Curating an online checklist for Erica L. (Ericaceae): contributing to and supporting global conservation through the World Flora Online.

To support the work of the Global Conservation Consortium for Erica and update the Erica checklist in the World Flora Online (WFO), we have curated the taxonomic backbone in the WFO by expanding it to include updated nomenclatural information from the International Plant Name Index, missing names present in the World Checklist of Vascular Plants (WCVP), the Botanical Database of Southern Africa (BODATSA), and from the "International register of heather names" database, a data source not readily available online. The result is the most robust database of Erica names to date, including 851 species, 111 subspecies, 244 varieties, and 2787 synonyms, which is a reliable reference for initiatives such as the Erica identification aid, conservation prioritisation, and gap analyses. We disambiguate common orthographic variants within the database and present an overview of these. We also comment on the correct orthography of E.heleophila Guthrie & Bolus and E.michellensis Dulfer and the validity of E.tegetiformis E.G.H.Oliv. are discussed, and the use of E.adunca Benth. for a South African species rather than E.triceps Link, which is here regarded as insufficiently known and of uncertain application, is clarified.

Predictors of failed primary abdominal closure in the trauma patient with an open abdomen.

BACKGROUND: We sought to characterize risk factors for failed closure after damage-control laparotomy and to examine the impact of two broad categories of open abdomen-management technique on rates of fascial approximation. METHODS: We retrospectively reviewed (January 2006-December 2008) all trauma patients with an open abdomen after damage-control laparotomy. Patients with definitive abdominal closure before discharge were classified as successful closure (SC) and those discharged with a planned ventral hernia were classified as failed closure (FC). Univariate stepwise logistical analyses were conducted to identify covariates related to resuscitation volumes and injury severity that were associated with FC. Surgical techniques were dichotomized as fascial based or vacuum based and compared with chi square. RESULTS: Sixty-two subjects met final eligibility (SC 44, FC 18). SC and FC were similar, with the exception of, respectively, initial base excess (-8.0 ± 4.2 vs -11.4 ± 4.9; P = 0.009), injury severity score (ISS; 29.0 ± 15.2 vs 20.6 ± 12.1; P = 0.04), and frequency of penetrating injury (47.7% vs 77.8%; P = 0.03). Stepwise regression showed significant associations between failed closure and increasing Penetrating Abdominal Trauma Index (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.01-1.11), worsening base excess on arrival (OR 0.79, 95% CI 0.66-0.93), and lower ISS (OR 0.94, 95% CI 0.89-1.00). Fascial-based versus vacuum-based management techniques had no effect on closure rates. CONCLUSIONS: Volume of blood transfused, crystalloid given, and open abdomen management technique were not related to closure rates; however, worsened base excess on arrival, penetrating trauma, higher Penetrating Abdominal Trauma Index, and a lower ISS were associated with FC. The latter was true despite an association also being found between FC and lower ISS scores, reflecting the propensity of ISS to underestimate injury burden after penetrating injury.

Needle electromyography predicts outcome after lumbar epidural steroid injection.

INTRODUCTION: Needle electromyography (NEE) would be more valuable if it could predict outcomes after lumbar epidural steroid injections (LESIs) in lumbosacral radiculopathy (LSR). METHODS: We investigated the predictive value of NEE for outcome after LESI compared with other known predictive variables in 89 subjects with clinical LSR. Seventy patients completed the study, which included diagnostic lower extremity NEE and LESI. Outcome measures included changes in pain, physical function, and psychosocial function [assessed using the Pain Disability Questionnaire (PDQ)]. RESULTS: NEE was an independent predictor of long-term pain improvement after LESI and was not predictive of PDQ functional improvement. A regression model, with NEE as one of several independent variables, showed strong outcome-predictive ability. CONCLUSIONS: NEE is an independent predictor of long-term pain relief after LESI for LSR. Abnormal NEE is predictive of better outcome than normal NEE. A regression equation including NEE and other independent predictors was predictive of pain and functional outcomes.

Higher-order reasoning training years after traumatic brain injury in adults.

OBJECTIVE: To conduct a feasibility study to compare the effects of top-down Strategic Memory and Reasoning Training (SMART) versus information-based Brain Health Workshop (BHW, control) on gist-reasoning (ie, abstracting novel meaning from complex information), memory, executive functions, and daily function in adults with traumatic brain injury. PARTICIPANTS: Twenty-eight participants (of the 35 recruited), 16 men & 12 women, aged 20 to 65 years (M = 43, SD = 11.34) at chronic stages posttraumatic brain injury (2 years or longer) completed the training. Fourteen participants that received SMART and 14 participants that completed BHW were assessed both pre- and posttraining. Thirteen of the SMART trained and 11 from BHW participated in a 6-month testing. DESIGN: The study was a single blinded randomized control trial. Participants in both groups received a minimum of 15 hours of training over 8 weeks. RESULTS: The SMART group significantly improved gist-reasoning as compared to the BHW group. Benefits of the SMART extended to untrained measures of working memory and participation in functional activities. Exploratory analyses suggested potential transfer effects of SMART on memory and executive functions. The benefits of the SMART program as compared to BHW were evident at immediately posttraining and 6 months posttraining. CONCLUSION: This study provides preliminary evidence that short-term intensive training in top-down modulation of information benefits gist-reasoning and generalizes to measures of executive function and real life function at chronic stages of post-TBI.

Prediction of pulmonary morbidity and mortality in patients with femur fracture.

BACKGROUND: We aimed to determine the effect of femur fractures on mortality, pulmonary complications, and adult respiratory distress syndrome (ARDS). In addition, we aimed to compare the effect of femur fractures with other major musculoskeletal injuries and to determine the effect of timing to surgery on these complications. METHODS: All patients were identified from the trauma registries of two Level I trauma centers. Outcomes were defined at mortality in hospital, pulmonary complications, and ARDS in hospital. Regression analysis was used to determine the effect of femur fractures, while controlling for age, Abbreviated Injury Scales, Glasgow Coma Scale, and systolic blood pressure at presentation. We compared femur fractures with other major musculoskeletal injuries in similar models. Within the patients with femur fracture, time to surgery (< 8 hours, 8 hours to 24 hours, and > 24 hours) was evaluated using similar regression analysis. RESULTS: Of the total 90,510 patients, 3,938 (4.35%) died in the hospital, 2,055 (2.27%) had a pulmonary complication, and 285 (0.31%) developed ARDS. Femur fracture is statistically predictive of mortality (odds ratio [OR], 1.606; 95% confidence interval [CI], 1.288-2.002) and pulmonary complications (OR, 1.659; 95% CI, 1.329-2.070), when controlling for other injury factors. This was comparable with the effect of pelvic fracture and other major musculoskeletal injuries. Femur fracture had a strong relationship with ARDS (OR, 2.129; 95% CI, 1.382-3.278). Patients treated in the 8 hours to 24 hours window had the lowest mortality risk (OR, 0.140; 95% CI, 0.052-0.375), and there was a trend to increased risk of ARDS in a delay to surgery of > 24 hours. CONCLUSIONS: Femur fractures are a major musculoskeletal injury and increase the risk of mortality and pulmonary complications as much as any other musculoskeletal injuries. There is a unique relationship between ARDS and femur fractures, and this must be considered carefully in treatment planning for these patients.

When policy meets statistics: the very real effect that questionable statistical analysis has on limiting health care access for bariatric surgery.

HYPOTHESIS: Bariatric surgery for Medicare patients must be performed in an accredited hospital that performs at least 125 cases per year. We assessed the validity of this volume threshold and its policy implications. DESIGN: Using the 2001-2003 National Inpatient Survey, the effect of hospital volume on in-hospital mortality was statistically modeled and the effect of a 125-case per year threshold on access to bariatric surgery was calculated. We performed Monte Carlo modeling to investigate the effect random sampling has on the apparently high mortality rate for low-volume hospitals. SETTING: US inpatient hospitals. PATIENTS: Patients with hospital discharge codes indicating bariatric surgery. Main Outcome Measure In-house mortality. RESULTS: The observed in-hospital mortality distribution as a function of hospital volume was similar to the expected frequency attributable to random sampling alone. A small number of excess deaths in very low-volume facilities cause statistically significant results for volume-outcome studies. Although 74% of all bariatric surgeries are performed in high-volume centers, 73% of all hospitals currently offering these services are now classified as low volume. CONCLUSIONS: When the results of statistical analysis are used for policy determination, the consequences for patient care may be substantial. Most studies of volume-outcome relationships rely on statistical methods that tend to amplify the effects and few fully characterize their statistical models. Despite the weak evidence for a volume-outcome relationship for bariatric surgery, a 125-case per year threshold has been set for center-of-excellence status, which eliminates most hospitals currently providing these services and disproportionately restricts access for the poor and underinsured.

Ethnic disparities exist in trauma care.

BACKGROUND: An estimated 5.3 million people in the United States live with permanent disability related to traumatic brain injury (TBI). Access to rehabilitation after TBI is important in minimizing these disabilities. Ethnic disparities in access to health care have been documented in other diseases, but have not been studied in trauma care. We hypothesized that access to rehabilitation after TBI is influenced by race or ethnicity. METHODS: Retrospective analysis of the National Trauma Data Bank patients with severe blunt TBI (head abbreviated injury score 3-5, n = 58,729) who survived the initial hospitalization was performed. Placement into rehabilitation after discharge was studied in three groups: non-Hispanic white (NHW 77%), African American (14%), and Hispanic (9%). The two minority groups were compared with NHW patients using logistic regression to control for differences in age, gender, overall injury severity (injury severity score), TBI severity (head abbreviated injury score and Glasgow Coma Scale score), associated injuries, and insurance status. RESULTS: The three groups were similar in injury severity score, TBI severity, and associated injuries. After accounting for differences in potential confounders, including injury severity and insurance status, minority patients were 15% less likely to be placed in rehabilitation (odds ratio 0.85, 95% confidence interval 0.8-0.9, p < 0.0001). CONCLUSIONS: Ethnic minority patients are less likely to be placed in rehabilitation than NHW patients are, even after accounting for insurance status, suggesting existence of systematic inequalities in access. Such inequalities may have a disproportionate impact on long-term functional outcomes of African American and Hispanic TBI patients, and suggest the need for an in-depth analysis of this disparity at a health policy level.

Use of a pressure sensing sheath: comparison with standard means of blood pressure monitoring in catheterization procedures.

PURPOSE: Monitoring of blood pressure (BP) during procedures is variable, depending on multiple factors. Common methods include sphygmomanometer (BP cuff), separate radial artery catheterization, and side port monitoring of an indwelling sheath. Each means of monitoring has disadvantages, including time consumption, added risk, and signal dampening due to multiple factors. We sought an alternative approach to monitoring during procedures in the catheterization laboratory. METHODS: A new technology involving a 330 µm fiberoptic sensor embedded in the wall of a sheath structure was tested against both radial artery catheter and sphygmomanometer readings obtained simultaneous with readings recorded from the pressure sensing system (PSS). Correlations and Bland-Altman analysis were used to determine whether use of the PSS could substitute for these standard techniques. RESULTS: The results indicated highly significant correlations in systolic, diastolic, and mean arterial pressures (MAP) when compared against radial artery catheterization (p<0.0001), and MAP means differed by <4%. Bland-Altman analysis of the data suggested that the sheath measurements can replace a separate radial artery catheter. While less striking, significant correlations were seen when PSS readings were compared against BP cuff readings. CONCLUSIONS: The PSS has competitive functionality to that seen with a dedicated radial artery catheter for BP monitoring and is available immediately on sheath insertion without the added risk of radial catheterization. The sensor is structurally separated from the primary sheath lumen and readings are unaffected by device introduction through the primary lumen. Time delays and potential complications from radial artery catheterization are avoided.

Preparing data for analysis using microsoft Excel.

A critical component essential to good research is the accurate and efficient collection and preparation of data for analysis. Most medical researchers have little or no training in data management, often causing not only excessive time spent cleaning data but also a risk that the data set contains collection or recording errors. The implementation of simple guidelines based on techniques used by professional data management teams will save researchers time and money and result in a data set better suited to answer research questions. Because Microsoft Excel is often used by researchers to collect data, specific techniques that can be implemented in Excel are presented.

Outcome Following Surgical Correction of Grade 4 Medial Patellar Luxation in Dogs: 47 Stifles (2001-2012).

Grade 4/4 medial patellar luxation (MPL) is a complex disease of the canine stifle that often requires surgical realignment of the patella to resolve clinical lameness. Outcome following surgery remains poorly described. Medical records were retrospectively reviewed for surgical correction of grade 4 MPL. Signalment and exam findings, surgical procedures performed, complications, and clinical outcome were reported. Data was statistically analyzed for association with major complication occurrence and unacceptable function following surgery. Forty-seven stifles from 41 dogs were included. The surgical procedures most frequently utilized for patellar realignment were the combination of femoral trochleoplasty, tibial tuberosity transposition, and joint capsule modification. Median in-hospital veterinary examination was performed at 69 days (range 30-179 days) following surgery. Full function was reported for 42.6% of cases (n=20). Acceptable function was reported for 40.4% of cases (n=19). Unacceptable function was reported for 17% of cases (n=8). The overall complication rate was 25.5% (n=12), with revision surgery for major complications required in 12.8% of cases (n=6). Corrective osteotomies were associated with major complications (P < 0.001). In general, pelvic limb function improves following surgical correction of grade 4 MPL; however, a return to full function should be considered guarded.

Injury severity and comorbidities alone do not predict futility of care after geriatric trauma.

BACKGROUND: When counseling surrogates of massively injured elderly trauma patients, the prognostic information they desire is rarely evidence based. OBJECTIVE: We sought to objectively predict futility of care in the massively injured elderly trauma patient using easily available parameters: age, Injury Severity Score (ISS), and preinjury comorbidities. METHODS: Two cohorts (70-79 years and ≥80 years) were constructed from The National Trauma Data Bank (NTDB) for years 2007-2011. Comorbidities were tabulated for each patient. Mortality rates at every ISS score were tabulated for subjects with 0, 1, or ≥2 comorbidities. Futility was defined a priori as an in-hospital mortality rate of ≥95% in a cell with ≥5 subjects. RESULTS: A total of 570,442 subjects were identified (age 70-79 years, n=217,384; age ≥80 years, n=352,608). Overall mortality was 5.3% for ages 70-79 and 6.6% for ≥80 years. No individual ISS score was found to have a mortality rate of ≥95% for any number of comorbidities in either age cohort. The highest mortality rate seen in any cell was for an ISS of 66 in the ≥80 year-old cohort with no listed comorbidities (93.3%). When upper extremes of ISS were aggregated into deciles, mortality for both cohorts across all number of comorbidities was 45.5%-60.9% for ISS 40-49, 56.6%-81.4% for ISS 50-59, and 73.9%-93.3% for ISS ≥60. CONCLUSIONS: ISS and preinjury comorbidities alone cannot be used to predict futility in massively injured elderly trauma patients. Future attempts to predict futility in these age groups may benefit from incorporating measures of physiologic distress.

Gender differences in outcomes of patients with cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) is a common life-shortening genetic disease in which women have been described to have worse outcomes than males, particularly in response to respiratory infections with Pseudomonas aeruginosa. However, as advancements in therapies have improved life expectancy, this gender disparity has been challenged. The objective of this study is to examine whether a gender-based survival difference still exists in this population and determine the impact of common CF respiratory infections on outcomes in males versus females with CF. METHODS: We conducted a retrospective cohort analysis of 32,766 patients from the United States Cystic Fibrosis Foundation Patient Registry over a 13-year period. Kaplan-Meier and Cox proportional hazards models were used to compare overall mortality and pathogen based survival rates in males and females. RESULTS: Females demonstrated a decreased median life expectancy (36.0 years; 95% confidence interval [CI] 35.0-37.3) compared with men (38.7 years; 95% CI 37.8-39.6; p<0.001). Female gender proved to be a significant risk factor for death (hazard ratio 2.22, 95% CI 1.79-2.77), despite accounting for variables known to influence CF mortality. Women were also found to become colonized earlier with several bacteria and to have worse outcomes with common CF pathogens. CONCLUSIONS: CF women continue to have a shortened life expectancy relative to men despite accounting for key CF-related comorbidities. Women also become colonized with certain common CF pathogens earlier than men and show a decreased life expectancy in the setting of respiratory infections. Explanations for this gender disparity are only beginning to be unraveled and further investigation into mechanisms is needed to help develop therapies that may narrow this gender gap.

Cognitive gains from gist reasoning training in adolescents with chronic-stage traumatic brain injury.

Adolescents with traumatic brain injury (TBI) typically demonstrate good recovery of previously acquired skills. However, higher-order and later emergent cognitive functions are often impaired and linked to poor outcomes in academic and social/behavioral domains. Few control trials exist that test cognitive treatment effectiveness at chronic recovery stages. The current pilot study compared the effects of two forms of cognitive training, gist reasoning (top-down) versus rote memory learning (bottom-up), on ability to abstract meanings, recall facts, and utilize core executive functions (i.e., working memory, inhibition) in 20 adolescents (ages 12-20) who were 6 months or longer post-TBI. Participants completed eight 45-min sessions over 1 month. After training, the gist reasoning group (n = 10) exhibited significant improvement in ability to abstract meanings and increased fact recall. This group also showed significant generalizations to untrained executive functions of working memory and inhibition. The memory training group (n = 10) failed to show significant gains in ability to abstract meaning or on other untrained specialized executive functions, although improved fact recall approached significance. These preliminary results suggest that relatively short-term training (6 h) utilizing a top-down reasoning approach is more effective than a bottom-up rote learning approach in achieving gains in higher-order cognitive abilities in adolescents at chronic stages of TBI. These findings need to be replicated in a larger study; nonetheless, the preliminary data suggest that traditional cognitive intervention schedules need to extend to later-stage training opportunities. Chronic-stage, higher-order cognitive trainings may serve to elevate levels of cognitive performance in adolescents with TBI.

Altered mental status in cirrhosis: etiologies and outcomes.

BACKGROUND: Cirrhotic patients admitted with altered mental status (AMS) represent a clinical challenge, as many potentially life-threatening diseases must be considered. Although many patients with AMS have hepatic encephalopathy (HE), other causes of AMS occur, and we hypothesized that these may have different outcomes. AIM: We aimed to understand the causes of AMS in cirrhotic patients admitted to the hospital and investigate their associated outcomes. METHODS: We performed a retrospective cohort study in 1218 inpatients with cirrhosis. Altered mental status was defined a priori (HE, sepsis/infectious, metabolic, exogenous drugs/toxins, structural lesions, or psychiatric abnormalities). RESULTS: Patients with AMS had higher levels of serum bilirubin, international normalized ratio, blood urea nitrogen, creatinine, and lower levels of albumin and platelets than those with normal mental status (NMS) (P = < 0.001). The most common cause of AMS was HE, accounting for nearly half of all patients. Other causes of AMS included the following: sepsis/infection (23%), metabolic disorders (8%), drugs/toxins (7%), structural lesions (5%), psychiatric disorders (1%), or multiple causes (8%). Mortality in patients with AMS was 35% compared to 16% in those with NMS (P < 0.0001). Patients with sepsis/infection, structural lesions, or multiple disorders causing AMS had the highest mortality (61%, 68%, and 79%, respectively). CONCLUSIONS: Nearly one third of admissions in cirrhotic patients were due to AMS, most commonly caused by HE. The overall mortality of patients admitted with AMS was greater than with NMS, particularly for those with infection or structural lesions, emphasizing the importance of a search for these causes of AMS in all patients with cirrhosis.

A SAS(®) macro implementation of a multiple comparison post hoc test for a Kruskal-Wallis analysis.

The Kruskal-Wallis (KW) nonparametric analysis of variance is often used instead of a standard one-way ANOVA when data are from a suspected non-normal population. The KW omnibus procedure tests for some differences between groups, but provides no specific post hoc pair wise comparisons. This paper provides a SAS(®) macro implementation of a multiple comparison test based on significant Kruskal-Wallis results from the SAS NPAR1WAY procedure. The implementation is designed for up to 20 groups at a user-specified alpha significance level. A Monte-Carlo simulation compared this nonparametric procedure to commonly used parametric multiple comparison tests.

Interrater reliability of needle electromyographic findings in lumbar radiculopathy.

OBJECTIVE: This study was performed to investigate the interrater reliability of needle electromyographic findings and electrodiagnostic impressions among expert electrodiagnosticians. DESIGN: Twenty-nine electromyographic recordings were chosen for this study from a larger prospective, observational cohort of 89 consecutive subjects, who were referred for electrodiagnostic evaluation of the lower limbs in a hospital-based spine clinic. The parent study was designed to evaluate the utility of electrodiagnostic findings in predicting outcomes after epidural steroid injections in lumbar radiculopathy. An unmasked, American Board of Electrodiagnostic Medicine board-certified examiner with knowledge of the patient's history and physical examination performed all initial electrodiagnostic evaluations, including needle electromyographic examination of a standardized set of six limb muscles and lumbar paraspinals representing L3 through S1 myotomes. The insertional and spontaneous activities of all muscles were recorded as de-identified digital video files with only muscle names visible. Motor units were not analyzed. Two independent, American Board of Electrodiagnostic Medicine board-certified examiners, who were masked to the patient's name, history, physical examination, and the electrodiagnostic report, reviewed 29 study subjects' digital video files. They rated each muscle's insertional and spontaneous activity on a standardized scoring sheet. After the examination was scored, they also generated a diagnostic impression of no evidence, possible evidence, or clear evidence of lumbar radiculopathy. Interrater reliability between the unmasked examiner and the two independent, masked examiners was assessed by Cohen's kappa statistic for electromyographic scoring of the muscles examined and for diagnostic impression. RESULTS: The interrater reliability was substantial (kappa >0.60) showing >60% agreement for the scoring of most of the muscles examined. The overall diagnostic impression showed outstanding interrater reliability (kappa >0.90) showing >90% agreement between the unmasked and masked examiners. There were no significant differences in the scoring between the two masked examiners. CONCLUSIONS: Needle electromyographic assessment of lower-limb and lumbar paraspinal muscles in the electrodiagnostic evaluation of lumbar radiculopathy is objective and highly reliable when performed by well trained and qualified electromyographers. Masked validation can be performed in electromyographic-based research.

Creation and use of a database in clinical and translational research.

Often data collection for clinical studies is an afterthought. The results of such an approach are incomplete or confusing data that can, as a worst case, result in scrapping and restarting the entire study. We discuss the planning process for data collection and storage to include encounter form development; data flow and capture; data checking, verification, and validation; advantage of relational databases over spreadsheets; data security; and aspects of a complete data system.

Prospective comparison of methicillin-susceptible and methicillin-resistant community-associated Staphylococcus aureus infections in hospitalized patients.

BACKGROUND: We sought to determine the proportion of community-associated Staphylococcus aureus infections due to methicillin-resistant S. aureus (CA-MRSA) at a large county hospital. In addition, we sought to identify the demographic and clinical risk factors associated with CA-MRSA infection. METHODS: Patients were prospectively enrolled if they were admitted to Parkland Hospital and had a positive culture for S. aureus isolated within 72 h of admission. The patients were interviewed using a standardized data questionnaire. Data collected included patient demographics, clinical history, as well as health care and non-health care associated MRSA risk factors. Bacterial susceptibilities were verified through review of microbiology laboratory and pharmacy records. Isolates were tested for Panton-Valentine leukocidin (PVL) gene, SCCmec type, and for inducible clindamycin resistance. RESULTS: One hundred and ninety-eight patients were interviewed prospectively, of which eight had colonization without active infection. One hundred and nineteen patients were infected with MRSA and 71 patients were infected with methicillin-susceptible S. aureus (MSSA). Patients with MRSA were more likely to be African-American and unemployed. Patients with MRSA most commonly presented with a skin or soft tissue infection (SSTI): 69% versus 45%, p=0.0012, while patients with MSSA were more likely to have infection of the respiratory tract: 11% versus 3%, p=0.02. Patients with MRSA were more likely to have used antibiotics in the past six months, been homeless, have a history of incarceration, have abused alcohol and have a history of infection with MRSA. In multivariate analysis, African-American race, antibiotics in the past six months, and a history of being homeless were associated with MRSA infection. Only 11 of 119 (9%) MRSA patients did not have at least one of these risk factors. PVL gene was present in 72 of 74 (97%) MRSA isolates and SCCmec type IV was present in 63 of 75 (84%) MRSA isolates. CONCLUSIONS: The majority of patients hospitalized with community-associated S. aureus infections were due to MRSA, most of which involved an SSTI. African-American race, recent antibiotics and past homeless status predicted infection with MRSA; however, no clinical profile could reliably exclude MRSA. Clinicians should be aware of the increasing prevalence of CA-MRSA.

Effect of trauma systems on motor vehicle occupant mortality: A comparison between states with and without a formal system.

BACKGROUND: Population-based studies using a "before-and-after" methodology report a reduction in motor vehicle collision mortality with implementation of statewide trauma systems (TS). However, concurrent improvements in roads, cars, restraint systems, and changes in rates of drunk driving, socioeconomics, speed limits, urban or rural mix, and traffic density may also be responsible for the progressive reduction in mortality rates. We hypothesized that a statewide TS independently reduces injury mortality, irrespective of other factors. METHODS: Data were acquired from several federal agencies including the Centers for Disease Control (CDC), The National Highway Traffic Safety Administration (NHTSA), the United States Department of Transportation (DOT), and the United States Census Bureau. Age-adjusted motor vehicle occupant (MVO) death rates per 100,000 population were compared in states with and without a TS. Negative binomial regression was used to calculate risk ratios (RR) comparing mortality in TS and non-TS states after adjusting for effects of gender, race, primary seat belt laws, seat belt use, alcohol use, miles traveled, population density, per capita income, types of registered vehicles, and rural or urban mix. RESULTS: : The number of states with a TS increased from 7 in 1981 to 36 in 2002. Concurrently, nationwide MVO death rates decreased by 2.6 per 100,000 (95% confidence interval 1.2-3.9; p < 0.001). Income, primary seat belt laws, restraint use, speed limits, and rural or urban population distribution (p < 0.05 for all), were independent predictors of MVO mortality, but not presence of a TS (RR 0.95, 95% confidence interval 0.73-1.23; p = 0.68). CONCLUSIONS: MVO death rates have declined over time, and are lower in TS states. However, the cause is multi-factorial, and cannot be attributed solely to presence of TS. Further studies are needed to identify beneficial components of a statewide trauma system.

Systemic hypotension is a late marker of shock after trauma: a validation study of Advanced Trauma Life Support principles in a large national sample.

BACKGROUND: Systolic blood pressure is used extensively to triage trauma patients as stable or unstable, contrary to Advanced Trauma Life Support recommendations. We hypothesized that systemic hypotension is a late marker of shock. METHODS: The National Trauma Data Bank was queried (n = 115,830). Base deficit was used as a measure of circulatory shock. Systolic blood pressure was correlated with the presence and the severity of base-deficit derangement. RESULTS: Systolic blood pressure correlated poorly with base deficit (r = .28). There was wide variation in systolic blood pressure within each base-deficit group. The mean and median systolic blood pressure did not decrease to less than 90 mm Hg until the base deficit was worse than -20, with mortality reaching 65%. CONCLUSIONS: We validated the Advanced Trauma Life Support principle that systemic hypotension is a late marker of shock. A normal blood pressure should not deter aggressive evaluation and resuscitation of trauma patients.