Helmet use and risk of head injuries in alpine skiers and snowboarders

Context  Although using a helmet is assumed to reduce the risk of head injuries in alpine sports, this effect is questioned. In contrast to bicycling or inline skating, there is no policy of mandatory helmet use for recreational alpine skiers and snowboarders. Objective  To determine the effect of wearing a helmet on the risk of head injury among skiers and snowboarders while correcting for other potential risk factors. Design, Setting, and Participants  Case-control study at 8 major Norwegian alpine resorts during the 2002 winter season, involving 3277 injured skiers and snowboarders reported by the ski patrol and 2992 noninjured controls who were interviewed on Wednesdays and Saturdays. The controls comprised every 10th person entering the bottom main ski lift at each resort during peak hours. The number of participants interviewed corresponded with each resort's anticipated injury count based on earlier years. Main Outcome Measure  Injury type, helmet use, and other risk factors (age, sex, nationality, skill level, equipment used, ski school attendance, rented or own equipment) were recorded. A multivariate logistic regression analysis was used to assess the relationship between individual risk factors (including helmet wear) and risk of head injury by comparing skiers with head injuries with uninjured controls, as well as to skiers with injuries other than head injuries. Results  Head injuries accounted for 578 injuries (17.6%). Using a helmet was associated with a 60% reduction in the risk for head injury (odds ratio [OR], 0.40; 95% confidence interval [CI], 0.30-0.55; adjusted for other risk factors) when comparing skiers with head injuries with uninjured controls. The effect was slightly reduced (OR, 0.45; 95% CI, 0.34-0.59) when skiers with other injuries were used as controls. For the 147 potentially severe head injuries, those who were referred to an emergency physician or for hospital treatment, the adjusted OR was 0.43 (95% CI, 0.25-0.77). The risk for head injury was higher among snowboarders than for alpine skiers (adjusted OR, 1.53; 95% CI, 1.22-1.91). Conclusion  Wearing a helmet is associated with reduced risk of head injury among snowboarders and alpine skiers.      

Extended work duration and the risk of self-reported percutaneous injuries in interns

Context  In their first year of postgraduate training, interns commonly work shifts that are longer than 24 hours. Extended-duration work shifts are associated with increased risks of automobile crash, particularly during a commute from work. Interns may be at risk for other occupation-related injuries. Objective  To assess the relationship between extended work duration and rates of percutaneous injuries in a diverse population of interns in the United States. Design, Setting, and Participants  National prospective cohort study of 2737 of the estimated 18 447 interns in US postgraduate residency programs from July 2002 through May 2003. Each month, comprehensive Web-based surveys that asked about work schedules and the occurrence of percutaneous injuries in the previous month were sent to all participants. Case-crossover within-subjects analyses were performed. Main Outcome Measures  Comparisons of rates of percutaneous injuries during day work (6:30 AM to 5:30 PM) after working overnight (extended work) vs day work that was not preceded by working overnight (nonextended work). We also compared injuries during the nighttime (11:30 PM to 7:30 AM) vs the daytime (7:30 AM to 3:30 PM). Results  From a total of 17 003 monthly surveys, 498 percutaneous injuries were reported (0.029/intern-month). In 448 injuries, at least 1 contributing factor was reported. Lapse in concentration and fatigue were the 2 most commonly reported contributing factors (64% and 31% of injuries, respectively). Percutaneous injuries were more frequent during extended work compared with nonextended work (1.31/1000 opportunities vs 0.76/1000 opportunities, respectively; odds ratio [OR], 1.61; 95% confidence interval [CI], 1.46-1.78). Extended work injuries occurred after a mean of 29.1 consecutive work hours; nonextended work injuries occurred after a mean of 6.1 consecutive work hours. Injuries were more frequent during the nighttime than during the daytime (1.48/1000 opportunities vs 0.70/1000 opportunities, respectively; OR, 2.04; 95% CI, 1.98-2.11). Conclusion  Extended work duration and night work were associated with an increased risk of percutaneous injuries in this study population of physicians during their first year of clinical training.      

Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy

Context  Intraoperative cholangiography (IOC) may decrease the risk of common bile duct (CBD) injury during cholecystectomy by helping to avoid misidentification of the CBD. Objective  To characterize the relationship of IOC use and CBD injury while controlling for patient and surgeon characteristics. Design, Setting, and Patients  Retrospective nationwide cohort analysis of Medicare patients undergoing cholecystectomy from January 1, 1992, to December 31, 1999. Patients were identified using Current Procedural Terminology codes from the Medicare Part B depository. Common bile duct injury was defined by a second surgical procedure to repair the CBD injury within 1 year of cholecystectomy. Surgeon demographic features were obtained from matching the Medicare Part B data to the American Medical Association Physician Masterfile database. Main Outcome Measure  Frequency of CBD injury in patients who did and did not have IOC performed during cholecystectomy, controlling for patient-level (age, sex, race, and case complexity) and surgeon-level (surgeon's age, sex, race, year of surgical procedure, case order, percentage of IOC use in prior surgical procedures, years in medical practice, board certification, and specialization) factors. Results  The database search identified 1 570 361 cholecystectomies and 7911 CBD injuries (0.5%). Common bile duct injury was found in 2380 (0.39%) of 613 706 patients undergoing cholecystectomy with IOC and in 5531 (0.58%) of 956 655 patients undergoing cholecystectomy without IOC (unadjusted relative risk, 1.49; 95% confidence interval, 1.42-1.57). After controlling for patient-level factors and surgeon-level factors, the risk of injury was increased when IOC was not used (adjusted relative risk, 1.71; 95% confidence interval, 1.38-2.28). While surgeons performing IOCs routinely had a lower rate of CBD injuries than those who did not, this difference disappeared when IOC was not used. Conclusions  In this study of Medicare patients undergoing cholecystectomy in the 1990s, the risk of CBD injury was significantly higher when IOC was not used. Although IOCs may not prevent all CBD injuries, this study suggests that the routine use of IOC may decrease the rate of CBD injury.      

Hospital characteristics associated with the management of pediatric splenic injuries

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

The Medical Costs of Gunshot Injuries in the United States

Context  The cost of treating gunshot injuries imposes a financial burden on society. Estimates of such costs are relevant to evaluation of gun violence reduction programs and may help guide reimbursement policies. Objectives  To develop reliable US estimates of the medical costs of treating gunshot injuries and to present national estimates for the sources of payment for treating these injuries. Design and Setting  Cost analysis using E-coded discharge data from hospitals in Maryland for 1994-1995 and New York for 1994 and from emergency departments in South Carolina for 1997. Other sources of data included the National Electronic Injury Surveillance System for 1994 incidence of nonfatal gun injuries, the National Spinal Cord Injury Statistical Center database for 1988-1992 estimates of lifetime medical costs of gun injuries, and the 1994 Vital Statistics census for incidence of fatal gun injuries. Main Outcome Measures  Estimated national acute-care and follow-up treatment costs and payment sources for gunshot injuries. Results  At a mean medical cost per injury of about $17,000, the 134,445 (95% confidence interval [CI], 109,465-159,425) gunshot injuries in the United States in 1994 produced $2.3 billion (95% CI, $2.1 billion–$2.5 billion) in lifetime medical costs (in 1994 dollars, using a 3% real discount rate), of which $1.1 billion (49%) was paid by US taxpayers. Gunshot injuries due to assaults accounted for 74% of total costs. Conclusions  Gunshot injury costs represent a substantial burden to the medical care system. Nearly half this cost is borne by US taxpayers.      

Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization

Context  Although medical injuries are recognized as a major hazard in the health care system, little is known about their impact. Objective  To assess excess length of stay, charges, and deaths attributable to medical injuries during hospitalization. Design, Setting, and Patients  The Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) were used to identify medical injuries in 7.45 million hospital discharge abstracts from 994 acute-care hospitals across 28 states in 2000 in the AHRQ Healthcare Cost and Utilization Project Nationwide Inpatient Sample database. Main Outcome Measures  Length of stay, charges, and mortality that were recorded in hospital discharge abstracts and were attributable to medical injuries according to 18 PSIs. Results  Excess length of stay attributable to medical injuries ranged from 0 days for injury to a neonate to 10.89 days for postoperative sepsis, excess charges ranged from $0 for obstetric trauma (without vaginal instrumentation) to $57 727 for postoperative sepsis, and excess mortality ranged from 0% for obstetric trauma to 21.96% for postoperative sepsis (P<.001). Following postoperative sepsis, the second most serious event was postoperative wound dehiscence, with 9.42 extra days in the hospital, $40 323 in excess charges, and 9.63% attributable mortality. Infection due to medical care was associated with 9.58 extra days, $38 656 in excess charges, and 4.31% attributable mortality. Conclusion  Some injuries incurred during hospitalization pose a significant threat to patients and costs to society, but the impact of such injury is highly variable.      

External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury

Context  Two decision rules for indications of computed tomography (CT) in patients with minor head injury, the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC), suggest that CT scanning may be restricted to patients with certain risk factors, which would lead to important reductions in the use of CT scans. Objective  To validate and compare these 2 published decision rules in Dutch patients with head injuries. Design, Setting, and Patients  A prospective multicenter study conducted between February 11, 2002, and August 31, 2004, in 4 university hospitals in the Netherlands of 3181 consecutive adult patients with minor head injury who presented with a Glasgow Coma Scale (GCS) score of 13 to 14 or with a GCS score of 15 and at least 1 risk factor. Main Outcome Measures  Primary outcome was any neurocranial traumatic finding on CT scan. Secondary outcomes were neurosurgical intervention and clinically important CT findings. Sensitivity and specificity were estimated for each outcome for the CCHR and the NOC, using both rules as originally derived and also as adapted to apply to an expanded patient population. Results  Of 3181 patients with a GCS score of 13 to 15, neurosurgical intervention was performed in 17 patients (0.5%); neurocranial traumatic CT findings were present in 312 patients (9.8%). Sensitivity for neurosurgical intervention was 100% for both the CCHR and the NOC. The NOC had a higher sensitivity for neurocranial traumatic findings and for clinically important findings (97.7%-99.4%) than did the CCHR (83.4%-87.2%). Specificities were very low for the NOC (3.0%-5.6%) and higher for the CCHR (37.2%-39.7%). The estimated potential reduction in CT scans for patients with minor head injury would be 3.0% for the adapted NOC and 37.3% for the adapted CCHR. Conclusions  For patients with minor head injury and a GCS score of 13 to 15, the CCHR has a lower sensitivity than the NOC for neurocranial traumatic or clinically important CT findings, but would identify all cases requiring neurosurgical intervention, and has greater potential for reducing the use of CT scans.      

Evaluation of safety balls and faceguards for prevention of injuries in youth baseball

Context  Safety balls and faceguards are widely used in youth baseball, but their effectiveness in reducing injury is unknown. Objective  To evaluate the association of the use of faceguards and safety balls and injuries in youth baseball. Design, Setting, and Participants  Ecological study using a national database of compensated insurance claims maintained by Little League Baseball Incorporated, combined with data on the number of participants in Little League and data from a census of protective equipment usage for youth aged 5 to 18 years participating in Little League Baseball in the United States during 1997-1999. Main Outcome Measures  Rate of injury and injury rate ratio comparing users with nonusers of protective equipment. Results  A total of 6 744 240 player-seasons of follow-up and 4233 compensated injury claims were available for analysis. The absolute incidence of compensated injury per 100 000 player-seasons was 28.02 (95% confidence interval [CI], 26.76-29.29) for ball-related injury and 2.71 (95% CI, 2.32-3.11) for facial injury. Overall, use of safety balls was associated with a reduced risk of ball-related injury (adjusted rate ratio, 0.77; 95% CI, 0.64-0.93). This reduction was essentially due to 1 type of safety ball, known as the reduced-impact ball (adjusted rate ratio, 0.72; 95% CI, 0.57-0.91). Use of faceguards reduced the risk of facial injury (adjusted rate ratio, 0.65; 95% CI, 0.43-0.98). Metal and plastic guards appeared to be equally effective. Safety balls appeared to be more effective in the minor division (ages 7-12 years) than in the regular division (ages 9-12 years). Conclusions  Reduced-impact balls and faceguards were associated with a reduced risk of injury in youth baseball. These findings support increased usage of these items; however, it should be noted that the absolute incidence of injury in youth baseball is low and that these equipment items do not prevent all injuries.      

Fall-Induced Injuries and Deaths Among Older Adults

Context  Although various fall-induced injuries and deaths among older adults are increasing, little is known about the epidemiology of these events. Objective  To determine the trends in the number and incidence of fall-induced injuries and deaths of older adults in a well-defined white population. Design and Setting  Secular trend analysis of the population of Finland, using the Finnish National Hospital Discharge Register and the Official Cause-of-Death Statistics of Finland. Participants  All persons aged 50 years or older who were admitted to hospitals in Finland for primary treatment of a first fall-induced injury from the years of 1970 to 1995, and for comparison, all fall-induced deaths in the same age group from the years 1971 to 1995. Main Outcome Measure  The number and the age-specific and age-adjusted incidence rate (per 100,000 persons) of fall-induced injuries and deaths in each year of the study. Results  For the study period, both the total and population-adjusted number (per 100,000 persons) of Finns aged 50 years or older with fall-induced injury increased substantially. Total fall-induced injuries increased from 5622 in 1970 to 21,574 in 1995, a 284% increase, and the rate increased from 494 to 1398 per 100,000 persons, a 183% increase. The age-adjusted incidence also increased in both women (from 648 in 1970 to 1469 in 1995, a 127% increase) and men (from 434 in 1970 to 972 in 1995, a 124% increase). Moreover, the number of deaths due to falls in the overall population increased from 441 in 1971 to 793 in 1995, an 80% increase, and the rate increased from 38 in 1971 to 51 in 1995, a 34% increase. However, after age adjustment the incidence of fall-induced death did not show a clear upward trend. Conclusions  In a well-defined white population, the number of older persons with fall-induced injuries is increasing at a rate that cannot be explained simply by demographic changes. Preventive measures should be adopted to control the increasing burden of these injuries. Fortunately, the age-adjusted incidence of the fall-induced deaths shows no increasing trend over time.      

National surveillance of emergency department visits for outpatient adverse drug events

Context  Adverse drug events are common and often preventable causes of medical injuries. However, timely, nationally representative information on outpatient adverse drug events is limited. Objective  To describe the frequency and characteristics of adverse drug events that lead to emergency department visits in the United States. Design, Setting, and Participants  Active surveillance from January 1, 2004, through December 31, 2005, through the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project. Main Outcome Measures  National estimates of the numbers, population rates, and severity (measured by hospitalization) of individuals with adverse drug events treated in emergency departments. Results  Over the 2-year study period, 21 298 adverse drug event cases were reported, producing weighted annual estimates of 701 547 individuals (95% confidence interval [CI], 509 642-893 452) or 2.4 individuals per 1000 population (95% CI, 1.7-3.0) treated in emergency departments. Of these cases, 3487 individuals required hospitalization (annual estimate, 117 318 [16.7%]; 95% CI, 13.1%-20.3%). Adverse drug events accounted for 2.5% (95% CI, 2.0%-3.1%) of estimated emergency department visits for all unintentional injuries and 6.7% (95% CI, 4.7%-8.7%) of those leading to hospitalization and accounted for 0.6% of estimated emergency department visits for all causes. Individuals aged 65 years or older were more likely than younger individuals to sustain adverse drug events (annual estimate, 4.9 vs 2.0 per 1000; rate ratio [RR], 2.4; 95% CI, 1.8-3.0) and more likely to require hospitalization (annual estimate, 1.6 vs 0.23 per 1000; RR, 6.8; 95% CI, 4.3-9.2). Drugs for which regular outpatient monitoring is used to prevent acute toxicity accounted for 41.5% of estimated hospitalizations overall (1381 cases; 95% CI, 30.9%-52.1%) and 54.4% of estimated hospitalizations among individuals aged 65 years or older (829 cases; 95% CI, 45.0%-63.7%). Conclusions  Adverse drug events among outpatients that lead to emergency department visits are an important cause of morbidity in the United States, particularly among individuals aged 65 years or older. Ongoing, population-based surveillance can help monitor these events and target prevention strategies.      

Risk of injury to child passengers in compact extended-cab pickup trucks

Context  An increasing number of compact pickup trucks can accommodate restrained rear occupants. Rear seats in these pickup trucks are exempt from regulatory safety testing though their relative safety has not been determined. Objectives  To evaluate the risk of injury to children in compact extended-cab pickup trucks compared with children in other vehicles and to determine if any unique hazards exist. Design  Cross-sectional study of children aged 15 years or younger in crashes of insured vehicles, with data collected via insurance claim records and a telephone survey. Setting and Participants  Probability sample of 7192 multirow vehicles involved in crashes, with 11 335 child occupants, in 3 large US regions from December 1, 1998, to November 30, 2000. Main Outcome Measure  Relative risk of injury, defined as concussions and more serious brain injuries, spinal cord injuries, internal organ injuries, extremity fractures, and facial lacerations, estimated by odds ratios (ORs) adjusting for age, restraint use, point of impact, vehicle weight, and crash severity. Results  Injuries were reported for 1356 children, representing 1.6% of the population. Children in compact extended-cab pickup trucks were at greater risk of injury than children in other vehicles (adjusted OR, 2.96; 95% confidence interval [CI], 1.68-5.21). Children in the rear seats of compact pickup trucks were at substantially greater risk of injury than rear-seated children in other vehicles (adjusted OR, 4.75; 95% CI, 2.39-9.43). Children seated in the front seat of compact extended-cab pickup trucks were at greater risk of injury than children in the front seats of other vehicles, but this risk was not statistically significant (adjusted OR, 1.70; 95% CI, 0.78-3.69). Conclusions  Children in compact extended-cab pickup trucks are not as safe as children in other vehicles, primarily due to the increased relative risk of injury in the back seat. For families with another choice of vehicle, clinicians should advise parents against transporting children in compact pickup trucks. The current exemption for regulatory testing for occupant protection in the rear seats of compact pickup trucks should be reconsidered.      

Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury

Context  Current use of cranial computed tomography (CT) for minor head injury is increasing rapidly, highly variable, and inefficient. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) are previously developed clinical decision rules to guide CT use for patients with minor head injury and with Glasgow Coma Scale (GCS) scores of 13 to 15 for the CCHR and a score of 15 for the NOC. However, uncertainty about the clinical performance of these rules exists. Objective  To compare the clinical performance of these 2 decision rules for detecting the need for neurosurgical intervention and clinically important brain injury. Design, Setting, and Patients  In a prospective cohort study (June 2000-December 2002) that included 9 emergency departments in large Canadian community and university hospitals, the CCHR was evaluated in a convenience sample of 2707 adults who presented to the emergency department with blunt head trauma resulting in witnessed loss of consciousness, disorientation, or definite amnesia and a GCS score of 13 to 15. The CCHR and NOC were compared in a subgroup of 1822 adults with minor head injury and GCS score of 15. Main Outcome Measures  Neurosurgical intervention and clinically important brain injury evaluated by CT and a structured follow-up telephone interview. Results  Among 1822 patients with GCS score of 15, 8 (0.4%) required neurosurgical intervention and 97 (5.3%) had clinically important brain injury. The NOC and the CCHR both had 100% sensitivity but the CCHR was more specific (76.3% vs 12.1%, P<.001) for predicting need for neurosurgical intervention. For clinically important brain injury, the CCHR and the NOC had similar sensitivity (100% vs 100%; 95% confidence interval [CI], 96%-100%) but the CCHR was more specific (50.6% vs 12.7%, P<.001), and would result in lower CT rates (52.1% vs 88.0%, P<.001). The values for physician interpretation of the rules, CCHR vs NOC, were 0.85 vs 0.47. Physicians misinterpreted the rules as not requiring imaging for 4.0% of patients according to CCHR and 5.5% according to NOC (P = .04). Among all 2707 patients with a GCS score of 13 to 15, the CCHR had sensitivities of 100% (95% CI, 91%-100%) for 41 patients requiring neurosurgical intervention and 100% (95% CI, 98%-100%) for 231 patients with clinically important brain injury. Conclusion  For patients with minor head injury and GCS score of 15, the CCHR and the NOC have equivalent high sensitivities for need for neurosurgical intervention and clinically important brain injury, but the CCHR has higher specificity for important clinical outcomes than does the NOC, and its use may result in reduced imaging rates.      

Bile duct injury during cholecystectomy and survival in medicare beneficiaries

Context  Common bile duct (CBD) injury during cholecystectomy is a significant source of patient morbidity, but its impact on survival is unclear. Objective  To demonstrate the relation between CBD injury and survival and to identify the factors associated with improved survival among Medicare beneficiaries. Design, Setting, and Patients  Retrospective study using Medicare National Claims History Part B data (January 1, 1992, through December 31, 1999) linked to death records and to the American Medical Association's (AMA's) Physician Masterfile. Records with a procedure code for cholecystectomy were reviewed and those with an additional procedure code for repair of the CBD within 365 days were defined as having a CBD injury. Main Outcome Measure  Survival after cholecystectomy, controlling for patient (sex, age, comorbidity index, disease severity) and surgeon (procedure year, case order, surgeon specialty) characteristics. Results  Of the 1 570 361 patients identified as having had a cholecystectomy (62.9% women), 7911 patients (0.5%) had CBD injuries. The entire population had a mean (SD) age of 71.4 (10.2) years. Thirty-three percent of all patients died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD injury remained alive. The adjusted hazard ratio (HR) for death during the follow-up period was significantly higher (2.79; 95% confidence interval [CI]; 2.71-2.88) for patients with a CBD injury than those without CBD injury. The hazard significantly increased with advancing age and comorbidities and decreased with the experience of the repairing surgeon. The adjusted hazard of death during the follow-up period was 11% greater (HR, 1.11; 95% CI, 1.02-1.20) if the repairing surgeon was the same as the injuring surgeon. Conclusions  The association between CBD injury during cholecystectomy and survival among Medicare beneficiaries is stronger than suggested by previous reports. Referring patients with CBD injuries to surgeons or institutions with greater experience in CBD repair may represent a system-level opportunity to improve outcome.      

A population-based study of inflicted traumatic brain injury in young children

Context  Physical abuse is a leading cause of serious head injury and death in children aged 2 years or younger. The incidence of inflicted traumatic brain injury (TBI) in US children is unknown. Objective  To determine the incidence of serious or fatal inflicted TBI in a defined US population of approximately 230 000 children aged 2 years or younger. Design, Setting, and Subjects  All North Carolina children aged 2 years or younger who were admitted to a pediatric intensive care unit or who died with a TBI in 2000 and 2001 were identified prospectively. Injuries were considered inflicted if accompanied by a confession or a medical and social service agency determination of abuse. Main Outcome Measure  Incidence of inflicted TBI. Multivariate logistic regression models were used to compare children with inflicted injuries with those with noninflicted injuries and with the general state population aged 2 years or younger. Results  A total of 152 cases of serious or fatal TBI were identified, with 80 (53%) incurring inflicted TBI. The incidence of inflicted traumatic brain injury in the first 2 years of life was 17.0 (95% confidence interval [CI], 13.3-20.7) per 100 000 person-years. Infants had a higher incidence than children in the second year of life (29.7 [95% CI, 22.9-36.7] vs 3.8 [95% CI, 1.3-6.4] per 100 000 person-years). Boys had a higher incidence than girls (21.0 [95% CI, 15.1-26.6] vs 13.0 [95% CI, 8.4-17.7] per 100 000 person-years). Relative to the general population, children who incurred an increased risk of inflicted injury were born to young mothers (21 years), non–European American, or products of multiple births. Conclusions  In this population of North Carolina children, the incidence of inflicted TBI varied by characteristics of the injured children and their mothers. These data may be helpful for informing preventive interventions.      

Incidence of Dog Bite Injuries Treated in Emergency Departments

Context.— Dog bites that result in injuries occur frequently, but how frequently dog bite injuries necessitate medical attention at a hospital or hospital admission is unknown. Objective.— To describe the incidence and characteristics of dog bite injuries treated in US emergency departments (EDs). Design.— Emergency department survey from the National Center for Health Statistics National Hospital Ambulatory Medical Care Survey for 1992 to 1994. Patients.— National probability sample of patients visiting EDs. Main Outcome Measure.— Incidence of dog bites treated in EDs, defined as a cause of injury recorded as the E-code E906.0. Results.— The 3-year annualized, adjusted, and weighted estimate of new dog bite–related injury visits to US EDs was 333687, a rate of 12.9 per 10000 persons (95% confidence interval [CI], 10.5-15.4). This represents approximately 914 new dog bite injuries requiring ED visits per day. The median age of patients bitten was 15 years, with children, especially boys aged 5 to 9 years, having the highest incidence rate (60.7 per 10000 persons for boys aged 5 to 9 years). Children seen in EDs were more likely than older persons to be bitten on the face, neck, and head (73% vs 30%). We estimated that for each US dog bite fatality there are about 670 hospitalizations and 16000 ED visits. Conclusions.— Dog bite injuries are an important source of injury in the US population, especially among children. Improved surveillance and prevention of dog bite–related injuries, particularly among children, are needed.      

Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes

Context  Although more than a dozen states have ratified laws that require booster seats for children older than 4 years, most states continue to have child restraint laws that only cover children through age 4 years. Lack of booster seat effectiveness data may be a barrier to passage of stronger child restraint laws. Objectives  To quantify the association of belt-positioning booster seats compared with seat belts alone and risk of injury among 4- to 7-year-old children and to assess patterns of injury among children in booster seats vs seat belts. Design, Setting, and Population  Cross-sectional study of children aged 4 to 7 years in crashes of insured vehicles in 15 states, with data collected via insurance claims records and a telephone survey. A probability sample of 3616 crashes involving 4243 children, weighted to represent 56 593 children in 48 257 crashes was collected between December 1, 1998, and May 31, 2002. Main Outcome Measure  Parent report of clinically significant injuries. Results  Injuries occurred among 1.81% of all 4- to 7-year-olds, including 1.95% of those in seat belts and 0.77% of those in belt-positioning booster seats. The odds of injury, adjusting for child, driver, crash, and vehicle characteristics, were 59% lower for children aged 4 to 7 years in belt-positioning boosters than in seat belts (odds ratio, 0.41; 95% confidence interval, 0.20-0.86). Children in belt-positioning booster seats had no injuries to the abdomen, neck/spine/back, or lower extremities, while children in seat belts alone had injuries to all body regions. Conclusion  Belt-positioning booster seats were associated with added safety benefits compared with seat belts to children through age 7 years, including reduction of injuries classically associated with improper seat belt fit in children.      

Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study

Context  Approximately 300 000 sport-related concussions occur annually in the United States, and the likelihood of serious sequelae may increase with repeated head injury. Objective  To estimate the incidence of concussion and time to recovery after concussion in collegiate football players. Design, Setting, and Participants  Prospective cohort study of 2905 football players from 25 US colleges were tested at preseason baseline in 1999, 2000, and 2001 on a variety of measures and followed up prospectively to ascertain concussion occurrence. Players injured with a concussion were monitored until their concussion symptoms resolved and were followed up for repeat concussions until completion of their collegiate football career or until the end of the 2001 football season. Main Outcome Measures  Incidence of concussion and repeat concusion; type and duration of symptoms and course of recovery among players who were injured with a concussion during the seasons. Results  During follow-up of 4251 player-seasons, 184 players (6.3%) had a concussion, and 12 (6.5%) of these players had a repeat concussion within the same season. There was an association between reported number of previous concussions and likelihood of incident concussion. Players reporting a history of 3 or more previous concussions were 3.0 (95% confidence interval, 1.6-5.6) times more likely to have an incident concussion than players with no concussion history. Headache was the most commonly reported symptom at the time of injury (85.2%), and mean overall symptom duration was 82 hours. Slowed recovery was associated with a history of multiple previous concussions (30.0% of those with =" BORDER="0">3 previous concussions had symptoms lasting >1 week compared with 14.6% of those with 1 previous concussion). Of the 12 incident within-season repeat concussions, 11 (91.7%) occurred within 10 days of the first injury, and 9 (75.0%) occurred within 7 days of the first injury. Conclusions  Our study suggests that players with a history of previous concussions are more likely to have future concussive injuries than those with no history; 1 in 15 players with a concussion may have additional concussions in the same playing season; and previous concussions may be associated with slower recovery of neurological function.      

Death and injury from landmines and unexploded ordnance in Afghanistan

Context  Afghanistan is one of the countries most affected by injuries due to landmines and unexploded ordnance. Objective  To understand the epidemiological patterns and risk factors for injury due to landmines and unexploded ordnance. Design and Setting  Analysis of surveillance data on landmine and unexploded ordnance injuries in Afghanistan collected by the International Committee of the Red Cross in 390 health facilities in Afghanistan. Surveillance data were used to describe injury trends, injury types, demographics, and risk behaviors of those injured and explosive types related to landmine and unexploded ordnance incidents. Participants  A total of 1636 individuals injured by landmines and unexploded ordnance, March 2001 through June 2002. Results  Eighty-one percent of those injured were civilians, 91.6% were men and boys, and 45.9% were younger than 16 years. Children were more likely to be injured by unexploded ordnance (which includes grenades, bombs, mortar shells, and cluster munitions), whereas adults were injured mostly by landmines. The most common risk behaviors for children were playing and tending animals; for adults, these risk behaviors were military activity and activities of economic necessity (eg, farming, traveling). The case-fatality rate of 9.4% is probably underestimated because surveillance predominantly detects those who survive long enough to receive medical care. Conclusions  Landmine risk education should focus on hazards due to unexploded ordnance for children and on landmine hazards for adults and should address age-specific risk behaviors. Expanding community-based and clinic-based reporting will improve the sensitivity and representativeness of surveillance.      

Myocardial injury and long-term mortality following moderate to severe carbon monoxide poisoning

Context  Carbon monoxide (CO) poisoning is a common cause of toxicological morbidity and mortality. Myocardial injury is a frequent consequence of moderate to severe CO poisoning. While the in-hospital mortality for these patients is low, the long-term outcome of myocardial injury in this setting is unknown. Objective  To determine the association between myocardial injury and long-term mortality in patients following moderate to severe CO poisoning. Design, Setting, and Participants  Prospective cohort study of 230 consecutive adult patients treated for moderate to severe CO poisoning with hyperbaric oxygen and admitted to the Hennepin County Medical Center, a regional center for treatment of CO poisoning, between January 1, 1994, and January 1, 2002. Follow-up was through November 11, 2005. Main Outcome Measure  All-cause mortality. Results  Myocardial injury (cardiac troponin I level 0.7 ng/mL or creatine kinase-MB level 5.0 ng/mL and/or diagnostic electrocardiogram changes) occurred in 85 (37%) of 230 patients. At a median follow-up of 7.6 years (range: in-hospital only to 11.8 years), there were 54 deaths (24%). Twelve of those deaths (5%) occurred in the hospital as a result of a combination of burn injury and anoxic brain injury (n = 8) or cardiac arrest and anoxic brain injury (n = 4). Among the 85 patients who sustained myocardial injury from CO poisoning, 32 (38%) eventually died compared with 22 (15%) of 145 patients who did not sustain myocardial injury (adjusted hazard ratio, 2.1; 95% confidence interval, 1.2-3.7; P = .009). Conclusion  Myocardial injury occurs frequently in patients hospitalized for moderate to severe CO poisoning and is a significant predictor of mortality.      

Neurologic adverse events associated with smallpox vaccination in the United States, 2002-2004

Context  Neurologic illness is an infrequent but severe adverse event associated with smallpox vaccination. The reinstatement of smallpox vaccination in the United States in response to possible bioterrorism renewed concerns about vaccine-related adverse neurologic events. Objective  To determine rates and describe the clinical features of neurologic events associated with smallpox vaccination. Design and Setting  We assessed reports of adverse events obtained through active case reporting and review of data reported to the Vaccine Adverse Event Reporting System among 665 000 persons vaccinated against smallpox by the Departments of Defense (n = 590 400) and Health and Human Services (n = 64 600) during the 2002-2004 US Smallpox Vaccination Program. Main Outcome Measure  Adverse neurologic events temporally associated with smallpox vaccination. Results  Between December 16, 2002, and March 11, 2004, 214 neurologic adverse events temporally associated with smallpox vaccination were reported; 111 reports involved Department of Health and Human Services and 103 involved Department of Defense vaccinees. Fifty-four percent of these events occurred within 1 week of vaccination, and 53% were among primary vaccinees. The most common neurologic adverse event was headache (95 cases), followed by nonserious limb paresthesias (n = 17) or pain (n = 13) and dizziness or vertigo (n = 13). Serious neurologic adverse events included 13 cases of suspected meningitis, 3 cases of suspected encephalitis or myelitis, 11 cases of Bell palsy, 8 seizures (including 1 death), and 3 cases of Guillain-Barré syndrome. Among these 39 events, 27 (69%) occurred in primary vaccinees and all but 2 occurred within 12 days of vaccination. Conclusions  During the 2002-2004 smallpox vaccination campaign, reported neurologic events were generally mild and self-limited, and no neurologic syndrome was identified at a rate above baseline estimates. Serious neurologic adverse events, such as postvaccinal encephalitis, Bell palsy, and Guillain-Barré syndrome, occurred in accordance with expected ranges.