Uninsured status may be more predictive of outcomes among the severely injured than minority race

AimWorse outcomes in trauma in the United States have been reported for both the uninsured and minority race. We sought to determine whether disparities would persist among severely injured patients treated at trauma centres where standard triage trauma protocols limit bias from health systems and providers.MethodsWe performed a retrospective analysis of the 2010–2012 National Sample Program from the National Trauma Databank, which is a nationally representative sample of trauma centre performance in the United States. The database was screened for adults ages 18–64 who had a known insurance status. Outcomes measured were in-hospital mortality and post-hospital care.ResultsThere were 739,149 injured patients included in the analysis. Twenty-eight percent were uninsured, and 34 percent were of minority race. In the adjusted analysis, uninsured status (OR 1.60, 1.29–1.98, p < 0.001) and black race (OR 1.24, 1.04–1.49, p = 0.019) were significant predictors of mortality. Only uninsured status was a significant negative predictor of post-hospital care (OR 0.43, 0.36–0.51, p < 0.001). As injury severity increased, only insurance status was a significant predictor of both increased mortality (OR 1.68, 1.29–2.19, p < 0.001) and decreased post-hospital care (OR 0.45, 0.32–0.63, p < 0.001).ConclusionUninsured status is independently associated with higher in-hospital mortality and decreased post-hospital care in patients with severe injuries in a nationally representative sample of trauma centres in the United States. Increased in-hospital mortality is likely due to endogenous patient factors while decreased post-hospital care is likely due to economic constraints. Minority race is less of a factor influencing disparate outcomes among the severely injured.     

The value of ‘binder-off’ imaging to identify occult and unexpected pelvic ring injuries

AimsTo determine the effectiveness of ‘binder-off’ plain pelvic radiographs in the assessment of pelvic ring injuries.Patients and methodsAll patients requiring operative intervention at our tertiary referral pelvic unit/major trauma centre for high-energy pelvic injuries between April 2012 and December 2014 were retrospectively identified. Pre-operative pelvic imaging with and without pelvic binder was reviewed with respect to fracture pattern and pelvic stability. The frequency with which the imaging without pelvic binder changed the opinion of the pelvic stability and need for operative intervention, when compared with the computed tomography (CT) scans and anteroposterior (AP) radiographs with the binder on, was assessed.ResultsSeventy-three percent (71 of 97) of patients had initial imaging with a pelvic binder in situ. Of these, 76% (54 of 71) went on to have ‘binder-off’ imaging. Seven percent (4 of 54) of patients had unexpected unstable pelvic ring injuries identified on ‘binder-off’ imaging that were not identified on CT imaging in binder.ConclusionsTrauma CT imaging of the pelvis with a pelvic binder in place is inadequate at excluding unstable pelvic ring injuries, and, based on the original findings in this paper, we recommend additional plain film ‘binder-off’ radiographs, when there is any clinical concern.     

New pitfalls of high-density postmortem computed tomography

An 80-year-old female was transferred to the hospital due to a traffic accident. Multiple cranial bone fractures with intracranial hemorrhage and intracranial air were detected. Despite treatment, the patient died after 6 h. Twenty-one hours after the patient died, her whole body was scanned by postmortem CT, and a region of high density was detected within the left putamen. The autopsy revealed a cerebral contusion and multiple skull base fractures. Moreover, superabsorbent polymers (SAPs) were found within the left lateral ventricle and adjacent to the putamen, which appeared as a high-density lesion on postmortem CT at the left putamen, where the SAPs were compacted. Both ante- and postmortem conditions should be considered to prevent misdiagnoses based only on postmortem CT.     

Blood transfusions and hip fracture mortality - A retrospective cohort study

BackgroundHip fractures are associated with serious morbidity and mortality. Low haemoglobin at presentation has been shown to be associated with increased mortality in hip fracture patients. This comorbid patient group commonly receives packed red cell blood transfusions during their hospital admission, the impact of which is less clear.Aims and objectivesWe aim to assess the rate, appropriateness and impact of blood transfusions on one-year mortality in hip fracture patients. We also aim to assess the impact of patients taking anticoagulant medications at presentation on the rates of blood transfusions in this patient group.MethodsA retrospective cohort study of 324 consecutive hip fracture patients. Data was collected from the national hip fracture database, electronic patient records and PACS.Results75 patients received a blood transfusion. Receiving a blood transfusion increased absolute risk of one-year mortality by 2.466 (p < 0.05). Adjusted for age, sex, comorbidities, residence prior to admission and time from presentation to surgery increased the risk of one-year mortality was 2.790 (p < 0.05).28% of patients who went on to receive a transfusion had a haemoglobin of less than 100 g/L at presentation. 94.6% of transfused patients had a pre-transfusion haemoglobin of less than 90 g/L. There was no increased risk of requiring a blood transfusion if anticoagulant medication was being taken at presentation.ConclusionReceiving a blood transfusion during an admission for hip fracture carried an increased risk of one-year mortality of almost two and a half times. With appropriate preoperative optimisation, taking an anticoagulant medication at presentation did not increase the risk of requiring a transfusion. Most blood transfusions were administered appropriately using thresholds. Just over a quarter of patients who received a transfusion had an admission haemoglobin of less than 100 g/L, showing it as a poor predictor of blood transfusion requirement during admission.     

Osteochondral defects of the talus: radiological appearance and surgical candidate profiling — A retrospective analysis

BackgroundOsteochondral defects of the talus (OCD) are a well-established pathology within the ankle. They are most commonly associated with ankle trauma and whilst many are asymptomatic, they can have a significant negative impact on the patient, most notably with regards pain and mobility.Treatment of these lesions remains variable across the diverse cohort of these patients.AimsEvaluating the incidence of talus OCDs.Evaluating anatomic and morphologic data of the lesions against previous studies.Establishing if there was there any associated ligamentous injury.Determining the cohort of patients who were considered/underwent surgical intervention.MethodsA retrospective review was performed on patients presenting to a single Scottish Hospital with Talar OCDs between 2012–2016.Data collected included radiological appearance of the lesions (location and size), clinical history, associated ligament injury, treatment given and subsequent outcome.Categorical variables were presented as count and percentage while non-parametric variables were presented as median and interquartile range.Results90 new cases that matched our inclusion criteria were identified.Using the Raikin classification, the majority of injuries are in the posteromedial (26%), centrolateral (21%), and centromedial (18%) segments of the talus. Of note, no lesions were identified in the posterocentral segment.46% of patients had an associated ligamentous injury, either in the form of a sprain or tear. Most commonly the injury involved both ATFL and CFL (82%). 70% of patients that underwent surgery had radiological evidence of ligamentous injury.No statistically significant difference was identified between the management option and the involved segment according to Orr/Raikin classifications.ConclusionTalus osteochondral defects are a pathology which is more common than originally thought and their treatment remain a controversial topic. Little is known about the physical history of the condition as most cases are asymptomatic, thus poorly documented by definition.There is a clear opportunity and need for further research into developing evidence-based guidelines for their management. This study tried to correlate the management of OCDs with epidemiological and radiological data.     

Trauma exposure,incident psychiatric disorders,and disorder transitions in a longitudinal population representative sample

Heterotypic continuity, whereby individuals transition from one disorder to another, is common; however, longitudinal studies examining transdiagnostic predictors of heterotypic continuity are lacking. The current study examined whether trauma exposure during childhood (maltreatment) and adulthood (interpersonal and non-interpersonal trauma) is associated with heterotypic continuity in a national sample. Men and women (N = 34,653) who participated in Waves 1 (2001–2002) and 2 (2004–2005) of the National Survey of Alcohol and Related Conditions (NESARC) completed face-to-face interviews about trauma exposure and psychopathology. Risk ratios and population attributable risk proportions (PARPs) quantified the effects of childhood maltreatment and interpersonal and non-interpersonal trauma exposure between Waves 1 and 2 on risk for incident disorders and transitions between specific types of disorders. Twenty percent of respondents reported a Wave 2 incident disorder. Those with any Wave 1 disorder were at increased risk of incident mood (RR range = 1.2–2.1) and anxiety (RR = 1.5–2.7) disorders at Wave 2. Child maltreatment and interpersonal trauma exposure since Wave 1 were associated with roughly 50% of the risk for disorder transitions (RR range = 1.2–2.7); non-interpersonal trauma was associated with 30% of the risk for disorder transitions (RR range = 1.0–1.7). Findings suggest that new onset disorders were common in U.S. adults and trauma exposure explained a large proportion of disorder incidence as well as progression from one disorder to another. Universal prevention efforts that begin early in life, rather than those targeted at specific disorders, would be fruitful for reducing the burden of population mental health and preventing a cascade of mental disorders over the life course.     

Preexisting psychiatric illness worsens acute care outcomes after orthopaedic trauma in obese patients

PurposePre-existing psychiatric illness, illicit drug use, and alcohol abuse adversely impact patients with orthopaedic trauma injuries. Obesity is an independent factor associated with poorer clinical outcomes and discharge disposition, and higher hospital resource use. It is not known whether interactions exist between pre-existing illness, illicit drug use and obesity on acute trauma care outcomes.Patients and methodsThis cohort study is from orthopaedic trauma patients prospectively measured over 10 years (N = 6353). Psychiatric illness, illicit drug use and alcohol were classified by presence or absence. Body mass index (BMI) was analyzed as both a continuous and categorical measure (<30 kg/m² [non-obese], 30–39.9 kg/m² [obese] and ≥40 kg/m² [morbidly obese]). Main outcomes were the number of acute care services provided, length of stay (LOS), discharge home, hospital readmissions, and mortality in the hospital.ResultsStatistically significant BMI by pre-existing condition (psychiatric illness, illicit drug use) interactions existed for LOS and number of acute care services provided (β values 0.012–0.098; all p < 0.05). The interaction between BMI and psychiatric illness was statistically significant for discharge to locations other than home (β = 0.023; p = 0.001).DiscussionObese patients with orthopaedic trauma, particularly with preexisting mental health conditions, will require more hospital resources and longer care than patients without psychiatric illness. Early identification of these patients through screening for psychiatric illness and history of illicit drug use at admission is imperative to mobilize the resources and provide psychosocial support to facilitate the recovery trajectory of affected obese patients.     

Pattern of ocular injuries in stone pelters in Kashmir valley

PurposeTo describe the pattern and types of ocular injuries in stone pelters in Kashmir valley during recent turmoil.DesignCross sectional study.MethodsSixty patients with different types of eye injuries were assessed between June–September 2010 and initial visual acuity was recorded. The injuries were classified according to Systems for Classifying Ocular Injuries (OTCS) and Ocular Trauma Score (OTS) was calculated in order to estimate the probability of follow-up visual acuity range.ResultsMost of the victims (75%) were young boys between 16–26 years with a mean age of 20.95, 95% of cases were males. The main cause of injury was stones (48.3%) and pellets (30%) besides rubber bullets, sling shots and tear gas shells.Most of the open-globe injuries due to stones were of Type B and A, Grade E, Zone II and III with Afferent Pupillary Defect (APD) in 30% of the cases. Closed-globe injuries were mostly of Type A, Grade C and D and Zone II and III.Most of the open-globe injuries due to pellets were of Type D, Grade D, Zone II and APD in 33.3%. Pellets Intra Ocular Foreign Body (IOFB) was in 41.6%. Most of the closed-globe injuries were of Type A, Grade D and E and of Zone III.Overall OTS of 1 was calculated in 16.6% and 3 in 53.3% of the cases.ConclusionIn stone pelting demonstrations eye injuries can result in visually significant trauma. Injuries due to pellets are mostly perforating and pellet IOFB, and both tend to have a very poor prognosis. OTS can be used to estimate visual prognosis.     

Early parenting: The roles of maltreatment,trauma symptoms,and future expectations

The psychosocial determinants of early parenting are still not well understood. The current study used data on 115 girls in the Capella Project, who were followed longitudinally for the first 18 years of life. Potential predictors of early parenting assessed were child maltreatment, trauma symptoms, and girls' expectations for their socioeconomic outcomes. Cox regression survival analyses were conducted to predict time to the birth of first child. Significant unique predictors of early parenting included neglect, anxiety, low depression, and low expectations of going to college. Practice and research implications of these findings include the importance of neglect for risk of early parenting, the importance of ongoing trauma symptoms in youth, and the potentially protective influence of expectations of going to college.