Urban versus rural trauma recidivism: is there a difference?

Purpose

Understanding the characteristics of trauma recidivists may allow trauma centers to tailor prevention programs. We hypothesized that there would be an increased incidence of violent injuries and falls in the urban vs. rural recidivists, respectively.

Methods

Trauma admissions from 2000 to 2011 were queried for incidences of recidivism. Age (<65 or ≥65 years), gender, Injury Severity Score (ISS, <9 or ≥9), mortality, and injury cause (fall, violence, or other) were analyzed with univariate analyses to test for differences between urban and rural patients. Significant variables were then included in a binary logistic model and further stratified based on environment.

Results

There were a total of 19,600 trauma admissions from 2000 to 2011, representing 18,711 unique patients, with 1,690 admissions (8.6 %) attributed to 801 recidivists (4.3 %). The overall percentages of recidivist trauma admissions attributed to urban and rural patients were 8.6 and 6.9 %, respectively (p < 0.001). When adjusting for age ≥65 years as well as falls and violent injuries, patients from urban environments were at 1.12 times higher odds of being a recidivist than their rural counterparts [odds ratio (OR) 1.12; 95 % confidence interval (CI) 1.01–1.25; p = 0.039]. When stratified into rural and urban groups, falls and violent injuries were significant in both groups of recidivist admissions; however, age ≥65 years was only significant in rural recidivist admissions.

Conclusion

An urban trauma admission had 12 % higher odds of being attributed to a recidivist than its rural counterpart, when controlling for age and mechanism of injury (MOI). Age ≥65 years was a significant variable in rural but not urban recidivist admissions. Characterizing the recidivist may allow for targeted prevention and intervention programs to decrease repeat hospital visits.

     

Human immunodeficiency virus infection in trauma patients: where do we stand?

OBJECTIVE: The human immunodeficiency virus (HIV) epidemic is a growing health care problem. The purpose of this study was to examine the relationship between HIV infection and trauma patient treatment, complications, and mortality. METHODS: The Pennsylvania Trauma Outcome Study database was used to identify trauma patients with known HIV-positive status (HP) and randomly selected age-matched controls (CL). Demographics, Injury Severity Score, Glasgow Coma Scale score, mechanism of injury, preexisting conditions, complications, mortality, hospital length of stay (HLOS), intensive care unit length of stay (ILOS), and operative interventions were compared. RESULTS: Demographics, vital signs on presentation, and Injury Severity Score were similar between the HP and CL groups. There was no difference in mortality between the two groups (3.6% vs. 3.1%, p = 0.6447). HP patients were more likely to present with penetrating injuries (22.6% vs. 15.8%, p < 0.0031) and had significantly fewer major orthopedic injuries than CL patients (p < 0.01). HP patients were more likely to have a history of a neurologic condition; chronic drug/alcohol use; psychiatric diagnosis; or liver, pulmonary, and/or renal disease (all p < 0.01). HP patients had more pulmonary complications (12.3% vs. 4.1%), renal complications, and infectious/septic complications (all p < 0.01) than controls. Infection/sepsis and pulmonary complications were associated with significant mortality in HP patients. HP patients underwent more thoracostomies (7.5% vs. 4.4%, p = 0.0235) and exploratory laparotomies (7.0% vs. 2.4%, p = 0.0002). HLOS (10.2 +/- 10 vs. 6.8 +/- 8.6 days, p = 0.001) and ILOS (2.3 +/- 7.2 vs. 1.5 +/- 4.9 days, p = 0.0178) were greater for HP patients. HP patients were less likely than controls to be discharged directly to home (67.8% vs. 82.7%, p = 0.0001). CONCLUSION: HP patients had more preexisting conditions and complications than controls. There was no difference in overall mortality between the two groups. However, pulmonary/infectious complications were associated with significant mortality in HP patients. HP patients consumed more health care resources than controls, as exemplified by greater ILOS and HLOS and more operative procedures.     

Xenotransplantation: where are we in 2008?

Xenotransplantation holds promise to solve the ever increasing shortage of donor organs for allotransplantation. In the last 2 decades, major progress has been made in understanding the immunobiology of pig-into-(non)human primate transplantation and today we are on the threshold of the first clinical trials. Hyperacute rejection, which is mediated by pre-existing anti-alpha Gal xenoreactive antibodies, can in non-human primates be overcome by complement- and/or antibody-modifying interventions. A major step forward was the development of genetically engineered pigs, either transgenic for human complement regulatory proteins or deficient in the alpha1,3-galactosyltranferase enzyme. However, several other immunologic and nonimmunologic hurdles remain. Acute vascular xenograft rejection is mediated by humoral and cellular mechanisms. Elicited xenoreactive antibodies play a key role. In addition to providing B cell help, xenoreactive T cells may directly contribute to xenograft rejection. Long-term survival of porcine kidney- and heart xenografts in non-human primates has been obtained but required severe T and B cell immunosuppression. Induction of xenotolerance, e.g. through mixed hematopoietic chimerism, may represent the preferred approach, but although proof of principle has been delivered in rodents, induction of pig-to-non-human primate chimerism remains problematic. Finally, it is now clear that innate immune cells, in particular macrophages and natural killer cells, can mediate xenograft destruction, the determinants of which are being elucidated. Chronic xenograft rejection is not well understood, but recent studies indicate that non-immunological problems, such as incompatibilities between human procoagulant and pig anticoagulant components may play an important role. Here, we give a comprehensive overview of the currently known obstacles to xenografting: immune and non-immune problems are discussed, as well as the possible strategies that are under development to overcome these hurdles.     

Citric acid or citrates in urine: which should we focus on in the prevention of calcium oxalate crystals and stones?

In order to distinguish between normocitraturia and hypocitraturia, the 24 h urine excretion value of citric acid is evaluated in relation to the established limit value of 2.5 mmol/day. We propose changing this widely-used excretion value to a "minimum contribution" of citric acid to the total urine's ionic strength, since the inhibitory effect of citric acid on crystallization depends on citrate anions being available to complex calcium ions or to associate with the crystal surface. A total of 71424 h-urine samples, taken from 74 healthy persons and 58 calcium stone formers, were investigated for pH, citric acid concentration ([CA]), and related relative calcium oxalate supersaturation (RS). Based on the Henderson-Hasselbalch-equation, the individual concentrations of the differently charged citrate anion species in each of the urines were calculated from the urinary pH and [CA]. From the anion concentrations determined, the contribution of the urine's citric acid to the total urine's ionic strength, ISCA, was calculated. Referring to the limit value of 2.5 mmol/day and assuming an average urine volume of 1.5 l/day, a hypothetical concentration limit of 1.67 mmol/l can be obtained. Grouping the samples into "stone-formers" and "non-stone-formers" as well as into three different ranges of RS revealed: (1). that the groups' median [CA]-values were below 1.67 mmol/l, and (2). that [CA] was not inversely associated with the risk of stone formation. Within the pH-range of 5 and 7, the ISCA-values which are related to, for example, [CA]=1.67 mmol/l, vary considerably by a factor of nearly three between 2.48 mmol/l and 6.64 mmol/l. The use of a fixed citric acid excretion level for the distinction of normocitraturia from hypocitraturia does not take into account the different citrate species which actually modify the urine's crystallization behaviour. The proposed ISCA approach takes this fact into consideration. From this parameter, a desirable "minimum impact of citric acid" can be derived. In a first approach, a potential ISCA-limit value, which currently distinguishes between urines indicated by a "normo-protective" impact and those indicated by a "hypo-protective" impact with respect to calcium oxalate precipitation, may be set at 2.48 mmol/l.     

Injury prevention activities in U.S. trauma centres: are we doing enough?

BACKGROUND: Despite the requirement for and endorsement of injury prevention efforts among U.S. trauma centres, little is known about the breadth and depth of their current activities. METHODS: A survey was sent to eligible institutions in the National Inventory of Trauma Centres to better describe how level I and II centres are fulfilling their injury prevention requirement, to identify the barriers to conducting prevention activities, and to determine trauma centre personnel's interest in enhancing their prevention role. RESULTS: A total of 268 trauma centres (60%) completed the survey. Only 19% reported having an injury prevention director/coordinator but more than half of centres reported participating in 9 of 11 injury prevention activities, including participating in community events (97%), sending speakers to local schools (89%), and preparing or distributing educational materials (84%). Lack of time (68%), dedicated funding (68%), and an injury prevention specialist (45%) were the most frequently cited barriers to conducting injury prevention activities. Injury prevention collaborations were reported with safety groups (24%) and with emergency medical services, fire and police (23%). Trauma centres partnered less frequently with academic institutions (11%) and local or state health departments (16%). Topics and formats for injury prevention training as well as training barriers were also explored. CONCLUSIONS: Improved partnerships and linkages with established agencies and organisations at the local and state levels could assist trauma centres in leveraging their more limited resources and expertise to offer state-of-the-art injury prevention programs and policies. As low- and middle-income countries are developing or strengthening their trauma systems, they should be encouraged to view injury prevention as a fundamental responsibility.     

ACL injury prevention: Where have we come from and where are we going?

Anterior cruciate ligament (ACL) injuries are one of the most common and severe knee injuries across sports. As such, ACL injury prevention has been a focus of research and sports medicine practice for the past three-plus decades. Examining the current research and identifying both clinical strategies and research gaps, the aim of this review is to empower clinicians and researchers with knowledge of where the ACL injury prevention literature is currently and where it is going in the future. This paper examines the mechanism of ACL injury prevention, screening, implementation, compliance, adherence, coronavirus, and areas of future research. Clinical significance: The time lag between research and practical implementation in general healthcare settings can be as long as 17 years; however, athletes playing sports today are unable to wait that long. With effective programs already established, implementation and adherence to these programs is essential. Strategies such as coaching education, increasing awareness of free programs, identifying barriers, and overcoming implementation obstacles through creative collaboration are just a few ways that could help improve both ACL injury prevention implementation and adherence.     

Abdominal CT scanning for trauma: how low can we go?

PURPOSE: computed tomography (CT) of the abdomen is an established, albeit expensive and perhaps overused, diagnostic modality for the evaluation of the injured patient. We developed a practice management guideline for blunt abdominal trauma intended to reduce the percentage of negative CT scans, yet minimize delayed recognition of injury and non-therapeutic laparotomy. PROCEDURES: between April 1996 and March 1997, 1147 adult patients at risk for blunt abdominal injury were admitted to our Level I trauma centre and underwent abdominal evaluation according to the practice management guideline. MAIN FINDINGS: abdominal CT was performed in 522 patients (45%), and 441 scans were negative (85%). Delayed recognition of injury and non-therapeutic laparotomy rates were low, 4% and 1.6%, respectively. PRINCIPAL CONCLUSION: abdominal CT scanning in trauma patients can achieve low non-therapeutic laparotomy and delayed recognition of injury rates but at the expense of high negative CT scan rates. Greater reliance on the physical examination and perhaps abdominal ultrasound may reduce negative CT scan rates and yet preserve low non-therapeutic laparotomy and delayed recognition of injury rates.