous range of age, sex and injuries despite a relatively low case number. The range of MAIS, ISS and NACA index scores shows the inhomogeneity of the people classified as "severely injured". 70 % of the study group revealed ISS < 16 which means that they are not polytraumatised patients. The correlation analysis according to Spearman certifies the validity of these scores (r MAIS/NACA = 0.645 and r ISS/NACA = 0.592). The further differentiation on the basis of MAIS, ISS and NACA showed that 51 % of the study group should be classified as slightly injured and 83 % of these were discharged in less than 5 days., Conclusion: This study shows that the traffic safety classification of "severely injured" people is not sufficient and most severely injured people are not even approximately recorded. We propose that a new continuous link system between police and medical data will be inevitable for future improvements in traffic safety. The use of established trauma scores and a differentiated look at lengths of stay could be an option., (© Georg Thieme Verlag KG Stuttgart · New York.)

This paper presents findings from the rural and remote road safety study, conducted in Queensland, Australia, from March 2004 till June 2007, and compares fatal crashes and non-fatal but serious crashes in respect of their environmental, vehicle and operator factors. During the study period there were 613 non-fatal crashes resulting in 684 hospitalised casualties and 119 fatal crashes resulting in 130 fatalities. Additional information from police sources was available on 103 fatal and 309 non-fatal serious crashes. Over three quarters of both fatal and hospitalised casualties were male and the median age in both groups was 34 years. Fatal crashes were more likely to involve speed, alcohol and violations of road rules and fatal crash victims were 2½ times more likely to be unrestrained inside the vehicle than non-fatal casualties, consistent with current international evidence. After controlling for human factors, vehicle and road conditions made a minimal contribution to the seriousness of the crash outcome. Targeted interventions to prevent fatalities on rural and remote roads should focus on reducing speed and drink driving and promoting seatbelt wearing., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Various systems for rating secondary safety of particular makes and models of vehicles have been developed internationally. These measures generally evaluate crashworthiness (the ability of the vehicle to protect its own occupants in the event of a crash) separately from aggressivity (the harm a vehicle is liable to impose on other road users into which it crashes). This paper describes an approach using Australian and New Zealand data that combines these two facets of secondary safety into one 'Total Secondary Safety Index' estimated from real world crash outcomes. The Index estimates the risk of death or serious injury to all key road users in crashes involving light passenger vehicles across the full range of crash types. This paper describes the rationale and method for producing this Index, together with some estimates for common Australian and New Zealand makes and models of light passenger vehicles., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

This paper reports on the findings of a retrospective case series study of fatal motorcyclist-roadside barrier collisions. Cases were retrieved from the National Coroners Information System (NCIS), the coronial case files of Australian jurisdictions, and the Crash Analysis System (CAS) of the New Zealand Transport Agency. Seventy seven (77) motorcycle fatalities involving a roadside barrier in Australia and New Zealand were examined. The fatalities usually involved a single vehicle crash and young men. The roadside barriers predominantly involved were steel W-beams, typically on a bend in the horizontal alignment of the road. A majority of fatalities occurred on a weekend, during daylight hours, on clear days with dry road surface conditions indicating predominantly recreational riding. Speeding and driving with a blood alcohol level higher than the legal limit contributed to a significant number of these fatalities., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objectives: Previous research has found that older driver fatal crash involvement rates per licensed driver declined substantially in the United States during 1997-2006 and declined much faster than the rate for middle-age drivers. The current study examined whether the larger-than-expected decline for older drivers extended to nonfatal crashes and whether the decline in fatal crash risk reflects lower likelihood of crashing or an improvement in survivability of the crashes that occur., Methods: Trends in the rates of passenger vehicle crash involvements per 100,000 licensed drivers for drivers 70 and older (older drivers) were compared with trends for drivers ages 35-54 (middle-age drivers). Fatal crash information was obtained from the Fatality Analysis Reporting System for years 1997-2008, and nonfatal crash information was obtained from 13 states with good reporting information for years 1997-2005. Analysis of covariance models compared trends in annual crash rates for older drivers relative to rates for middle-age drivers. Differences in crash survivability were measured in terms of the odds of fatality given a crash each year, and the historical trends for older versus middle-age drivers were compared., Results: Fatal crash involvement rates declined for older and middle-age drivers during 1997-2008 (1997-2005 for the 13 state subsample), but the decline for drivers 70 and older far exceeded the decline for drivers ages 35-54 (37 versus 23 percent, nationally; 22 versus 1 percent, 13 states). Nonfatal injury crash involvement rates showed similarly larger-than-expected declines for older drivers in the 13 state subsample, but the differences were smaller and not statistically significant (27 percent reduction for older drivers versus 16 percent for middle-age drivers). Property-damage-only crash involvement rates declined for older drivers (10 percent) but increased for middle-age drivers (1 percent). In 1997, older drivers were 3.5 times more likely than middle-age drivers to die in police-reported crashes (6.2 versus 1.8 deaths per 1000 crashes), but this difference was reduced during the 9-year study period to 2.9 times, as the rate of older drivers dying in a crash declined (5.5 deaths per 1000 crashes in 2005) and the death risk remained relatively stable for middle-age drivers., Conclusions: Contrary to expectations based on increased licensure and travel by older drivers, their fatal crash risk has declined during the past decade and has declined at a faster rate than for middle-age drivers. The decreased risk for older drivers appears to extend not only to nonfatal injury crashes but also to property-damage-only crashes, at least as reported to police in the 13 states included in the nonfatal injury analysis. Although insurance collision data suggest that overall crash risk of older drivers may not be changing relative to middle-age drivers, the current analysis indicates that the reduced fatality risk of older drivers reflects both less likelihood of being involved in a police-reported crash and greater likelihood that they will survive when they do crash., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Standard multinomial logit (MNL) and mixed logit (MXL) models are developed to estimate the degree of influence that bicyclist, driver, motor vehicle, geometric, environmental, and crash type characteristics have on bicyclist injury severity, classified as property damage only, possible, nonincapacitating or severe (i.e., incapacitating or fatal) injury. This study is based on 10,029 bicycleinvolved crashes that occurred in the State of Ohio from 2002 to 2008. Results of likelihood ratio tests reveal that some of the factors affecting bicyclist injury severity at intersection and non-intersection locations are substantively different and using a common model to jointly estimate impacts on severity at both types of locations may result in biased or inconsistent estimates. Consequently, separate models are developed to independently assess the impacts of various factors on the degree of bicyclist injury severity resulting from crashes at intersection and non-intersection locations. Several covariates are found to have similar impacts on injury severity at both intersection and non-intersection locations. Conversely, six variables were found to significantly influence injury severity at intersection locations but not non-intersection locations while four variables influenced bicyclist injury severity only at non-intersection locations. In crashes occurring at intersection locations, the likelihood of severe bicyclist injury increases by 14.8 percent if the bicyclist is not wearing a helmet, 82.2 percent if the motorist is under the influence of alcohol, 141.3 percent if the crash-involved motor vehicle is a van, 40.6 percent if the motor vehicle strikes the side of the bicycle, and 182.6 percent if the crash occurs on a horizontal curve with a grade. Results from non-intersection locations show the likelihood of severe injuries increases by 374.5 percent if the bicyclist is under the influence of drugs, 150.1 percent if the motorist is under the influence of alcohol, 53.5 percent if the motor vehicle strikes the side of the bicycle and 99.9 percent if the crash-involved motor vehicle is a heavy-duty truck., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

The titanium rib procedure is a safe and effective way of surgically treating pediatric patients with thoracic insufficiency syndrome and scoliosis. As with any invasive surgical procedure, it is not without risks. This article explains the potential risks to neurological structures while outlining the surgical approach and the neurological anatomy in the vicinity of the implanted instrumentation. The types of potential nerve injury involve ischemia, trauma, compression, and stretch. Furthermore, a suitable compilation of modalities of intraoperative neurophysiologic monitoring is recommended to detect and avoid long-term nerve or spinal cord insult. Monitoring modalities that would be appropriate for this procedure are discussed.

Over the course of 2009, dozens of nations signed a new convention on cluster munitions, and several nations ratified the convention. To determine how public health professionals can participate in preventing death and injury from cluster munitions, we review the history of these weapons, their effects on individuals and communities, the history of efforts to limit their use, the Convention on Cluster Munitions, and ways that health professionals can support efforts to ban their use. Cluster munitions are a threat to civilians in conflict and post-conflict settings. They render homes, farms and businesses dangerous and inaccessible, and delay resettlement after the end of a conflict. Health professionals have led efforts to limit the use and proliferation of other weapons, and global collaboration to support the Convention on Cluster Munitions would be a step towards protecting the public's health.

Patients with the seat belt sign (SBS) from motor vehicle crashes (MVCs) are prone to specific regional injury patterns. Investigators at a Level 1 trauma center analyzed the incidence, clinical implications, and spectrum of regional injuries in patients injured in MVC over 2 years. SBS was seen in 11.3 per cent of patients injured in MVCs and 20.5 per cent of patients with known restraint use. Restrained patients were less severely injured with lower injury severity scores (7.62 vs 11.33) and mortality (1.1 vs 5.7%). Patients with SBS had lower mortality rates than patients without SBS (1.4 vs 3.7%). Thoraco-abdominal injuries were present in 47 per cent (34 of 72) of patients with SBS. Compared with patients without SBS, patients had a higher incidence of hollow viscous injuries (HVI) and solid organ trauma (8 and 17% vs 1 and 3%, P < 0.05); splenic trauma was 24-fold higher (9.7 vs 0.4%), liver injuries 3.1-fold higher (6 vs 3%), and rib fractures 2.4-fold higher (P < 0.05). Children had 2.8-fold higher rates of HVI (18 vs 9%, P < 0.05). SBS is associated with underlying regional injuries in nearly half of patients with a higher prevalence of HVI and solid organ trauma.

Background: Side impact crashes, the most lethal type, account for 26% of all motor vehicle crashes in the United States. The purpose of this study is to delineate side impact airbag (SIAB) deployment rates, injury rates, and analyze crash factors associated with SIAB deployment and occupant injury., Methods: All passenger vehicles equipped with SIABs that were involved in a side impact crash were identified from the National Automotive Sampling System database. Crashes with multiple impacts, ejections, unbelted drivers or rollovers were excluded from the study. The outcome variables of interest were SIAB deployment and driver injury. SIAB deployment was compared in similar crashes to analyze the impact on driver's injury severity score. Other crash factors were also examined to analyze what role they play in SIAB deployment rates and injury rates, such as plane of contact, striking object and Delta-V., Results: The data set for this study contained 247 drivers in near and far side crashes in vehicles with installed SIABs. Overall SIAB deployment was 43% in side impact crashes. A significant factor associated with both the SIAB deployment rate and the driver's injury rate was increased Delta-V., Conclusions: SIABs do not deploy consistently in crashes with a high Delta-V or with a lateral primary direction of force and a front plane of contact. In these two scenarios, further research is warranted on SIAB deployments. With SIAB deployment, it appears drivers are able to sustain a higher Delta-V impact without serious injury.

Background: Motorcyclists profit from improved safety measures and medical care only slightly compared with other road users. The aims of this study were to gain new insights into crash mechanisms and the resulting injuries of motorcyclists and to understand trends in road traffic accident statistics over the last 10 years., Methods: In our prospective analysis we documented data from collisions in which at least one subject sustained an injury of 2-6 on the Maximum Abbreviated Injury Scale (MAIS). Additionally, key parameters published by the German Federal Statistical Office were analysed., Results: Data were studied for 66 motorcycle crashes and 66 injured subjects. The mean ISS was 17.9, with injuries of the lower limb (44%) and head (41%) being the most frequent in motorcyclists. Psychometric questionnaires revealed that motorcyclists had a significantly higher willingness to take risks compared with drivers of other vehicles. Federal statistics revealed a dramatic increase in mortality in the first months of 2007, but in the next months, mortality decreased to levels comparable to those of the preceding year., Conclusions: Knowledge of crash mechanisms, injury patterns and profiles of high-risk drivers can help reduce the collision rates and injury severity of motorcyclists.

In many acute or chronic vestibular diseases in old age, the risk of falling is increased. A fear of falling often develops together with further limitations to physical activity and subsequent physical and psychological consequences. Falls represent a substantial health-related risk factor. A regular balance, walking and muscle training is an effective prophylaxis. Components of the treatment of vestibular diseases in old age are counselling and encouragement (psychotherapy), treatment of the specific organic disease, specific vestibular rehabilitation and a symptomatic medication therapy. Vertigo in old age is a multifactorial process. The differential diagnosis of disorders of the equilibrium function in old age represents a challenge which can only be overcome by interdisciplinary cooperation.

Crush syndrome in patients rescued from earthquake is a complex clinical syndrome with many medical conditions. The most common complications are hyperkalemia, acute kidney injury, shock, infection, ARDS, malnutrition and multiorgan dysfunction. Managing these critical issues appropriately is essential for effective treatment of the crush syndrome.

To define the roles of endothelial-intrinsic nuclear factor kappaB (NF-kappaB) activity in host defense and multiple organ injury in response to sepsis, we generated double transgenic (TG) mice (EC-rtTA/I-kappaB alpha mt) that conditionally overexpress a degradation-resistant form of the NF-kappaB inhibitor I-kappaB alpha (I-kappaB alpha mt) selectively on vascular endothelium. The EC-rtTA/I-kappaB alpha mt mice had no basal, but a relatively high level of doxycycline-inducible, I-kappaB alpha mt expression. I-kappaB alpha mt expression was detected in endothelial cells, but not in fibroblasts, macrophages, and whole blood cells, confirming that transgene expression was restricted to the endothelium. When subjected to endotoxemia, EC-rtTA/I-kappaB alpha mt mice showed endothelial-selective blockade of NF-kappaB activation, repressed expression of multiple endothelial adhesion molecules, reduced neutrophil infiltration into multiple organs, decreased endothelial permeability, ameliorated multiple organ injury, reduced systemic hypotension, and abrogated intravascular coagulation. When subjected to cecal ligation and puncture-induced sepsis, the TG mice had less severe multiple organ injury and improved survival compared with wild-type (WT) mice. WT and EC-rtTA/I-kappaB alpha mt mice had comparable capacity to clear three different pathogenic bacteria. Our data demonstrate that endothelial NF-kappaB activity is an essential mediator of septic multiple organ inflammation and injury but plays little role in the host defense response to eradicate invading pathogenic bacteria.

The goal of the Canadian Association of Pediatric Surgeons is to improve the surgical care of infants and children in Canada. Its areas of interest include all aspects of general and thoracic pediatric surgery with recognition of its unique responsibility to infants born with congenital anomalies and children with malignancies. Although its responsibility to pediatric trauma is not unique, that injury remains the number one cause of death of all children beyond infancy creates a pivotal role of this association in issues related to pediatric trauma. With modern methods of first aid, transportation, resuscitation, intensive care, and specialized surgical team effort, many of these seriously traumatized children can be saved. However, despite these advances in trauma care, it is recognized that the most important and ultimate approach to childhood injuries lies in the realm of prevention.

During 2006-2007, a midwest pediatric level I trauma center and affiliated urgent care centers treated 181 children for sledding-related trauma. Twenty-one children required hospitalization for injuries. Some children sustained injuries that were severe including cervical fracture with spinal cord injury, splenic laceration, pulmonary contusion, and head injury. The most frequent mechanism of injury was collision with an object or a person. Although most injuries are minor, some are serious and may have life-changing outcomes. Sledding in unobstructed areas may decrease injuries. An increased public awareness of the risks of serious injury associated with sledding is needed.

Fourteen children (median age 43 months, range 14-82 months; 7 girls and 7 boys) were treated for mangle injuries (one hot steam, and 13 cold roller presses) to the hand and forearm between 1996-2002 at the Department of Hand Surgery, Malmö, Sweden. All children had unilateral skin damage with avulsion or necrosis of skin in nine. Seven of the 14 had signs of compartment and carpal tunnel syndromes and three had fractures (phalanges or hamate bone). Initial treatment included fasciotomy, decompression, and skin revision with split skin grafts and later further skin cover, including one pedicled ulnar flap. IN eight the injuries healed uneventfully, while six had slight consequences (such as minor extension deficit of fingers or slight contracture of the scar). Ten of the 14 children came from immigrant families. Mangle injuries can be prevented through better supervision of children by parents when the mangle is being used, and dissemination of information of the potential hazards in relevant languages in residential areas with large immigrant populations.

Rodeo is a fast-moving sport with highly talented and tough athletes. Prevalence of injury is high, especially in rough stock events, which include bareback, saddle bronc, and bull riding. In bull riding, the incidence of injury is reported at 32.2 injuries per 1000 competitor-exposures. While a number of different injuries can occur during bull riding, concussions are often the most alarming. However, they may also be the most amenable to prevention, despite resistance from rodeo cowboys and organization rulemakers to the use of protective headgear and lack of adherence to recovery guidelines. Rodeo athletes want to return to their sport despite injuries and rarely seek medical care; nonetheless, arena-side health care is still utilized and appreciated by rodeo cowboys. This article addresses the need for greater use of preventative equipment, the importance of allowing full recovery from concussions, and the need to make medical care more available to the rodeo athlete.

Background: In major trauma patients, multiple organ failure (MOF) is considered a leading cause of death. Acute lung injury is deemed a "pacemaker" of MOF. The purpose of this study was to determine if incidence of organ failure and mortality in multiple trauma patients can be reduced by implementation of lung-protective strategies., Methods: All critically ill multiple trauma patients admitted to the ICU of a major trauma center in Berlin, Germany from January 1999 to December 2002 were analyzed retrospectively. Patients were ventilated pressure controlled with low tidal volumes and adequate PEEP., Results: n=287 patients were included. The most frequent injuries were traumatic brain injury (TBI-68%), chest trauma (68%), and lung contusions (55%). Injury severity score (ISS) was 32+/-19 (mean+/-standard deviation), polytraumaschluessel (PTS) 34+/-19, and APACHE II 14+/-7. During their ICU-stay 16 patients died, 9 (56%) from TBI. Single-organ-failure occurred in n=69 patients (24%, mortality 5%), two-organ-failure in n=22 (8%, mortality 14%), and MOF in n=9 (3%, mortality 13%); one patient died from MOF 14 days after trauma. The number of days on mechanical ventilation increased depending on the number of organs failed (R=0.618, p<0.001). Seven patients (2%) fulfilled ARDS criteria for longer than 24h despite optimized ventilatory settings, one died of irreversible shock. Patients with MOF had a significantly increased ICU-LOS (35+/-15 days) compared to patients without organ failure (11+/-11 days; p<0.001)., Conclusion: The low incidence of MOF in our series of trauma patients suggests that MOF may be prevented in some patients by implementation of lung-protective strategies. The improved outcome was associated with an increased ICU-LOS.

Background: The care for trauma patients has undergone major changes during the last decades. Additionally, many injury prevention measures have been established. The objective of these efforts was to reduce the number of traumatic incidents and to reduce mortality and morbidity in injured patients. The aim of our study was to assess how these measures and improved care have altered trauma mechanisms, occurrence of injuries, treatment, and outcome in the trauma population treated at our trauma center., Methods: Two cohorts of trauma patients with an Injury Severity Score >15, treated at the University Medical Center Groningen were compared. The first cohort was treated from 1985 to 1990, the second cohort from September 2002 to January 2005., Results: The annual mean number of severely injured patients increased by 76%. Fourteen percent more patients had sustained an injury at home. The mean age increased from 33 +/- 22 years to 41 +/- 23 years. The presence of severe head and neck injuries in the patients increased from 62% to 73%. Inhospital mortality remained unchanged at 25%. The outcome of survivors improved; 67% of patients made a moderate or good recovery versus 40% almost 20 years ago., Conclusions: Striking are the consequences of the aging of the Dutch population: an almost 10-year increase in mean age and a rise in severe head and neck injuries in the population treated at our trauma center. The unchanged mortality and improved outcome of survivors represented the enhanced trauma care.

In Germany, more than 9 million individuals yearly sustain injuries and more than 30,000 fatal injuries. Based on estimations, preventive measures could avoid more than one half of all accidents and could influence the other half of the accidents such that the injuries caused are minor. The aim of an initiative of the Study Group on Injury Prevention of the German Trauma Society (DGU) is a complete inventory of all prevention programs from different expert groups in Germany. A synopsis of the gathered knowledge should serve as a basis for further interdisciplinary preventive measures. The consistent interdisciplinary orientation of this program is a special characteristic including trauma surgery, orthopedics, pediatric surgery, pediatrics, sociology, legal medicine, psychology, sports medicine, geriatrics, anesthesiology, and others. Special attention was also directed to the age groups of children/adolescents and the elderly.

Objectives: American Indians (AI's) have the lowest rate of seatbelt use in the nation, putting them at significant risk for motor vehicle crash (MVC) morbidity and mortality. This study compares seatbelt use in victims of level one trauma crashes presenting from on and off AI reservations. Predictors of seatbelt use were evaluated as well. We hypothesized that AI's in crashes on a reservation would have lower rates of seatbelt use, even compared to AI's in crashes from off the reservation., Methods: This is a retrospective cohort study of consecutive MVC victims presenting to a level one trauma facility in Phoenix, Arizona from July 2003 to June 2005. Inclusion criteria were age >11 and transported directly from the crash; struck pedestrians were excluded. Inter-facility transports were also excluded, as these patients would likely represent a sicker population, possibly introducing bias. Characteristics of those patients (sex, race, location of crash, alcohol and seatbelt use) were analyzed in univariate and multivariate logistic regression., Results: Data were collected on 2339 patients. Three hundred ninety-two were excluded, leaving 1947 (83%) available for analysis. AI's had lower rates of seatbelt use compared to all other races. Additionally, AI's on a reservation were less likely to wear seatbelts than those off a reservation (25.9% versus 42.7%). However, when tested in a multivariate analysis with alcohol as a covariate, race and location became insignificant. Low seatbelt use by AI's on the reservation was primarily associated with alcohol use., Conclusion: In this analysis, alcohol, rather than race or location, is the overriding predictor of seatbelt use. This study compared patients that were in crashes, and only those triaged to a level one trauma facility. If we assume unbelted passengers are more severely injured, this would bias our results. The application of these data may help direct future public service efforts to increase seatbelt use in target populations.

Occupational light vehicle (OLV) use is the leading cause of work related traumatic deaths in Westernised countries. Previous research has focused primarily on narrow contexts of OLV-use such as corporate fleet vehicles. We have proposed a comprehensive systems model for OLV-use to provide a framework for identifying research needs and proposing policy and practice interventions. This model presents the worker as the locus of injury at the centre of work- and road-related determinants of injury. Using this model, we reviewed existing knowledge and found most studies focused only on company car drivers, neglecting OLV-users in non-traditional employment arrangements and those using other vehicle types. Environmental exposures, work design factors and risk and protective factors for the wider OLV-user population are inadequately researched. Neither road- nor work-related policy appropriately addresses OLV-use, and population surveillance relies largely on inadequate workers compensation insurance data. This review demonstrates that there are significant gaps in understanding the problem of OLV-use and a need for further research integrating public health, insurance and road safety responses. The model provides a framework for understanding the theory of OLV-use OHS and guidance for urgently needed intervention research, policy and practice.

Injury prevention strategies for child bicyclists have focused on helmet use to prevent head trauma. Handlebars are another source of injury. A retrospective review from 2005 identified 385 admissions to a Level 1 pediatric trauma center of which 23 (5.9%) were pedal cyclists. Four cases (<1.0%) of handlebar injuries were identified. Three children (two bicyclists, one riding a scooter) sustained handlebar impact to the neck. All children with neck injuries had subcutaneous emphysema. Two of the children had pneumomediastinum, which after work-up was managed nonoperatively. One child had a tracheal injury requiring operative intervention. Another child was struck in the upper abdomen resulting in a traumatic abdominal wall hernia requiring emergent exploration and hernia repair. Discordance exists between the apparently minor circumstances of handlebar trauma and the severity of injury sustained by bicyclists. Recognizing the mechanism of handlebar-related injuries and maintaining a high index of suspicion for visceral injuries aids in the diagnosis. The incidence of these injuries is underestimated due to insufficient documentation of the circumstances of injury events and a lack of applicable E-codes specific for handlebar injury.

Summary: A survey conducted between May and September 2005 in the Paris Region collected 67 cases of accidental "falls from heights" among the children under the age of 15. Most of the injured children were under the age of 6 (72%), the majority were boys (72%). More than half of the children's families were from extra-European origin, mostly from Sub-Saharan Africa. In 32% of the cases, the fall occurred as the opening had a protection. A piece of furniture was in place beneath the window or was disposed by the child in 55% of the cases; 33% of the children climbed the parapet or the opening. In third of the falls, there was an adult present with the child in the room. Seven children died (10%) and eight (12%) had sequelae. The risk of fall due to the lack of surveillance is not enough known by adults. It is therefore recommended to organise prevention campaigns. To prevent falls, one should revise the regulations for building the parapet and the mechanisms for opening the windows.

Biomechanical analysis of Indy car crashes using on-board impact recorders (Melvin et al. 1998, Melvin et al. 2001) indicates that Indy car driver protection in high-energy crashes can be achieved in frontal, side, and rear crashes with severities in the range of 100 to 135 G peak deceleration and velocity changes in the range of 50 to 70 mph. These crashes were predominantly single-car impacts with the rigid concrete walls of oval tracks. This impressive level of protection was found to be due to the unique combination of a very supportive and tight-fitting cockpit-seating package, a six-point belt restraint system, and effective head padding with an extremely strong chassis that defines the seat and cockpit of a modern Indy car. In 2000 and 2001, a series of fatal crashes in stock car racing created great concern for improving the crash protection for drivers in those racecars. Unlike the Indy car, the typical racing stock car features a more spacious driver cockpit due to its resemblance to the shape of a passenger car. The typical racing seat used in stock cars did not have the same configuration or support characteristics of the Indy car seat, and five-point belt restraints were used. The tubular steel space frame chassis of a stock car also differs from an Indy car's composite chassis structure in both form and mechanical behavior. This paper describes the application of results of the biomechanical analysis of the Indy car crash studies to the unique requirements of stock car racing driver crash protection. Sled test and full-scale crash test data using both Hybrid III frontal crash anthropomorphic test devices (ATDs) and BioSID side crash ATDs for the purpose of evaluating countermeasures involving restraint systems, seats and head/neck restraints has been instrumental in guiding these developments. In addition, the development of deformable walls for oval tracks (the SAFER Barrier) is described as an adjunct to improved occupant restraint through control of the crash forces acting on a racing car. NASCAR (National Association for Stock Car Auto Racing, Inc) implemented crash recording in stock car racing in its three national series in 2002. Data from 2925 crashes from 2002 through the 2005 season are summarized in terms of crash severity, crash direction, injury outcome, and protective system performance.