Social inequalities in unintentional childhood injury incidence suggest subgroup identification and differentiation in the municipal planning of preventive efforts.

Aims: This registry-based study examined differences according to socio-economic factors in the incidence of unintentional childhood injuries involving main injury types. Methods: All children aged 0-15 years living in the municipality of Odense were followed from January 1 2006 to December 31 2010 (n=176,585). Injury outcome (n=27,745) was defined as visits to the local emergency department. Cohort data were transferred to Statistics Denmark and linked with socio-economic registry data based on unique personal identification numbers. Results: Children aged 10-15 years were at the highest risk for any injury (incidence rate ratio (IRR)=1.14), traffic injury (IRR=5.89) and sports injury (IRR=49.58) compared to children aged 0-4 years. Girls were at lower risk for any injury (IRR=0.85) and higher risk for sports injury (IRR=1.11) and home injuries (IRR=1.12) compared to boys. Children of parents with the lowest household income were at the highest risk for any injury (IRR=1.19) and traffic injury (IRR=2.16) compared to children of parents with the highest group. Children of parents with primary education were at the highest risk of any injury (IRR=1.22) and the lowest risk of traffic injury (IRR=0.80) and sports injury (IRR=0.75) compared to children of parents with tertiary education. Immigrants and descendants were at lower risk for any injury (IRR=0.75 and 0.79, respectively) and sports injury (IRR=0.81 and 0.68, respectively) compared to Danish children. Conclusions: Injury risk varied with socio-economic factors in a Danish municipal setting. The effect varied between specific injury types. Social and ethnic background is important in establishing targeted preventive efforts, but some aspects of selection bias may occur.

Development of the annual incidence rate of fracture in children 1980-2018: a population-based study of 32,375 fractures.

Background and purpose - Pediatric fractures are a common cause of morbidity. So far, no larger Danish study has described the development in the incidence rates. Therefore, we describe the development in the incidence rates of pediatric fractures in the time period 1980-2018 and the frequency of the most common type of fractures.Patients and methods - This is a retrospective register study of all children aged 0-15 years with a fracture treated in the Emergency Department at Odense University Hospital, Denmark, between 1980 and 2018. For all cases, information on age, sex, date of treatment, diagnosis, and treatment was obtained from the patient registration system. Based on official public population counts we estimated age and sex-specific annual incidence rates.Results - 32,375 fractures were included. In the study period the incidence rate decreased by 12%. The incidence increased until the early 1990s. Thereafter incidence rates decreased until 2004-09, from then onward increasing towards the end of the study period. The highest age-specific incidence rate in boys of 522 per 10,000 person-years was at 13 years of age. In girls the age of the highest incidence rate decreased from 11 years in 1980 to 10 years in 2018. Fracture of the lower end of the forearm, the clavicle, and the lower end of the humerus had the highest single fracture incidence rates.Interpretation - The incidence rate of pediatric fractures decreased in the study period by 12%. The highest single fracture incidence rates were for fracture of the lower end of the forearm, the clavicle, and the lower end of the humerus. As the first longitudinal Danish study of pediatric fractures this study is a baseline for evaluating future interventions and future studies.

Marked induction of the helix-loop-helix protein Id3 promotes the gammadelta T cell fate and renders their functional maturation Notch independent.

alphabeta and gammadelta T cells arise from a common thymocyte progenitor during development in the thymus. Emerging evidence suggests that the pre-T cell receptor (pre-TCR) and gammadelta T cell receptor (gammadeltaTCR) play instructional roles in specifying the alphabeta and gammadelta T-lineage fates, respectively. Nevertheless, the signaling pathways differentially engaged to specify fate and promote the development of these lineages remain poorly understood. Here, we show that differential activation of the extracellular signal-related kinase (ERK)-early growth response gene (Egr)-inhibitor of DNA binding 3 (Id3) pathway plays a defining role in this process. In particular, Id3 expression served to regulate adoption of the gammadelta fate. Moreover, Id3 was both necessary and sufficient to enable gammadelta-lineage cells to differentiate independently of Notch signaling and become competent IFNgamma-producing effectors. Taken together, these findings identify Id3 as a central player that controls both adoption of the gammadelta fate and its maturation in the thymus.

Rpl22 Loss Selectively Impairs αß T Cell Development by Dysregulating Endoplasmic Reticulum Stress Signaling.

Although ribosomal proteins (RP) are thought to primarily facilitate biogenesis of the ribosome and its ability to synthesize protein, emerging evidence suggests that individual RP can perform critical regulatory functions that control developmental processes. We showed previously that despite the ubiquitous expression of the RP ribosomal protein L22 (Rpl22), germline ablation of Rpl22 in mice causes a selective, p53-dependent block in the development of αß, but not γδ, T cell progenitors. Nevertheless, the basis by which Rpl22 loss selectively induces p53 in αß T cell progenitors remained unclear. We show in this study that Rpl22 regulates the development of αß T cells by restraining endoplasmic reticulum (ER) stress responses. In the absence of Rpl22, ER stress is exacerbated in αß, but not γδ, T cell progenitors. The exacerbated ER stress in Rpl22-deficient αß T lineage progenitors is responsible for selective induction of p53 and their arrest, as pharmacological induction of stress is sufficient to induce p53 and replicate the selective block of αß T cells, and attenuation of ER stress signaling by knockdown of protein kinase R-like ER kinase, an ER stress sensor, blunts p53 induction and rescues development of Rpl22-deficient αß T cell progenitors. Rpl22 deficiency appears to exacerbate ER stress by interfering with the ability of ER stress signals to block new protein synthesis. Our finding that Rpl22 deficiency exacerbates ER stress responses and induces p53 in αß T cell progenitors provides insight into how a ubiquitously expressed RP can perform regulatory functions that are selectively required by some cell lineages but not others.

Empirical validation of the New Zealand serious non-fatal injury outcome indicator for 'all injury'.

Our purpose was to empirically validate the official New Zealand (NZ) serious non-fatal 'all injury' indicator. To that end, we aimed to investigate the assumption that cases selected by the indicator have a high probability of admission. Using NZ hospital in-patient records, we identified serious injury diagnoses, captured by the indicator, if their diagnosis-specific survival probability was ≤0.941 based on at least 100 admissions. Corresponding diagnosis-specific admission probabilities from regions in Canada, Denmark and Greece were estimated. Aggregate admission probabilities across those injury diagnoses were calculated and inference made to New Zealand. The admission probabilities were 0.82, 0.89 and 0.90 for the regions of Canada, Denmark and Greece, respectively. This work provides evidence that the threshold set for the official New Zealand serious non-fatal injury indicator for 'all injury' captures injuries with high aggregate admission probability. If so, it is valid for monitoring the incidence of serious injuries.

Incidence of Moyamoya Disease in Denmark: A Population-Based Register Study.

In this first population-based study of moyamoya disease (MMD) in Europe, the authors identified 56 patients with MMD in Denmark during the period 1994-2015 using nationwide registers. The overall incidence was 0.047 per 100,000 person-years, which is about one-tenth that reported in Japan. Otherwise the epidemiological features were comparable: there was a bimodal age distribution with peaks in the age groups 0-9 years and 30-39 years, with twice as many females as males.

The major diversification of Vγ1.1+ and Vγ2+ thymocytes in mice occurs after commitment to the γδ T-cell lineage.

γδ T cells are a heterogeneous cell population with different subsets playing specialized and often opposing roles during immune responses. A key question is whether γδ thymocytes are determined for their effector function already at an early stage, before their commitment to the γδ T-cell lineage, or are instructed during their later development. Here, we show that the adult Vγ1.1+ and Vγ2+ γδ T-cell subsets both go through a CD73+ CD24+ development stage, and that the gene regulation involved in lineage commitment is shared by both subsets. We demonstrate that the major subset diversification first occurs after the cells have committed to the γδ T-cell lineage, strongly supporting an instructive model for functional programming of γδ T cells. In conclusion, we show that the two major adult γδ T-cell subsets in mice develop through a shared pathway utilizing similar cellular machinery and that they diverge after the CD24+ CD73+ maturity stage.

Selection bias in follow-up interviews with individuals attending the emergency department for occupational injuries.

OBJECTIVE: To examine whether supplementary interview participation was comparable for occupationally injured patients attending two hospital emergency departments and to investigate the magnitude of selection bias in relation to sex, age, severity, job tasks and industry risk level. METHODS: Workers aged 18-70 years who contacted the two emergency departments for an acute occupational injury in 2013 were eligible and given a short questionnaire. Following written consent, a semi-structured interview concerning health and transient risk factors was conducted by telephone. The two departments were compared for study recruitment by age and sex. Respondents and non-respondents to the interview were compared for age, sex, injury severity, job tasks and industry risk level. RESULTS: Of 4002 patients attending the two hospitals, 1693 (42%) participated in the interview. One hospital had a markedly higher response rate to the questionnaire, but the proportions of participation in the interview were similar in the two hospitals. Patients aged <30 years were over-represented among non-respondents whereas sex, injury severity, job task and industry risk level were not significantly different between respondents and non-respondents. CONCLUSIONS: Despite a relatively low interview participation rate among injured individuals attending the emergency department, selection bias was limited. This indicates that results regarding injury risk patterns may be more widely generalisable when examining the causality of occupational injuries. However, the study also showed that young injured workers were less likely to participate in follow-up interviews, which is an important factor when interpreting age-related risk of injury.

Towards valid 'serious non-fatal injury' indicators for international comparisons based on probability of admission estimates.

BACKGROUND: Governments wish to compare their performance in preventing serious injury. International comparisons based on hospital inpatient records are typically contaminated by variations in health services utilisation. To reduce these effects, a serious injury case definition has been proposed based on diagnoses with a high probability of inpatient admission (PrA). The aim of this paper was to identify diagnoses with estimated high PrA for selected developed countries. METHODS: The study population was injured persons of all ages who attended emergency department (ED) for their injury in regions of Canada, Denmark, Greece, Spain and the USA. International Classification of Diseases (ICD)-9 or ICD-10 4-digit/character injury diagnosis-specific ED attendance and inpatient admission counts were provided, based on a common protocol. Diagnosis-specific and region-specific PrAs with 95% CIs were calculated. RESULTS: The results confirmed that femoral fractures have high PrA across all countries studied. Strong evidence for high PrA also exists for fracture of base of skull with cerebral laceration and contusion; intracranial haemorrhage; open fracture of radius, ulna, tibia and fibula; pneumohaemothorax and injury to the liver and spleen. Slightly weaker evidence exists for cerebellar or brain stem laceration; closed fracture of the tibia and fibula; open and closed fracture of the ankle; haemothorax and injury to the heart and lung. CONCLUSIONS: Using a large study size, we identified injury diagnoses with high estimated PrAs. These diagnoses can be used as the basis for more valid international comparisons of life-threatening injury, based on hospital discharge data, for countries with well-developed healthcare and data collection systems.

Intracranial Aneurysms in Sickle-Cell Disease Are Associated With the Hemoglobin SS Genotype But Not With Moyamoya Syndrome.

BACKGROUND AND PURPOSE: Intracranial aneurysms and aneurysmal subarachnoid hemorrhage may occur more frequently in sickle-cell disease (SCD), and this could be related to the sickle genotype and moyamoya syndrome seen in SCD. METHODS: Records from a total of 1002 patients with SCD attending 2 specialized adult hematologic services were retrospectively reviewed. We analyzed data of a cohort of 767 patients attending 1 SCD clinic between 2002 and 2013 and of 235 patients from the other clinic who have had neurovascular imaging between 2007 and 2014. RESULTS: We identified 4 patients in the cohort who had an aneurysmal subarachnoid hemorrhage during 9063 patient-years. The highest incidence rate was seen among women in the age group 30 to 39 years with the hemoglobin SS (HbSS) genotype (440 per 100 000 patient-years). Unruptured intracranial aneurysms were found in 20 of the 324 patients, who had imaging data; the prevalence was significantly higher in patients with HbSS genotype compared with other sickle genotypes with the highest prevalence (15%) observed in women in the age group 30 to 39 years. Fifty-one HbSS patients had a moyamoya vasculopathy, but only 3 of these had concomitant intracranial aneurysms. CONCLUSIONS: Intracranial aneurysms are common in HbSS SCD. There was also a trend toward more common occurrence of aneurysmal subarachnoid hemorrhage in HbSS; women in the age group 30 to 39 years were most at risk. There was no correlation between the occurrence of intracranial aneurysms and moyamoya syndrome.

Fine-tuning of T-cell development by the CD3γ di-leucine-based TCR-sorting motif.

The CD3γ di-leucine-based (diL) receptor-sorting motif plays a central role in TCR down-regulation and in clonal expansion of virus-specific T cells. However, the role of the CD3γ diL motif in T-cell development is not known. In this study, we show that protein kinase C-induced TCR down-regulation is abolished in thymocytes from CD3γLLAA mice with a mutated CD3γ diL motif, and that CD3γLLAA mice have reduced numbers of thymocytes compared with aged-matched wild-type mice. We found that early thymocyte development at the ß-selection checkpoint is impaired resulting in reduced numbers of double negative (DN) 4 cells in CD3γLLAA mice. This was not caused by reduced proliferation but most probably by increased down-regulation of the antiapoptotic molecule Bcl-2 causing enhanced apoptosis during the transition from the DN3 to the DN4 stage. In contrast, proliferation of immature CD8 single positive (ISP) thymocytes was increased resulting in normal numbers of ISP in CD3γLLAA mice. Despite the normal numbers of ISP, CD3γLLAA mice had reduced numbers of double positive and SP thymocytes indicating that the CD3γ diL motif also affected later stages of T-cell development. In accordance, we found that positive and negative selection, differentiation toward CD4 and CD8 SP T cells and the development of nonconventional T cells were affected in CD3γLLAA mice. In conclusion, our study identifies an important role of the CD3γ diL motif in T-cell development most probably mediated by its fine-tuning of pre-TCR and TCR expression, down-regulation and signaling.

A case-crossover study of transient risk factors influence on occupational injuries: a study protocol based on a review of previous studies.

BACKGROUND: The occupational injury incident rate remains relatively high in the European Union. The case-crossover study gives a unique opportunity to study transient risk factors that normally would be very difficult to approach. Studies like this have been carried out in both America and Asia, but so far no relevant research has been conducted in Europe. METHOD: Case-crossover studies of occupational injuries were collected from PubMed and Embase and read through. Previous experiences concerning method, exposure and outcome, time-related measurements and construction of the questionnaire were taken into account in the preparation of a pilot study. Consequently, experiences from the pilot study were used to design the study protocol. Approximately 2000 patients with an occupational injury will be recruited from the emergency departments in Herning and Odense, Denmark. A standardised questionnaire will be used to collect basic demographic data and information on eight transient risk factors. Based on previous studies and knowledge on occupational injuries the transient risk factors we chose to examine were: time pressure, performing a task with a different method/using unaccustomed technique, change in working surroundings, using a phone, disagreement, feeling ill, being distracted and using malfunctioning machinery/tools or work material. Exposure time 'just before the injury' will be compared with two control periods, 'previous day at the same time of the injury' (pair match) and the previous work week (usual frequency). DISCUSSION: This study protocol describes a unique opportunity to calculate the effect of transient risk factors on occupational injuries in a European setting.

Subdural haematoma complicating shunting for normal pressure hydrocephalus in the setting of concomitant antiplatelet medication - a report of 11 cases.

OBJECTIVE: To report on the occurrence and management of subdural haematoma after shunt implantation for normal pressure hydrocephalus and to determine the risk of recurrence in the setting of antiplatelet medication. METHODS: From a consecutive series of 80 patients implanted with a cerebrospinal fluid shunt for normal pressure hydrocephalus, records from 11 patients taking antiplatelet drugs, who subsequently had surgery for subdural haematoma were extracted and retrospectively reviewed. RESULTS: Patients were followed up for a mean of 1819 days after shunt implantation. Subdural haematomas occurred at a median of 335 days after shunt implantation - four ipsilateral, five contralateral and two bilateral with respect to the ventricular catheter. Three patients had reoperations done within a week without having resumed antiplatelet medication in the interim. One of them had three further reoperations done before the subdural collection disappeared. Only one patient had a late recurrence almost 11 years after shunt implantation. CONCLUSIONS: Subdural haematoma in the setting of a ventriculoperitoneal implantation for normal pressure hydrocephalus and concomitant antiplatelet medication can be managed along usual lines. Antiplatelet medication can be recommenced in due course with a low risk of recurrence.

Routine functional assessment for hip fracture patients.

Background and purpose - Pre-fracture functional level has been shown to be a consistent predictor of rehabilitation outcomes in older hip fracture patients. We validated 4 overall pre-fracture functional level assessment instruments in patients aged 65 or more, used the prediction of outcome at 4 months post-fracture, and assessed cutoff values for decision making in treatment and rehabilitation. Patients and methods - 165 consecutive patients with acute primary hip fracture were prospectively included in the study. Pre-fracture Barthel-20, Barthel-100, cumulated ambulation score, and new mobility score were scored immediately after admission. Outcome defined as mortality, residential status, and independent walking ability was assessed at 4 months. Results - 3 of the assessment instruments, namely Barthel-20, Barthel-100, and new mobility score, correlated with outcome at 4 months post-fracture and were valid predictors. Thresholds were estimated. We found no evidence that Barthel-100, with its finer granularity, performs better than Barthel-20 as a predictor. Interpretation - Our findings indicate that pre-fracture scores of Barthel-20 and new mobility score have predictive ability, and further investigation of usage for guidance of clinical and rehabilitation decisions concerning hip fracture patients is warranted.

PKC-θ exists in an oxidized inactive form in naive human T cells.

PKC-θ plays a central role in TCR-induced IL-2 production and T-cell proliferation. The aim of the present study was to analyse how PKC-θ is regulated in human T cells during T-cell activation and differentiation. We show that PKC-θ is found in a high-molecular disulfide-linked complex in naïve T cells, and that PKC-θ most likely is inactive in this form. In parallel with the accumulation of the major redox regulators, glutathione and thioredoxin, PKC-θ is gradually reduced to the 82 kDa active form during T-cell activation. We demonstrate that PKC-θ is recruited to the plasma membrane in the disulfide-linked form in naïve T cells, and that activation of PKC-θ is redox dependent and requires de novo synthesis of glutathione. This is the first study that shows that the activity of PKC-θ is regulated by the intracellular redox state, and that PKC-θ is recruited to the plasma membrane in an inactive form in naïve T cells. Our observations underscore the existence of major differences in TCR signaling in naïve versus primed T cells.

Patterns of work injuries: cases admitted to emergency room treatment compared to cases reported to the Danish Working Environment Authority during 2003-2010.

OBJECTIVE: To compare work injuries treated in an emergency department (ED) and injuries reported to the Danish Working Environment Authority (DWEA). METHODS: Work injuries of the ED, Odense University Hospital, and injuries from the geographical catchment area reported to the DWEA between 2003 and 2010 were included. The injuries included in both datasets were identified by merging the ED file and the DWEA file using the civil registry number and injury date information as key. RESULTS: Approximately 50 000 work injuries occurred in the catchment area of the ED. The intersection between the two injury registration systems was 16%. A major discordance concerned the type of injuries, as some injuries were seen frequently in the ED but not reported to the DWEA to any significant extent, for example 'eye injuries' and 'superficial lacerations or wounds'. On the other hand, some injuries are rarely seen in the ED, but often reported to the DWEA, for example 'low back pain'. Additionally, younger workers visit the ED more often than older workers, and injuries in the high risk sectors have the lowest reporting proportion. CONCLUSIONS: Neither the ED nor DWEA injury files alone give a complete picture of work injuries. But merged, they represent a significant number of injuries, taking into account differences in data sources, for example concerning uneven distribution of age, sex, type of injury and type of industry. Obviously, not all serious work related ED injuries resulting in lost work time are reported to the DWEA.

Low bone mineral density is not related to failure in femoral neck fracture patients treated with internal fixation.

BACKGROUND AND PURPOSE: Internal fixation (IF) in femoral neck fractures has high reoperation rates and some predictors of failure are known, such as age, quality of reduction, and implant positioning. Finding new predictors of failure is an ongoing process, and in this study we evaluated the importance of low bone mineral density (BMD). PATIENTS AND METHODS: 140 consecutive patients (105 females, median age 80) treated with IF had a dual-energy X-ray absorptiometry (DXA) scan of the hip performed median 80 days after treatment. The patients' radiographs were evaluated for fracture displacement, implant positioning, and quality of reduction. From a questionnaire completed during admission, 2 variables for comorbidity and walking disability were chosen. Primary outcome was low hip BMD (amount of mineral matter per square centimeter of hip bone) compared to hip failure (resection, arthroplasty, or new hip fracture). A stratified Cox regression model on fracture displacement was applied and adjusted for age, sex, quality of reduction, implant positioning, comorbidity, and walking disability. RESULTS: 49 patients had a T-score below -2.5 (standard deviation from the young normal reference mean) and 70 patients had a failure. The failure rate after 2 years was 22% (95% CI: 12-39) for the undisplaced fractures and 66% (CI: 56-76) for the displaced fractures. Cox regression showed no association between low hip BMD and failure. For the covariates, only implant positioning showed an association with failure. INTERPRETATION: We found no statistically significant association between low hip BMD and fixation failure in femoral neck fracture patients treated with IF.

The completeness of routine registration of the counterpart in deliberate interpersonal violence in an urban emergency department.

Most studies of violence from the health care system lack reliable information about the counterpart, which is important for distinguishing between different types of violence. Since 2014, the emergency department at Odense University Hospital in Denmark has routinely registered information about the counterpart. The purpose of this study was to evaluate the completeness of registering information about the counterpart during routine registration of victims of interpersonal violence in the emergency department. We included 11,200 victims treated at the emergency department 2014-2021. Using the patient registration data, we estimated the proportion of missing information on the counterpart, stratified by age group and gender of the victim as well as type of incident and severity of injury. Information about the counterpart was registered in 91.5 % of all cases. In 43.1 % (CI: 42.2-44.0) of the cases, the counterpart was unknown to the victim, in 24.3 % (CI: 23.5-25.1) the counterpart was an acquaintance, in 10.5 % (CI: 10.0-11.1) the counterpart was a partner, and in 4.2 % (CI: 3.8-4.5) the counterpart was another family member. The proportion of cases with no information about the counterpart varied with gender, age group, time of violence, place of violence, weapon use, and severity of injury. Half of the victims injured with firearms (46.2 %, CI: 30.1-62.8) and one-fourth of the victims injured with knives (25.9 %, CI: 21.9-30.2) did not reveal information about the counterpart. The majority of the victims revealed information about the counterpart, making it possible to analyse different types of violence separately.

Age-related trends in unintentional injuries among children and adolescents in an urban Danish population 1980-2021. A cohort study of 292,737 children and adolescents.

OBJECTIVE: This study describes the age-related trends in unintentional injuries in children and adolescents in an urban population 1980-2021. A retrospective study of all children and adolescents aged 0-17 years treated for unintentional injuries at Odense University Hospital, Denmark 1980-2021. METHODS: Information about age, gender, place of injury, and diagnoses from the emergency department register. We estimated gender specific annual incidence rates (IRs) in different age groups (0-4, 5-9, 10-14, and 15-17 years) per 1000 population/years. The severity was classified by mild or severe injuries. RESULTS: Overall, 292,737 unintentionally injured children and adolescents were included. The median age was 10 years and 57.4 % were boys. The overall IR was 241 (CI: 240-242) for boys and 188 (CI: 187-188) for girls per 1000 population/years. In the study period, the overall incidence decreased by 44 % in boys and by 38 % in girls. The overall IR for severe injuries did not change in the study period, whereas the IR of mild injuries decreased significantly in all age groups in both gender. The upper limbs were the most frequently injured in all age groups for both gender, except for children aged 0-4 years, where lesions mostly occurred in the head or neck. In the youngest age groups 0-4 years and 5-9 years wounds were the most common type of lesion, while bruises were the most common type of lesion in the oldest age groups. Fractures accounted for 14.5 % of the lesions with the highest proportions in the 5-9 years and 10-14 years age group. CONCLUSION: The study provides information, which is useful when coordinating the resources at emergency departments and for planning preventive campaigns targeting different age groups.

Change in injury pattern with mandatory, referred access compared to open access in an emergency department.

INTRODUCTION: This retrospective cohort study aimed to examine whether implementing mandatory referral changed the composition of patients visiting the Accident and Emergency (A and E) Department in relation to severity, demographics and activity at injury. METHODS: Patients visiting the A and E Department at Odense University Hospital, Denmark, in 2008-2019, were divided into three time periods: before (four years before any changes in the operation of the A and E), transition period (the four years during which mandatory referral and the centralised emergency medical service were implemented) and after (the four years after these changes had been implemented). The incidence rate ratios and odds were calculated. RESULTS: The absolute number of severe injuries declined, but to a lesser extent than the number of minor injuries. The incidence rate ratios throughout all subcategories, including severity, fracture, sex, age and activity at injury, indicate a smaller risk of visiting the A and E Department in the after period than in the before period, with a total lower (0.82 times; 95% confidence interval: 0.82-0.83 times) risk of visiting the A and E Department in the after period than in the before period. CONCLUSIONS: Changing from open to referred access altered the composition of injuries for patients seen in the A and E Department, indicating a smaller risk of a visit with referred access than with open access. The odds of a visit being due to a major injury increased after implementing referred access, and the number of visits decreased. FUNDING: The Nordentoft Fund TRIAL REGISTRATION. Not relevant.