Association of water temperature and submersion duration and drowning outcome.

AIM: Evaluate the roles of water temperature and submersion duration in the outcome of drowning victims. METHODS: Subjects were those who drowned in open water (lakes, rivers, and ocean) in three counties in Washington State between 1975 and 1996. We performed a case control study to assess the association between age, reported submersion duration, and estimated water temperature and drowning outcomes. Cases were victims with good outcomes (survival with normal or mild/moderate neurologic sequelae). Controls were victims with bad outcomes (death or severe neurologic sequelae or persistent vegetative state). We used Poisson regression to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Of the total 1094 open water drowning victims, most were male (85%),white (84%), and with a mean age of 27 years. Most drownings occurred in lakes (51%) and in cold (≥6-16 °C (44%)) or very cold waters (<6 °C (34%)). Most (78%) had bad outcomes (74% died; 4% survived with severe neurologic sequelae. Of those with good outcomes, 88.2% were submerged <6 min, 7.4% 6-10 min and 4.3% for 11-60 min. Victims with good outcomes were 61% (95% CI 0.23-0.65) less likely to be submerged for 6 to 10 min and 98% (95% CI 0.01-0.04) less likely to be submerged for 11 or more minutes. Water temperature was not associated with outcome. CONCLUSIONS: A protective effect of cold water for drowning victims was not found; estimated submersion duration was the most powerful predictor of outcome. Recommendations for initiation of rescue and resuscitation efforts should be revised to reflect the very low likelihood of good outcome following submersion greater than 10 min.

Crash test rating and likelihood of major thoracoabdominal injury in motor vehicle crashes: the new car assessment program side-impact crash test, 1998-2010.

BACKGROUND: The National Highway Traffic Safety Administration's New Car Assessment Program (NCAP) implemented side-impact crash testing on all new vehicles since 1998 to assess the likelihood of major thoracoabdominal injuries during a side-impact crash. Higher crash test rating is intended to indicate a safer car, but the real-world applicability of these ratings is unknown. Our objective was to determine the relationship between a vehicle's NCAP side-impact crash test rating and the risk of major thoracoabdominal injury among the vehicle's occupants in real-world side-impact motor vehicle crashes. METHODS: The National Automotive Sampling System Crashworthiness Data System contains detailed crash and injury data in a sample of major crashes in the United States. For model years 1998 to 2010 and crash years 1999 to 2010, 68,124 occupants were identified in the Crashworthiness Data System database. Because 47% of cases were missing crash severity (ΔV), multiple imputation was used to estimate the missing values. The primary predictor of interest was the occupant vehicle's NCAP side-impact crash test rating, and the outcome of interest was the presence of major (Abbreviated Injury Scale [AIS] score ≥ 3) thoracoabdominal injury. RESULTS: In multivariate analysis, increasing NCAP crash test rating was associated with lower likelihood of major thoracoabdominal injury at high (odds ratio [OR], 0.8; 95% confidence interval [CI], 0.7-0.9; p < 0.01) and medium (OR, 0.9; 95% CI, 0.8-1.0; p < 0.05) crash severity (ΔV), but not at low ΔV (OR, 0.95; 95% CI, 0.8-1.2; p = 0.55). In our model, older age and absence of seat belt use were associated with greater likelihood of major thoracoabdominal injury at low and medium ΔV (p < 0.001), but not at high ΔV (p ≥ 0.09). CONCLUSION: Among adults in model year 1998 to 2010 vehicles involved in medium and high severity motor vehicle crashes, a higher NCAP side-impact crash test rating is associated with a lower likelihood of major thoracoabdominal trauma. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Validation of prehospital trauma triage criteria for motor vehicle collisions.

BACKGROUND: Triage of an injured patient to an appropriate trauma center can have an impact on morbidity and mortality. We sought to validate the 2012 national field triage guidelines for motor vehicle crashes. METHODS: This is a retrospective cross-sectional study using the National Automotive Sampling System Crashworthiness Data System. Vehicle damage criteria proposed as prehospital triage guidelines were correlated with injury severity. RESULTS: There were 85,761 individuals representing 29,397,234 occupants in car crashes from 2003 to 2008. Of the patients, 3.8% met physiologic Step 1 criteria with a mean Injury Severity Score (ISS) of 9.1 (95% confidence interval [CI], -3.1 to 20.9); Step 1 had a positive predictive value (PPV) of 20.8% (95% CI, 20.1-21.4%) for severe injury (ISS > 15). Of the patients, 0.43% met anatomic Step 2 criteria alone, with a mean ISS of 18.1 (95% CI, 16.4-19.8) and a PPV of 48.5% (95% CI, 46.8-50.1%). Step 3 criteria include injury mechanism; 3.7% of the patients met one of these criteria alone with a mean ISS of 5.1 (95% CI, 4.4-5.8) and a PPV of 9.7% (95% CI, 9.3-10.2%).Patients who met only Step 3 criteria were examined to determine crash characteristics that predict severe injury. Intrusion of greater than 12 inches had a PPV of 10.4% (95% CI, 9.5-11.3); steering wheel collapse had a PPV of 25.7% (95% CI, 23.0-28.4%). Older patients (age > 55 years) who met Step 3 mechanism criteria had higher predictive values for injury for nearly all crash characteristics. CONCLUSION: Injury mechanism criteria alone predict significant injury in a substantial proportion of patients who did not meet the physiologic or anatomic criteria. Vehicular crash data could improve the ability of emergency medical service providers to triage injured occupants. Consideration of transport to a trauma center should be given for elderly patients and drivers with steering wheel collapse. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Long-term outcomes of ground-level falls in the elderly.

BACKGROUND: For older adults, even ground-level falls (GLFs) can result in multiple injuries and are associated with significant morbidity and mortality. Previous studies have focused on in-hospital outcomes and patients with isolated injuries. Our study examined outcomes following discharge for older adults who were hospitalized following a GLF. METHODS: A retrospective cohort study of patients older than 65 years admitted to a regional Level I trauma center, from 2005 to 2008, after a GLF was conducted. Hospital trauma registry data were linked to state hospital discharge data and the death certificate registry. Skilled nursing facilities (SNFs) were contacted to verify ultimate patient placement, with follow-up through December 2010. Kaplan-Meier and Cox proportional hazards models were used to analyze postdischarge mortality. RESULTS: There were 1,352 consecutive admissions; 48% had an Injury Severity Score (ISS) greater than 15, and 12% died during admission. Of the patients who survived hospitalization, 51% were discharged to an SNF, 33% to home without assistance, 6% to home with assistance, and 5% to inpatient rehabilitation facilities. Within 1 year of injury, 44.6% of the patients were readmitted. The 1-year mortality for the overall cohort was 33%; for patients who were discharged alive, the 1-year mortality was 24%. After adjusting for confounders, patients discharged to an SNF had a threefold greater risk of 1-year mortality (hazard ratio, 2.82; 95% confidence interval, 1.86-4.28), compared with patients discharged home with no assistance. Of the patients discharged to an SNF, 48% died by the end of the follow-up period (mean, 28.2 months), and 61% of these patients died while residing at an SNF. CONCLUSION: GLFs in the elderly result in severe injury, high rate of readmissions, and increased mortality, both in-hospital and after discharge. Overall, only one third of the patients were discharged home to independent living. Future efforts should examine whether improvements in the quality of posthospital care affect both mortality and functional outcomes. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Compulsive cell phone use and history of motor vehicle crash.

PURPOSE: Few studies have examined the psychological factors underlying the association between cell phone use and motor vehicle crash. We sought to examine the factor structure and convergent validity of a measure of problematic cell phone use, and to explore whether compulsive cell phone use is associated with a history of motor vehicle crash. METHODS: We recruited a sample of 383 undergraduate college students to complete an online assessment that included cell phone use and driving history. We explored the dimensionality of the Cell Phone Overuse Scale (CPOS) using factor analytic methods. Ordinary least-squares regression models were used to examine associations between identified subscales and measures of impulsivity, alcohol use, and anxious relationship style, to establish convergent validity. We used negative binomial regression models to investigate associations between the CPOS and motor vehicle crash incidence. RESULTS: We found the CPOS to be composed of four subscales: anticipation, activity interfering, emotional reaction, and problem recognition. Each displayed significant associations with aspects of impulsivity, problematic alcohol use, and anxious relationship style characteristics. Only the anticipation subscale demonstrated statistically significant associations with reported motor vehicle crash incidence, controlling for clinical and demographic characteristics (relative ratio, 1.13; confidence interval, 1.01-1.26). For each 1-point increase on the 6-point anticipation subscale, risk for previous motor vehicle crash increased by 13%. CONCLUSIONS: Crash risk is strongly associated with heightened anticipation about incoming phone calls or messages. The mean score on the CPOS is associated with increased risk of motor vehicle crash but does not reach statistical significance.

Burst fractures of the lumbar spine in frontal crashes.

BACKGROUND: In the United States, major compression and burst type fractures (>20% height loss) of the lumbar spine occur as a result of motor vehicle crashes, despite the improvements in restraint technologies. Lumbar burst fractures typically require an axial compressive load and have been known to occur during a non-horizontal crash event that involve high vertical components of loading. Recently these fracture patterns have also been observed in pure horizontal frontal crashes. This study sought to examine the contributing factors that would induce an axial compressive force to the lumbar spine in frontal motor vehicle crashes. METHODS: We searched the National Automotive Sampling System (NASS, 1993-2011) and Crash Injury Research and Engineering Network (CIREN, 1996-2012) databases to identify all patients with major compression lumbar spine (MCLS) fractures and then specifically examined those involved in frontal crashes. National trends were assessed based on weighted NASS estimates. Using a case-control study design, NASS and CIREN cases were utilized and a conditional logistic regression was performed to assess driver and vehicle characteristics. CIREN case studies and biomechanical data were used to illustrate the kinematics and define the mechanism of injury. RESULTS: During the study period 132 NASS cases involved major compression lumbar spine fractures for all crash directions. Nationally weighted, this accounted for 800 cases annually with 44% of these in horizontal frontal crashes. The proportion of frontal crashes resulting in MCLS fractures was 2.5 times greater in late model vehicles (since 2000) as compared to 1990s models. Belted occupants in frontal crashes had a 5 times greater odds of a MCLS fracture than those not belted, and an increase in age also greatly increased the odds. In CIREN, 19 cases were isolated as horizontal frontal crashes and 12 of these involved a major compression lumbar burst fracture primarily at L1. All were belted and almost all occurred in late model vehicles with belt pretensioners and buckets seats. CONCLUSION: Major compression burst fractures of the lumbar spine in frontal crashes were induced via a dynamic axial force transmitted to the pelvis/buttocks into the seat cushion/pan involving belted occupants in late model vehicles with increasing age as a significant factor.

CT use in hospitalized pediatric trauma patients: 15-year trends in a level I pediatric and adult trauma center.

PURPOSE: To evaluate the 15-year trend in the use of computed tomography (CT) in hospitalized pediatric trauma patients admitted to Harborview Medical Center (HMC) from 1996 to 2010. MATERIALS AND METHODS: This Health Insurance Portability and Accountability Act-compliant retrospective study was approved by the institutional review board. The requirement for informed consent was waived. The HMC trauma registry was linked to the billing department data, and patient and injury-related characteristics were extracted, in addition to type and frequency of CT procedures. Patients discharged from the emergency department and patients hospitalized for less than 24 hours were not included in this study. Patients were classified into three categories according to age: 0-14 years, 15-18 years, and 19-54 years (reference group). Multivariate negative binomial regression was used to compare CT usage among different age groups by adjusting for patient sex, race and/or ethnicity, insurance status, mechanism of injury, injury severity, final disposition (dead vs alive), and year of admission. The trend for CT use in children and teenagers was also evaluated. RESULTS: A total of 64 425 trauma patients 0-54 years of age were admitted during the study period. Compared with CT usage in adults 19-54 years old, usage in children up to 15 years of age was significantly lower for spine (incidence rate ratio [IRR], 0.89; 95% confidence interval [CI]: 0.85, 0.92), maxillofacial (IRR, 0.89; 95% CI: 0.81, 0.97), and thoracic (IRR, 0.91; 95% CI: 0.84, 0.99) CT. Increased use of head CT was observed in children up to 15 years old (IRR, 1.09; 95% CI: 1.05, 1.13) and 15-18 years old (IRR, 1.08; 95% CI: 1.04, 1.13). From 2008 to 2010, usage rates in children up to 15 years old and 15-18 years old was relatively unchanged or slightly decreased for almost all CT types. CONCLUSION: A decreasing or unchanged trend was observed in CT usage in hospitalized pediatric trauma patients in recent years. © RSNA, 2013.

Predicting severe injury using vehicle telemetry data.

BACKGROUND: In 2010, the National Highway Traffic Safety Administration standardized collision data collected by event data recorders, which may help determine appropriate emergency medical service (EMS) response. Previous models (e.g., General Motors ) predict severe injury (Injury Severity Score [ISS] > 15) using occupant demographics and collision data. Occupant information is not automatically available, and 12% of calls from advanced automatic collision notification providers are unanswered. To better inform EMS triage, our goal was to create a predictive model only using vehicle collision data. METHODS: Using the National Automotive Sampling System Crashworthiness Data System data set, we included front-seat occupants in late-model vehicles (2000 and later) in nonrollover and rollover crashes in years 2000 to 2010. Telematic (change in velocity, direction of force, seat belt use, vehicle type and curb weight, as well as multiple impact) and nontelematic variables (maximum intrusion, narrow impact, and passenger ejection) were included. Missing data were multiply imputed. The University of Washington model was tested to predict severe injury before application of guidelines (Step 0) and for occupants who did not meet Steps 1 and 2 criteria (Step 3) of the Centers for Disease Control and Prevention Field Triage Guidelines. A probability threshold of 20% was chosen in accordance with Centers for Disease Control and Prevention recommendations. RESULTS: There were 28,633 crashes, involving 33,956 vehicles and 52,033 occupants, of whom 9.9% had severe injury. At Step 0, the University of Washington model sensitivity was 40.0% and positive predictive value (PPV) was 20.7%. At Step 3, the sensitivity was 32.3 % and PPV was 10.1%. Model analysis excluding nontelematic variables decreased sensitivity and PPV. The sensitivity of the re-created General Motors model was 38.5% at Step 0 and 28.1% at Step 3. CONCLUSION: We designed a model using only vehicle collision data that was predictive of severe injury at collision notification and in the field and was comparable with an existing model. These models demonstrate the potential use of advanced automatic collision notification in planning EMS response. LEVEL OF EVIDENCE: Prognostic study, level II.

Strength and jump biomechanics of elite and recreational female youth soccer players.

CONTEXT: Most researchers investigating soccer injuries have studied elite athletes because they have greater athletic-exposure hours than other athletes, but most youth participate at the recreational level. If risk factors for injury vary by soccer level, then recommendations generated using research with elite youth soccer players might not generalize to recreational players. OBJECTIVE: To examine injury risk factors of strength and jump biomechanics by soccer level in female youth athletes and to determine whether research recommendations based on elite youth athletes could be generalized to recreational players. DESIGN: Cross-sectional study. SETTING: Seattle Youth Soccer Association. PATIENTS OR OTHER PARTICIPANTS: Female soccer players (N = 92) aged 11 to 14 years were recruited from 4 randomly selected elite (n = 50; age = 12.5 years, 95% confidence interval [95% CI]) = 12.3, 12.8 years; height = 157.8 cm, 95% CI = 155.2, 160.3 cm; mass = 49.9 kg, 95% CI = 47.3, 52.6 kg) and 4 randomly selected recreational (n = 42; age = 13.2 years, 95% CI = 13.0, 13.5 years; height = 161.1 cm, 95% CI = 159.2, 163.1 cm; mass = 50.6 kg, 95% CI = 48.3, 53.0 kg) soccer teams. MAIN OUTCOME MEASURE(S): Players completed a questionnaire about demographics, history of previous injury, and soccer experience. Physical therapists used dynamometry to measure hip strength (abduction, adduction, extension, flexion) and knee strength (flexion, extension) and Sportsmetrics to measure vertical jump height and jump biomechanics. We compared all measurements by soccer level using linear regression to adjust for age and mass. RESULTS: Elite players were similar to recreational players in all measures of hip and knee strength, vertical jump height, and normalized knee separation (a valgus estimate generated using Sportsmetrics). CONCLUSIONS: Female elite youth players and recreational players had similar lower extremity strength and jump biomechanics. This suggests that recommendations generated from research with elite youth soccer players could be generalized to recreational players.

Epidemiology of upper extremity replantation surgery in the United States.

PURPOSE: Replantation remains an important technique in the management of hand trauma. Given the resources necessary for a successful replantation program, regionalization of replantation care may ultimately be required. The purposes of this study were to analyze the geographic distribution of upper extremity replant procedures, analyze factors of patients undergoing replantation, and characterize the facilities performing these procedures. METHODS: We performed a cohort study using the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2001, 2004, and 2007. Patients with an upper extremity amputation were defined, and a subgroup of patients undergoing replantation was delineated. We analyzed patient demographics and injury characteristics and characteristics of treating facilities. RESULTS: A total of 9,407 patients were treated for upper extremity amputation, 1,361 of whom underwent replantation. Mean age of patients undergoing replantation was 36 years (range, 0-86 y), compared with 44 years (range, 0-104 y) in patients not undergoing replantation. Hospital charges (P < .001) and length of stay (P < .001) were significantly higher for patients with replantations versus those without replantations. Patients treated at teaching facilities were more likely to undergo replantation than those at a non-teaching facility (19% replantation rate at teaching hospitals vs 7% at non-teaching). Large hospitals and urban hospitals were more likely to perform replantation. Self-pay, Medicare, and Medicaid patients all had lower replantation rates than patients with other payer status. CONCLUSIONS: Patients who undergo replantation are younger, incur higher hospital charges, and have longer hospital stays compared with patients who do not undergo replantation. Treatment at large, urban, and teaching facilities is associated with higher replantation rates. Payer status appears to have some bearing on replantation rates. Further studies are needed to better elucidate the relationship between patient and injury characteristics, treatment location, and outcomes, to adequately distribute the finite resources for replantation. TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis IV.

Use and effect of vasopressors after pediatric traumatic brain injury.

BACKGROUND: Vasopressors are commonly used to increase mean arterial blood pressure (MAP) and cerebral perfusion pressure (CPP) after traumatic brain injury (TBI), but there are few data comparing vasopressor effectiveness after pediatric TBI. OBJECTIVE: To determine which vasopressor is most effective at increasing MAP and CPP in children with moderate-to-severe TBI. METHODS: After institutional review board approval, we performed a retrospective cohort study of children 0-17 years old admitted to a level 1 trauma center (Harborview Medical Center, Seattle, Wash., USA) between 2002 and 2007 with moderate-to-severe TBI who received a vasopressor to increase blood pressure. Baseline demographic and physiologic characteristics and hourly physiologic monitoring for 3 h after having started a vasopressor were abstracted. We evaluated differences in MAP and CPP at 3 h after initiation of therapy between phenylephrine, dopamine and norepinephrine among patients who did not require a second vasopressor during this time. Multivariate linear regression was used to adjust for age, gender, injury severity score and baseline MAP or CPP and to cluster by subject. RESULTS: Eighty-two patients contributed data to the entire dataset. The most common initial medication was phenylephrine for 47 (57%). Patients receiving phenylephrine and norepinephrine tended to be older than those receiving dopamine and epinephrine. Thirteen (16%) of the patients received a second vasopressor during the first 3 h of treatment and were thus not included in the regression analyses; these patients received more fluid resuscitation and exhibited higher in-hospital mortality (77 vs. 32%; p = 0.004) compared to patients receiving a single vasopressor. The norepinephrine group exhibited a 5 mm Hg higher MAP (95% CI: -4 to 13; p = 0.31) and a 12 mm Hg higher CPP (95% CI: -2 to 26; p = 0.10) than the phenylephrine group, and a 5 mm Hg higher MAP (95% CI: -4 to 15; p = 0.27) and a 10 mm Hg higher CPP (95% CI: -5 to 25; p = 0.18) than the dopamine group. However, in post hoc analysis, after adjusting for time to start of vasopressor, hypertonic saline and pentobarbital, the effect on MAP was lost, but the CPP was 8 mm Hg higher (95% CI: -10 to 25; p = 0.39) than in the phenylephrine group, and 5 mm Hg higher (95% CI: -14 to 24; p = 0.59) than in the dopamine group. CONCLUSIONS: Vasopressor use varied by age. While there was no statistically significant difference in MAP or CPP between vasopressor groups, norepinephrine was associated with a clinically relevant higher CPP and lower intracranial pressure at 3 h after start of vasopressor therapy compared to the other vasopressors examined.

Motor vehicle mismatch: a national perspective.

OBJECTIVE: To determine the RR of the severe injury associated with light truck vehicle (LTV) versus passenger vehicle (PV) mismatch following motor vehicle collisions across the USA. METHODS: This was a retrospective cohort study with the primary outcomes of Injury Severity Score (ISS) >8 and body region Abbreviated Injury Score (AIS) >2. The National Automotive Sampling System Crashworthiness Data System (NASS CDS) was searched for occupants in frontal and side impact crashes from 1993 to 2007. Occupants in PVs struck by LTVs were compared to PV occupants struck by another PV. Poisson regression was used to estimate the RR of severe injury after adjusting for driver age, driver gender, and change in velocity during the crash (Δv). Because 21% of cases were missing Δv, multiple imputation was used to estimate the missing values. NASS CDS weights were used to estimate the risk of severe injury nationally. RESULTS: PV occupants in front impact crashes with an LTV as the striking vehicle were at increased risk of severe injury compared to those struck by another PV (RR 1.37, 95% CI 1.09 to 1.73). A similar increase risk was observed in side impact crashes (RR 1.34, 95% CI 1.12 to 1.62). Increased risk of injury was also identified in several body regions. CONCLUSIONS: Motor vehicle mismatch crashes are associated with a significant increase in risk of severe injury for PV occupants in the USA. Addressing vehicle compatibility remains an important issue for occupant safety.

A comparison of self-report and direct observation of booster seat use in Latino families.

OBJECTIVE: To develop a reliable self-report tool for measuring child booster seat use among Latino families. DESIGN: Cross-sectional and observational survey of a convenience sample. SETTING: Five retail stores in King County, Washington. PARTICIPANTS: 50 parents of children 4-8 years old that self-identified as Latino or Hispanic. MAIN EXPOSURES: Parent-reported measures of how often the child uses a booster seat, if the child used a booster seat on the last trip, how often the child complains about using a booster seat, how often the child asks to not use a booster seat, and how often other families they know use a booster seat. OUTCOME MEASURE: Observed booster seat use by child. RESULTS: 26 children (52%) were observed using a booster seat. Parent-reported booster seat use was a poor predictor of observed booster seat use. Although 34 parents reported that their child 'always' uses a booster seat, 8 (24%) of these children were not using a booster seat. A logistic model to predict booster seat use had a sensitivity of 81% and a specificity of 71%, and misclassified 24% of the participants' observed use. CONCLUSIONS: Reliance on parent-reported booster seat use significantly overstated observed booster seat use in the study. Among this study population, accurate determination of booster seat use required direct observation.

Soccer injuries in female youth players: comparison of injury surveillance by certified athletic trainers and internet.

CONTEXT: Few authors have evaluated sports injury-surveillance systems that use parental, Internet-based surveys for data collection. OBJECTIVE: To determine whether certified athletic trainers (ATs) and parental, Internet-based surveys provided comparable data for identifying soccer injuries. DESIGN: Prospective feasibility cohort study. SETTING: A soccer association in Seattle, Washington. PATIENTS OR OTHER PARTICIPANTS: Eighty female youth soccer players, ages 12 to 14 years. MAIN OUTCOME MEASURE(S): We compared the data provided by ATs attending 1 soccer practice per week with a weekly soccer-parent, Internet-based system. We measured athlete-exposure hours (AEHs) for each player. We compared injury rates reported by ATs only, Internet-based surveys only, and both systems combined. We evaluated the 2 surveillance systems for agreement on injured body region and laterality of injury using the kappa statistic. RESULTS: For ATs only, Internet-based surveys only, and both systems combined, we found acute injury rates of 3.0 per 1000 AEHs, 3.9 per 1000 AEHs, and 4.7 per 1000 AEHs and overuse injury rates of 1.0 per 1000 AEHs, 2.9 per 1000 AEHs, and 2.9 per 1000 AEHs, respectively. Players sustained 27 acute injuries (44% ankle, 11% knee, 11% hip) reported by at least 1 of the 2 systems, with 63% reported by ATs and 85% by Internet-based survey. Players sustained 17 overuse injuries (35% knee, 29% lower leg) reported by either system, with 35% reported by ATs and 100% by Internet-based survey. Among players for whom we had both ATs' and Internet-based survey injury data, body region injured and laterality had very good agreement (kappa = 0.73 to 1.0). CONCLUSIONS: The injury rate based on the weekly parental, Internet-based survey was similar to the rate based on the ATs' reporting and had comparable classifications of injured body region and laterality of injury.

Describing a problem: rear seatback failure and unsecured cargo.

INTRODUCTION: Currently, there is little in the literature regarding the ability of rear seatbacks to act as a protective barrier from cargo in frontal crashes. However, it has been shown that unrestrained rear passengers pose a danger to front seat occupants. The association of rear seatback failures and intrusions with mortality and serious injury were examined. METHODS: The Seattle CIREN database for restrained, rear-seat passengers in front-end crashes with seatback failure or intrusion was searched. Injury patterns and crash characteristics, including the role of unrestrained cargo were examined. Next, the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) database was queried for restrained rear-seat passengers in front-end crashes with recorded seat failure or intrusion. Mortality, maximum Abbreviated Injury Scale (AIS) score and mean Injury Severity Scale (ISS) scores were compared with passengers who had no failure or intrusion. Linear regression was used to identify the differences between the groups. Logistic regression was used to estimate the mortality risk associated with seat failure. RESULTS: There were four CIREN cases that met the criteria. In each case, the occupant suffered significant injury or death. All four of the seat failures were the result of unrestrained cargo striking the seatback. The CDS data revealed a statistically significantly increased mortality (OR = 18.9, 95% CI = 14.0-25.7) associated with seat failure. Both the maximum AIS and mean of the ISS scores were higher in the failure/intrusion group (p <0.0001). CONCLUSIONS: Rear seatback failure/intrusion is associated with increased mortality and injury. Case reports suggest unrestrained cargo plays a significant role in these injuries.

Mortality and injury patterns associated with roof crush in rollover crashes.

BACKGROUND: In the United States, a significant number of spine injuries, traumatic brain injuries (TBI), and deaths result from motor vehicle rollover crashes each year though they make up a small percentage of total crashes. We sought to explore the relationship between these injuries and the degree of roof crush. METHODS: We searched the NASS CDS database for belted, adult (> or =16), non-middle seat passengers involved in rollover crashes from 1993 to 2006. We also searched the CIREN database for illustrative cases. Logistic regression was used to evaluate the relationship between different levels of roof crush and mortality, severe injury (AIS > or = 3) to the spine, spinal cord, and head injury. RESULTS: The risk of mortality, TBI, and spine injury all increased as the degree of roof crush increased. For mortality increased risk occurred at >15 cm [15-30 cm: OR 2.089 (95% CI: 1.461-2.987); >30 cm: OR 6.301 (95% CI: 4.369-9.087)]. For TBI, increased risk was seen above 15 cm crush [15-30 cm: OR 1.52 (95% CI: 1.045-2.21); >30 cm: OR 3.672 (95% CI: 2.456-5.490)]. For spine injury increased risk was seen above 8 cm crush [8-15 cm: OR 1.968 (95% CI 1.273-3.043); 15-30 cm: OR 2.530 (95% CI 1.634-3.917); > or =30 cm OR 2.682 (95% CI 1.474, 4.877). Results were similar across the different statistical models. CONCLUSION: There is an association between the degree of roof crush and mortality, spine injury, and head injury in rollover crashes.

Cost of spinal cord injuries caused by rollover automobile crashes.

OBJECTIVE: To determine the reduction in direct cost for treatment of spinal cord injuries (SCI) in belted occupants involved in rollover automobile crashes in the USA that would result if severe roof intrusion were eliminated. METHODS: Risk of SCI per rollover crash and by belted/unbelted status was calculated for roof intrusion magnitude categories using 1993-2006 National Automotive Sampling System Crashworthiness Data System (CDS) data. Direct costs of SCI based on neurological level and completeness of SCI were calculated using data from the National SCI Statistical Center. RESULTS: A reduction in rate of SCI for belted occupants with >15 cm roof intrusion to the rate seen for belted occupants with 8-15 cm roof intrusion would reduce the direct cost of SCI by approximately $97 million annually. CONCLUSION: There would be substantial cost savings solely by a reduction in one uncommon type of injury, SCI, if severe roof intrusion were eliminated.

The effect of air bags on pregnancy outcomes in Washington State: 2002-2005.

OBJECTIVE: To estimate whether air-bag deployment is associated with an increased risk of adverse pregnancy outcomes. METHODS: We performed a retrospective cohort study to assess the effect of air-bag availability and air-bag deployment on the risk of adverse pregnancy outcomes among pregnant, front-seat occupants in motor vehicle crashes in Washington State. Pregnant women involved in motor vehicle crashes were identified by linking birth and fetal death certificate data with Washington State Patrol crash data, which reported air-bag availability and deployment. We calculated relative risks (RRs) of adverse maternal and perinatal outcomes and 95% confidence intervals (CIs) using Poisson regression, adjusted for maternal age, seatbelt use, and vehicle model year. RESULTS: We found no increased risk of adverse maternal or perinatal pregnancy outcomes among occupants of air-bag-equipped vehicles in all collisions (n=2,207) compared with those in vehicles without air bags (n=1,141). Among crashes in which air-bag deployment would be likely, we found a nonsignificant 70% increased risk of preterm labor (RR 1.7, 95% CI 0.9-3.2) and a nonsignificant threefold increased risk (RR 3.1, 95% CI 0.4-22.1) of fetal death among occupants in vehicles with air-bag deployment compared with occupants in vehicles without air bags, although fetal death results were limited by small numbers (2/198 [1.0%] in pregnant women whose air bags deployed; 2/622 [0.3%] in pregnant women whose air bags did not deploy). CONCLUSION: Our findings provide clinicians with evidence to advise women that air bags do not seem to elevate risk of most potential adverse outcomes during pregnancy. LEVEL OF EVIDENCE: II.

Severity of injury and outcomes among obese trauma patients with fractures of the femur and tibia: a crash injury research and engineering network study.

OBJECTIVE: To understand the influence of obesity on the morbidity and mortality outcomes of patients who have sustained fractures of the femur and tibia. DESIGN: Retrospective review. SETTING: Multicenter level I trauma facilities. PATIENTS/PARTICIPANTS: Motor vehicle crash victims enrolled in multicenter databases were reviewed. MAIN OUTCOME MEASUREMENTS: Outcome measurements for obese (body mass index, BMI > or = 30 kg/m) versus nonobese (BMI < 30 kg/m) patients included Injury Severity Score, Abbreviated Injury Scores, OTA fracture types, length of hospital stay, disposition, complications, and 36-Item Short Form Survey Instrument. RESULTS: We included 665 cases from the database, of which 461 (69%) were nonobese and 204 (31%) were obese. There was no difference in sex, mechanism of injury, Injury Severity Score, and Abbreviated Injury Score. The obese population was older with a mean age of 44 years compared with 41 years for the nonobese (P < 0.01) and had a greater incidence of reported baseline cardiac disease (P < 0.01) and diabetes (P < 0.01). Obese patients had more severe injury patterns (OTA B and C type) in the distal femur fractures (90% versus 61%, P < 0.01). Mortality rates did not show a statistically significant difference (5.6% versus 9.4%, P = 0.07). The baseline physical component on the 36-Item Short Form Survey Instrument was lower among the obese but not statistically different (P = 0.08). At 6 and 12 months post injury, a decline was noted in both groups; however, no differential decline was noted between the groups (P > 0.05). CONCLUSIONS: Obese patients are significantly more likely to have more severe distal femur fractures compared with nonobese when involved in motor vehicle crashes. In this study, there was no statistically significant difference in length of stay, complications, or mortality in obese patients.

Fournier's Gangrene: population based epidemiology and outcomes.

PURPOSE: Case series have shown a Fournier's gangrene mortality rate of 20% to 40% with an incidence of as high as 88% in some studies. Because to our knowledge there are no population based data, we used a national database to investigate the epidemiology of Fournier's gangrene. MATERIALS AND METHODS: We used the State Inpatient Databases, the largest hospital based database available in the United States, which includes 100% of hospital discharges from participating states. Inpatients diagnosed with Fournier's gangrene (ICD-9 CM 608.83) who underwent genital/perineal débridement or died in the hospital were identified from 13 participating states in 2001 and from 21 in 2004. Population based incidence, regional trends and case fatality rates were estimated. RESULTS: We identified 1,641 males and 39 females with Fournier's gangrene. Cases represented less than 0.02% of hospital admissions. The overall incidence was 1.6/100,000 males, which peaked in males who were 50 to 79 years old (3.3/100,000) with the highest rate in the South (1.9/100,000). The overall case fatality rate was 7.5%. Patients with Fournier's gangrene were rarely treated at hospitals (mean +/- SD 0.6 +/- 1.2 per year, median 0, range 0 to 23). Overall 0 to 4 and 5 or greater cases were treated at 66%, 17%, 10%, 4%, 1% and 1% of hospitals, respectively. CONCLUSIONS: Patients with Fournier's gangrene are rarely treated at most hospitals. The population based mortality rate of 7.5% was substantially lower than that reported in case series from tertiary care centers.