Tram‐related trauma in Melbourne,Victoria

Objectives: To establish the incidence and pattern of injuries in patients presenting to hospital with tram‐related injuries. Methods: Data on tram‐related injury pertaining to 2001–2008 calendar years were extracted from three datasets: the population‐based Victorian State Trauma Registry for major trauma cases, the Victorian Emergency Minimum Dataset for ED presentations and the National Coroners' Information System for deaths. Incidence rates adjusted for the population of Melbourne, and trends in the incidence of tram‐related ED presentations and major trauma cases, were analysed and presented as incidence rate ratios (IRR). Results: There were 1769 patients who presented to ED after trauma related to trams in Melbourne during the study period. Of these, 107 patients had injuries classified as major trauma. There was a significant increase in the rate of ED presentations (IRR 1.03, P= 0.010) with falls (46%) the most commonly reported mechanism. Most falls occurred inside the trams. There was also a significant increase in the incidence rates of major trauma cases (IRR 1.12, P= 0.006) with pedestrians accounting for most major trauma cases. Conclusions: Most cases of trauma related to trams have minor injuries and are discharged following ED management. Primary prevention of falls in trams and the separation of pedestrians from trams are key areas requiring immediate improvement. In the face of increasing trauma associated with trams, continuing safety surveillance and targeted public safety messages are important to sustain trams as safe and effective mode of transport.     

Regional variation in the modeling of donation frequency: the case of Héma‐Québec,Canada

BACKGROUND: Many studies on factors that can affect the frequency of blood donation have shown the influence of several individual characteristics. However, few studies have analyzed regional variations in blood donation frequency. The objective of this article is to verify to what extent individual and geographic variables influence blood donation in the Province of Québec, Canada. STUDY DESIGN AND METHODS: This article used a database provided by Héma‐Québec (the organization in charge of blood collection in Québec), which included 426,247 donors, who made 1.4 million donations over a period of 5 years. Using the donors' residential postal codes and those of the blood collection sites, we created two geographic variables: the distance between the donor's place of residence and his or her collection site and each donor's region of residence. We subsequently modeled the frequency of blood donation and the different donor categories (based on the number of blood donations) using both a negative binomial regression model and an ordinal logistic regression model. RESULTS: The results indicate that, once the individual characteristics have been taken into account, the geographic variables, including proximity to the collection site, have a significant impact on the frequency of blood donation. Likewise, according to the results of the negative binomial model, among the 17 regions in the Province of Québec, there are five regions where blood donation incidence rate ratios (IRRs) are very high, that is, Abitibi‐Témiscamingue (IRR, 1.77; 95% confidence interval [CI], 1.61‐1.95); Bas‐Saint‐Laurent (IRR, 1.75; 95% CI, 1.59‐1.93); Saguenay‐Lac‐Saint‐Jean (IRR, 1.68; 95% CI, 1.53‐1.84); Centre‐du‐Québec (IRR, 1.66; 95% CI, 1.51‐1.83); and Chaudière‐Appalaches (IRR, 1.62; 95% CI, 1.48‐1.78). CONCLUSION: Such knowledge of the geography of blood donations makes it possible to better target certain regions when planning new blood drives, to ensure a constant blood supply.     

Trauma Center Utilization for Children in California 1998–2004: Trends and Areas for Further Analysis

Background: While it is known that trauma systems improve the outcome of injury in children, there is a paucity of information regarding trauma system function amid changes in policies and health care financing that affect emergency medical systems for children. Objectives: To describe the trends in the proportion of pediatric trauma patients acutely hospitalized in trauma‐designated versus non–trauma‐designated hospitals. Methods: This was a retrospective observational study of a population‐based cohort obtained by secondary analysis of a publicly available data set: the California Office of Statewide Health Planning and Development Patient Discharge Database from 1998 to 2004. Patients were included in the analysis if they were 0–19 years old, had International Classification of Disease, Ninth Revision (ICD‐9) diagnostic codes and E‐codes indicative of trauma, had an unscheduled admission, and were discharged from a general acute care hospital (N= 111,566). Proportions of patients hospitalized in trauma‐designated hospitals versus non–trauma‐designated hospitals were calculated for Injury Severity Score and death. Injury Severity Scores were calculated from ICD‐9 codes. Primary outcomes were hospitalization in a trauma center and death two or more days after hospitalization. Results: Over the study period, the proportion of children aged 0–14 years with acute trauma requiring hospitalization and who were cared for in trauma‐designated hospitals increased from 55% (95% confidence interval [CI] = 54% to 56%) in 1998 to 66% (95% CI = 65% to 67%) in 2004 (p < 0.01). For children aged 15–19 years, the proportion increased from 55% (95% CI = 54% to 57%) in 1998 to 74% (95% CI = 72% to 75%) in 2004 (p < 0.0001). When trauma discharges were stratified by injury severity, the proportion of children with severe injury who were hospitalized in trauma‐designated hospitals increased from 69% (95% CI = 66% to 72%) in 1998 to 84% (95% CI = 82% to 87%) in 2004, a rate higher than in children with moderate injury (59% [95% CI = 58% to 61%] in 1998 and 75% [95% CI = 74% to 76%] in 2004) and mild injury (51% [95% CI = 50% to 52%] in 1998 and 63% [95% CI = 62% to 64%] in 2004) (p < 0.0001 for each injury severity category and both age groups). Of the hospitalized children who died two or more days after injury (n= 502), 18.1% died in non–trauma‐designated hospitals (p < 0.002 for children aged 0–14 years; p = 0.346 for children aged 15–19 years). Conclusions: An increasing majority of children with trauma were cared for in trauma‐designated hospitals over the study period. However, 23% of children with severe injuries, and 18.1% of pediatric deaths more than two days after injury, were cared for in non–trauma‐designated hospitals. These findings demonstrate an important opportunity for improvement. If we can characterize those children who do not access the trauma system despite severe injury or death, we will be able to design clinical protocols and implement policies that ensure access to appropriate regional trauma care for all children in need.     

Determining the most effective level of TRISS‐derived probability of survival for use as an audit filter

Objective: To determine the most effective cut‐off of TRISS‐derived probability of survival (TRISS‐PS) for the selection of trauma deaths for audit, using a large sample of trauma deaths from the United Kingdom (UK). Methods: TRISS‐PS and avoidability of death (as judged by an independent peer review panel) were compared for a sample of 222 trauma deaths. Sensitivity, specificity and predictive values were calculated for the 0.5 screening cut‐off. ROC curves were derived to assess the ability of different levels of TRISS‐PS to identify avoidable deaths. Calculations were made for both the raw sample and the sample adjusted for the sampling method used. Results: For the weight‐adjusted sample, the sensitivity of TRISS‐PS greater than 0.5 for the detection of avoidable death is 80% (95% CI 61–91%), the specificity is 86% (95% CI 80–90%), PPV 42% (95% CI 29–56%) and NPV 97% (95% CI 93–99%). Twenty percent of avoidable deaths would have been ‘missed’ if the 0.5 level of audit filter had been used. Based on the same sample, the best cut‐off is at TRISS‐PS 0.33, with a sensitivity of 90% and specificity of 80%. It is estimated that this cut‐off would have selected 62 deaths for audit and failed to identify 2 out of 25 avoidable deaths. Conclusion: The previously accepted audit filter of TRISS‐PS of greater than 0.5 fails to identify a significant proportion of avoidable deaths. This study suggests that the most effective level of audit filter cut‐off of TRISS‐PS for the trauma system studied is 0.33. This level would identify 90% of avoidable deaths with 80% specificity. Similar ROC curve analysis could be used to determine appropriate TRISS‐PS cut‐offs for institutions or other trauma systems.     

Preventive effects of motorcycle helmets on intracranial injury and mortality from severe road traffic injuries

Introduction

Road traffic injuries caused by motorcycle crashes are one of the major public health burdens leading to high mortality, functional disability, and high medical costs. The helmet is crucial protective equipment for motorcyclists. This study aimed to measure the protective effect of motorcycle helmets on clinical outcomes and to compare the effects of high- and low-speed motorcycle crashes.

Most head injury related motorcycle crash deaths are related to poor riding practices

Objective: To report the characteristics of head injury related motorcycle crash deaths. Methods: Motorcycle crash deaths with head injury (Abbreviated Injury Severity score ≥ 2) between 1 January 1998 and 31 December 1999 were identified from the Western Australia State Coronial Database. Demographics, incident and death locations, type of incident and role of unsafe riding behaviour were examined. Results: There were 39 deaths analysed (35 motorcycle riders and four pillion passengers). The median age was 29 years (range 9–64 years), with 22 deaths (56.4%) in the range 15–29 years and 92.3% of those killed being male. Twenty‐one motorcycle crashes were single‐vehicle crashes (53.8%). There were 25 deaths at scene (64.1%). Ethanol was implicated in 12 cases (30.8%) and other drugs were implicated in 11 cases (28.2%). Speeding was implicated in 12 cases (30.8%) and a lack of appropriate safety equipment was implicated in five cases (12.8%). One or more of the unsafe practices above was identified in 23 cases (59%). Overall, there was no difference in the rate of unsafe practices in single‐vehicle incidents compared with incidents involving another vehicle (P = 0.342). Ethanol was associated with 10 single motorcycle incidents (47.6%) compared with two (11.1%) involving another vehicle (P = 0.018). Unsafe practices were involved in 76% of at‐scene deaths, compared with 28.6% in those surviving to hospital (P = 0.007). Conclusion: A large proportion of head injury related motorcycle crash deaths are related to the unsafe behaviour of motorcyclists. A preventative campaign focusing on young male motorcycle riders and unsafe driving behaviour may reduce this death toll.     

Autoimmune skin and connective tissue diseases and risk of venous thromboembolism: a population‐based case‐control study

Summary. Background: Systemic inflammation is associated with vessel wall damage, upregulation of procoagulants, downregulation of anticoagulants, and suppression of fibrinolysis. Autoimmune diseases may therefore increase the risk of venous thromboembolism (VTE). Objectives: To examine whether autoimmune skin and connective tissue diseases are associated with increased VTE risk. Methods: We conducted this population‐based case–control study in northern Denmark, using administrative databases. From 1999 to 2009, we identified 14 721 VTE cases and 147 210 birth year‐matched, sex‐matched and county‐matched population controls. The date of diagnosis/matching was considered to be the index date for cases and controls. For all study subjects, we identified hospital diagnoses of autoimmune skin or connective tissue diseases between 1977 and the index date. We used conditional logistic regression with adjustment for VTE risk factors to calculate odds ratios and 95% confidence intervals (CIs) for patients with vs. without autoimmune disease. Given the risk‐set sampling design, odds ratios estimate incidence rate ratios (IRRs). Results: Autoimmune skin disease was not associated with VTE (IRR 1.0; 95% CI 0.9–1.2). Patients with connective tissue disease had an increased VTE risk within 90 days (IRR 2.3; 95% CI 1.5–3.7) and 91–365 days (IRR 2.0; 95% CI 1.5–2.8) after diagnosis, but not thereafter (IRR 1.1; 95% CI 1.0–1.2). Among connective tissue diseases, the greatest overall risk increases were found for juvenile rheumatoid arthritis (IRR 3.0; 95% CI 1.4–6.4) and systemic lupus erythematosus (IRR 2.8; 95% CI 1.7–4.7). Conclusions: Autoimmune connective tissue disease was associated with an increased risk of VTE within 1 year after diagnosis, whereas skin diseases were not.     

Prehospital deaths in the Yorkshire Health Region.

OBJECTIVES: To estimate the proportion of prehospital deaths in a British population of trauma victims which may be preventable, and to investigate the effect of death at the scene and death in transit on potential survivorship. METHODS: Blinded review, by four specialists with an interest in trauma, of necropsy results and details of age, sex, and mechanism of injury for prehospital trauma deaths in the Yorkshire Health Region in a 12 month period. RESULTS: Complete records were traced on 305 of 337 trauma deaths, 190 being recorded as dead on arrival of emergency services and 115 dead on arrival at hospital. In the group declared dead at the scene, three of the four assessors considered 93% of deaths to have been inevitable and only 2% as potential survivors (25% of this group sustaining inevitably fatal injuries such as brain avulsion or decapitation). In the group dead on arrival 81% were felt to be inevitable deaths and 5% potential survivors. CONCLUSIONS: There seems to be less scope for salvage of victims of trauma death in a British population than has been recorded in America, possibly due to a higher proportion of blunt trauma deaths here. Those who die in transit consist of a less severely injured group with a higher potential for survival.     

Resource use associated with type 2 diabetes in Asia,Latin America,the Middle East and Africa: results from the International Diabetes Management Practices Study (IDMPS)

Aims: To estimate diabetes‐related resource use and investigate its predictors among individuals with type 2 diabetes in 24 countries in Asia, Latin America, the Middle East and Africa. Methods: Cross‐sectional observational data on diabetes‐related resource use were collected from 15,016 individuals with type 2 diabetes within the second wave of International Diabetes Management Practices Study. Mean (SD) annual quantities were determined and predictors of diabetes‐related hospitalisations, inpatient days, emergency room visits and absenteeism were investigated using negative binomial regression. Results: Patients in Asia (n = 4678), Latin America (n = 6090) and the Middle East and Africa (n = 4248) made a mean (SD) of 3.4 (6.9), 5.4 (6.7) and 2.5 (4.4) General Practitioner visits per year. The mean (SD) number of inpatient days amounted to 3.8 (18.1), 2.2 (13.9) and 2.6 (13.5) per year. Results of the regression analysis showed the major influence of diabetes‐related complications and inadequate glycaemic control on resource use. The expected annual rate of hospitalisation of patients with macrovascular complications compared with those without was 4.7 times greater in Asia [incidence rate ratio (IRR) = 4.7, 95% CI: 2.8–7.8, n = 2551], 5.4 times greater in Latin America (IRR = 5.4, 95% CI: 3.0–9.8, n = 3228) and 4.4 times greater in the Middle East and Africa (IRR = 4.4, 95% CI: 2.8–6.9, n = 2630). Conclusions: Micro‐ and macrovascular complications and inadequate glycaemic control are significant predictors of resource use in people with type 2 diabetes of developing countries. This knowledge confirms the health economic importance of early diagnosis of diabetes, education of patients and glycaemic control.     

The impact of trauma exposure and post-traumatic stress disorder on healthcare utilization among primary care patients

BACKGROUND: Trauma exposure and post-traumatic stress disorder (PTSD) increase healthcare utilization in veterans, but their impact on utilization in other populations is uncertain. OBJECTIVES: To examine the association of trauma exposure and PTSD with healthcare utilization, in civilian primary care patients. RESEARCH DESIGN: Cross-sectional study. SUBJECTS: English speaking patients at an academic, urban primary care clinic. MEASURES: Trauma exposure and current PTSD diagnoses were obtained from the Composite International Diagnostic Interview. Outcomes were nonmental health outpatient and emergency department visits, hospitalizations, and mental health outpatient visits in the prior year from an electronic medical record. Analyses included bivariate unadjusted and multivariable Poisson regressions adjusted for age, gender, income, substance dependence, depression, and comorbidities. RESULTS: Among 592 subjects, 80% had > or =1 trauma exposure and 22% had current PTSD. In adjusted regressions, subjects with trauma exposure had more mental health visits [incidence rate ratio (IRR), 3.9; 95% confidence interval (CI), 1.1-14.1] but no other increased utilization. After adjusting for PTSD, this effect of trauma exposure was attenuated (IRR, 3.2; 95% CI, 0.9-11.7). Subjects with PTSD had more hospitalizations (IRR, 2.2; 95% CI, 1.4-3.7), more hospital nights (IRR, 2.6; 95% CI, 1.4-5.0), and more mental health visits (IRR, 2.2; 95% CI, 1.1-4.1) but no increase in outpatient and emergency department visits. CONCLUSIONS: PTSD is associated with more hospitalizations, longer hospitalizations, and greater mental healthcare utilization in urban primary care patients. Although trauma exposure is independently associated with greater mental healthcare utilization, PTSD mediates a portion of this association.     

Unintentional injuries among older adults in northern Sweden – a one‐year population‐based study

Scand J Caring Sci; 2011; 25; 185–193
Unintentional injuries among older adults in northern Sweden – a one‐year population‐based study Aim: To study the epidemiology of unintentional injuries in a population of 21 000 Swedish older adults (65+) and to compare the injury incidence with similar data collected two decades earlier. Method: This is a retrospective epidemiologic cross‐sectional study based on a 1‐year data set of all the 1753 registered injury events from a well‐defined population. Result: The injury rate per 1000 individuals was three times higher in the 85+ age group than in the 65–74 age group. The rate was also higher in women than in men aged 75 and older. Fractures, especially on lower and upper extremities, were the most common injuries. Falls in residential care facilities caused the most serious injuries. In transport areas, pedestrian falls and bicyclist crashes were much more common than car crashes. Of the 1753 people injured, 42% were treated as inpatients for a total of 11 569 days; 86% of these days were caused by injury events in the home (57%) or in residential care facilities (29%). Our 65+ age group occupied 69% of all hospital bed‐days for trauma in all ages (0–102 years). Conclusion: Over the last two decades, the injury and fracture rate per 1000 individuals has increased by 40–50%, especially in the older age groups. During this time, the nursing strategy for older adults has changed in Sweden. As a result, more people live in their homes nowadays. This increase is distressing especially when we consider the current knowledge of preventive measures. The high number and proportion (>2/3) of inpatient trauma days for these age groups are a heavy burden for the medical sector. These facts call for more effective preventive measures, especially in the home and in residential care facilities, to minimize the negative health effects and the rising health costs.     

Paediatric and adolescent horse‐related injuries: Does the mechanism of injury justify a trauma response?

Objective: To identify the frequency, variety and disposition of horse‐related injury presentations to the ED and to use this information to evaluate the existing institutional trauma team activation criteria following horse‐related injuries. Methods: A retrospective case analysis was performed of all horse‐related injury presentations to the ED of Women's and Children's Hospital, Adelaide, Australia, in the 5 year period between January 1999 and December 2003. Results: A total of 186 children presented with horse‐related injuries during the 5 year study period. The median age of injury was 9 years (range 1–17 years), with 81% of presentations female and 60% of patients hospitalized. The mechanism of injury was divided into four groups: 148 falls (79%), 28 kicks (15%), 7 tramples (4%) and 5 bites (3%). There was one death. Seven presentations rated an Injury Severity Score >15, with full trauma team activation occurring for two of these presentations. Conclusion: Although horse‐related injury presentations are uncommon, severe injuries do occur. Patients presenting with severe horse‐related injuries do not always activate a full trauma team response based on current trauma team activation criteria. These severe injury presentations are supported by a limited trauma team response, which activates on the mechanism of injury. The effectiveness of this as a contingency system needs to be evaluated.     

Neighborhood Poverty and 9-1-1 Ambulance Contacts

Background: Neighborhood poverty is positively associated with frequency of 9-1-1 ambulance utilization, but it is unclear whether this association remains significant when accounting for variations in the severities and types of ambulance contacts. Methods: We merged EMS ambulance contact records in a single California county (n = 88,027) with data from the American Community Survey at the census tract level (n = 300). Using tract as a proxy for neighborhood and negative binomial regression as an analytical tool, we predicted 16 outcomes: any ambulance contacts, ambulance contacts stratified by three intervention severities, and ambulance contacts varied by 12 primary impression categories. For each model, we estimated the incident rate ratios for 10 percentage point increases in tract-level poverty while controlling for geographic patterns in race, citizenship, gender, age, emergency department proximity, population density, and population size. Results: Our study produced three major findings. First, tract-level poverty was positively associated with ambulance contacts (incident rate ratio [IRR] 1.45; 95% confidence interval [CI] 1.34 to 1.57). Second, poverty was positively associated with low severity contacts (IRR 1.48; 95% CI 1.35 to 1.61), medium severity contacts (IRR 1.38; 95% CI 1.28 to 1.49), and high severity contacts (IRR 1.40; 95% CI 1.30 to 1.51). Third, poverty was positively associated with 12 primary impression categories: abdominal (IRR 1.48; 95% CI 1.36 to 1.61), altered level of consciousness (IRR 1.37; 95% CI 1.25 to 1.50), cardiac (IRR 1.28; 95% CI 1.14 to 1.42), overdose/intoxication (IRR 1.59; 95% CI 1.40 to 1.81), pain (IRR 1.56; 95% CI 1.41 to 1.73), psych/behavioral (IRR 1.50; 95% CI 1.34 to 1.67), respiratory (IRR 1.42; 95% CI 1.29 to 1.56) seizure (IRR 1.52; 95% CI 1.38 to 1.68), stroke (IRR 1.14; 95% CI 1.01 to 1.28), syncope/near syncope (IRR 1.23; 95% CI 1.12 to 1.36), trauma (IRR 1.44; 95% CI 1.31 to 1.58), and general weakness (IRR 1.31; 95% CI 1.20 to 1.42). Conclusion: Our study suggests poverty is a positive, strong, and enduring predictor of ambulance contacts at the neighborhood level. The relationship between neighborhood poverty and ambulance utilization should be considered at multiple levels of EMS decision making     

Trauma bypass in south-eastern Sydney: an 8-year review

Objective: The New South Wales (NSW) Health Department and the Ambulance Service of NSW introduced a trauma bypass system in Sydney on 29 March 1992. This study aims to review the outcomes of trauma bypass patients brought to St George Hospital, a major trauma service in south‐eastern Sydney, and to assess the performance of the current prehospital trauma triage protocol. Methods: The St George Hospital Department of Trauma Services prospectively collected data on all trauma bypass patients for the 8‐year period from 29 March 1992 to 29 March 2000. Results: A total of 1990 patients were brought to hospital on trauma bypass. The average age was 32 years, 70% were men and 66% were from road traffic accidents. The positive predictive value of the prehospital triage tool for serious injury (Injury Severity Score [ISS] > 15) was 18.6% (95% CI 16.9–20.4). This is well below the benchmark previously established by the NSW Health Department Trauma System Advisory Committee. For all trauma bypass patients, 33.8% (95% CI 31.7–35.9) were discharged home from the ED. The overall death rate was 2.5% (95% CI 1.9–3.3). Conclusions: According to the proposed benchmark, current prehospital trauma triage guidelines are underperforming. This suggests that a review of the benchmarks of current local trauma systems and of the trauma triage tool is required.     

德阳市儿童道路交通伤流行病学特点和预防措施

目的：探讨德阳市儿童道路交通伤流行病学特征,提高患儿道路交通伤救治水平和防范措施。方法：回顾分析德阳市人民医院自2010-01-2011-12收治的2498例儿童道路交通伤致伤原因及临床特点。结果：2498例儿童道路交通伤最易发生年龄段在〉4-9岁（54.28%）,明显高于其他年龄段（P〈0.05）。儿童道路交通伤以轻伤为主,擦挫伤为主要类型。汽车和摩托车是最主要肇事车辆和导致死亡的肇事车辆,主要的致死原因为颅脑损伤和腹部损伤。道路交通伤害主要发生在市区,发生时间主要在交通拥堵的上、下班时段。结论：德阳市儿童道路交通伤害有其自身的流行病学特点,倡导文明驾驶,完善道路交通公共设施建设,开展针对儿童道路交通事故防范的宣传教育,改进急救体系和服务模式等社会多方面的共同协作,将能有效的减少儿童道路交通伤害的发生。     

Incidence of abacavir hypersensitivity reactions in euroSIDA

BACKGROUND: The aim of the study was to investigate the incidence of abacavir-related hypersensitivity reaction (HSR) and associated deaths in EuroSIDA HIV-1-infected patients. METHODS: Poisson regression models were developed to compare incidence of abacavir discontinuation according to the line of therapy within which abacavir was received, geographical regions, calendar time and drug formulation (abacavir/lamivudine combination tablet versus abacavir as a single drug or abacavir/zidovudine/lamivudine combination). RESULTS: Of 3,278 patients that started abacavir, 2,101 (64.1%) discontinued. Of these, 167 (5.1%) discontinued abacavir within 3 months due to HSR with an incidence of 22.1 (95% confidence interval [CI] 18.7-25.4) per 100 person-years of follow-up. After adjustment for gender, prior AIDS, hepatitis C serostatus, baseline CD4+ T-cell count, region and calendar time, HSR incidence was significantly higher in those starting abacavir in a first-line regimen compared with second-line (incidence rate ratio [IRR] 2.04 [95% CI 1.24-3.38]; P=0.005). There was no significant difference between regions. HSR incidence from 2005 onwards was significantly lower compared with 1999-2000 (IRR 0.54 [95% CI 0.32-0.92]; P=0.024). There was a lower observed incidence in patients starting abacavir/lamivudine compared with other formulations (IRR 0.33 [95% CI 0.13-0.88]; P=0.027), however, available data were limited. CONCLUSIONS: Incidence of abacavir-related HSR is higher in patients starting abacavir in first-line therapy, which could indicate increased over-diagnosis. HSR incidence has decreased in recent years, which might reflect the wider availability of genetic screening and improved awareness of symptoms. There were no reported deaths due to abacavir HSR.     

A change in road trauma attendances associated with a major campaign to lower the road toll

Objective: To document the patterns of hospital attendances due to road trauma before and after a campaign, which commenced in Victoria in late 1989, to reduce the road toll. Design: A retrospective review of the medical records of all patients presenting to an emergency department as a result of road trauma during June/July of 1989 and the corresponding period in 1990. Setting: Emergency department of a secondary level hospital in the outer eastern suburbs of Melbourne. Patients: Four hundred and twenty five patients presenting during June/July 1989 and 307 patients during June/July 1990. Main results: In the period following the new road toll initiatives, road trauma attendances and admissions dropped significantly. With respect to demographic data and measures of injury type and severity the two groups were similar. Conclusion: The savings to the community and health care system reflected in the observed changes should provide support for continuing campaigns to reduce the incidence of road trauma in Australia.     

Validation of Length of Hospital Stay as a Surrogate Measure for Injury Severity and Resource Use Among Injury Survivors

Objectives: While hospital length of stay (LOS) has been used as a surrogate injury outcome when more detailed outcomes are unavailable, it has not been validated. This project sought to validate LOS as a proxy measure of injury severity and resource use in heterogeneous injury populations. Methods: This observational study used four retrospective cohorts: patients presenting to 339 California emergency departments (EDs) with a primary International Classification of Diseases, Ninth Revision (ICD‐9), injury diagnosis (years 2005–2006); California hospital injury admissions (a subset of the ED population); trauma patients presenting to 48 Oregon EDs (years 1998–2003); and injured Medicare patients admitted to 171 Oregon and Washington hospitals (years 2001–2002). In‐hospital deaths were excluded, as they represent adverse outcomes regardless of LOS. Duration of hospital stay was defined as the number of days from ED admission to hospital discharge. The primary composite outcome (dichotomous) was serious injury (Injury Severity Score [ISS] ≥ 16 or ICD‐9 ISS ≤ 0.90) or resource use (major surgery, blood transfusion, or prolonged ventilation). The discriminatory accuracy of LOS for identifying the composite outcome was evaluated using receiver operating characteristic (ROC) analysis. Analyses were also stratified by age (0–14, 15–64, and ≥65 years), hospital type, and hospital annual admission volume. Results: The four cohorts included 3,989,409 California ED injury visits (including admissions), 236,639 California injury admissions, 23,817 Oregon trauma patients, and 30,804 Medicare injury admissions. Composite outcome rates for the four cohorts were 2.1%, 29%, 27%, and 22%, respectively. Areas under the ROC curves for overall LOS were 0.88 (California ED), 0.74 (California admissions), 0.82 (Oregon trauma patients), and 0.68 (Medicare patients). In general, the discriminatory value of LOS was highest among children, tertiary trauma centers, and higher volume hospitals, although this finding differed by the injury population and outcome assessed. Conclusions: Hospital LOS may be a reasonable proxy for serious injury and resource use among injury survivors when more detailed outcomes are unavailable, although the discriminatory value differs by age and the injury population being studied. ACADEMIC EMERGENCY MEDICINE 2010; 17:142–150 © 2010 by the Society for Academic Emergency Medicine     

Is Definitive Abdominal Evaluation Required in Blunt Trauma Victims Undergoing Urgent Extra‐abdominal Surgery?

Objectives: To evaluate the utility of routine abdominal computed tomographic (CT) scanning for abdominal evaluation of blunt trauma patients before urgent extra‐abdominal surgery. Methods: In this observational cohort study, we prospectively enrolled all blunt trauma patients at least 8 years of age presenting to the emergency department of a Level 1 trauma center who were initially considered to require urgent extra‐abdominal surgery within 24 hours of presentation. Patients were excluded if they had any of the following: 1) isolated extremity trauma, 2) signs or symptoms of intra‐abdominal injury (including systolic blood pressure <90 mm Hg; abdominal, flank, or costal margin tenderness; abdominal wall contusion or abrasion; pelvic fracture; and gross hematuria), or 3) unreliable findings on abdominal examination (Glasgow Coma Scale score <14, paralysis, or mental retardation). Clinical data were documented on a data sheet before abdominal CT scanning. Results: A total of 254 patients, with a mean (±SD) age of 32.3 (±16.1) years, were enrolled. A total of 201 patients ultimately underwent urgent extra‐abdominal surgery for the following procedures: orthopedic, 182 (91%); facial, 17 (8%); laceration, 7 (3%); vascular, 6 (2%); neurosurgical, 3 (1%); urology, 2 (1%); and ophthalmology, 1 (0.4%). Three patients (1.2%; 95% confidence interval = 0.2% to 3.4%) were found to have intra‐abdominal injuries. Two patients had splenic injuries that required only observation. One patient (0.4%; 95% confidence interval = 0% to 2.2%) underwent laparotomy. This patient sustained multiple injuries in a motorcycle crash, including splenic, kidney, and pancreatic injuries, and underwent a splenectomy. Conclusions: Abdominal CT scanning has a low yield in trauma patients whose sole indication for diagnostic abdominal evaluation is the need for general anesthesia for urgent extra‐abdominal surgery. A small percentage of these patients, however, will have important intra‐abdominal injuries such that further refinement of the recommendations for diagnostic study in this select population is needed.     

Should plasma from female donors be avoided? A population‐based cohort study of plasma recipients in Sweden from 1990 through 2002

BACKGROUND: Plasma from female donors has been implicated in the sometimes fatal complication known as transfusion‐related acute lung injury. In studies of patients in intensive care units, worsened gas exchange of the lungs has also been attributed to female plasma. Despite a lack of population‐based evidence, policies have already been introduced to exclude female donor plasma. STUDY DESIGN AND METHODS: Short‐term mortality after plasma transfusion was investigated using data from the Scandinavian Donations and Transfusions (SCANDAT) database. A cohort of 92,565 patients in 30 Swedish hospitals were followed for 14 days after their first plasma transfusion. The relative risk (RR) of death in recipients of female plasma compared to recipients of only male plasma was estimated from Poisson regression. RESULTS: Recipients had median age 70 years, received a mean of 4.4 plasma units, and had an overall 14‐day mortality of 8.43%. Sixty‐eight percent were exposed to female plasma, with a 14‐day mortality of 8.85% compared to 7.53% in the nonexposed group. After adjustment for potential confounding factors, the RRs were 1.16 (confidence interval [CI], 1.06‐1.27) and 1.32 (CI, 1.17‐1.49) for those receiving 3 to 4 and 5 or more units of female plasma, respectively. Risk estimates were increased in an analysis of deaths with a concomitant discharge diagnosis involving the respiratory or circulatory system or an adverse reaction. CONCLUSIONS: This large population‐based cohort study of unselected patients suggests that transfusion of plasma from female donors confers a short‐term survival disadvantage on recipients.