Sleep before and after work-related concussion: Sex differences in effects and functional outcomes.

BACKGROUND: Recent studies have started disentangling components of disturbed sleep as part of the post-concussive syndrome, but little is known about the workers with an injury' perspectives on post-injury sleep changes or what causes these changes. OBJECTIVES: To determine the effects of work-related concussion/mild traumatic brain injury (wr-mTBI) on perceptions of refreshing sleep in workers with an injury and to identify the relevant factors responsible for sleep changes. METHODS: We studied post-concussive changes in sleep in 66 adults (50% male workers, 42% aged 30-50 years, median post-injury days: 155) who had sustained wr-mTBI and experienced functional limitations long after the injury. We collected sociodemographic, occupational and health status data and identified variables related to post-concussive changes in refreshing sleep. RESULTS: Forty-seven workers with wr-mTBI (79% of male workers, 64% of female workers) perceived their sleep as being refreshing before injury and unrefreshing afterwards (χ2 = 67.70 for change, χ2 = 27.6 for female and χ2 = 41.1 for male workers, p < 0.0001). Post-concussive losses in refreshing sleep were associated with socio demographic, occupational, and health status data variables. Sex stratification revealed differences between male and female workers. CONCLUSIONS: Workers with wr-mTBI experience clinically meaningful changes in refreshing sleep that are associated with modifiable variables. The observed differences in functional outcomes between male and female workers warrant further study.

Multimodal Patient Blood Management Program Based on a Three-pillar Strategy: A Systematic Review and Meta-analysis.

OBJECTIVES: To determine whether a multidisciplinary, multimodal Patient Blood Management (PBM) program for patients undergoing surgery is effective in reducing perioperative complication rate, and thereby is effective in improving clinical outcome. BACKGROUND: PBM is a medical concept with the focus on a comprehensive anemia management, to minimize iatrogenic (unnecessary) blood loss, and to harness and optimize patient-specific physiological tolerance of anemia. METHODS: A systematic review and meta-analysis was performed. Eligible studies had to address each of the 3 PBM pillars with at least 1 measure per pillar, for example, preoperative anemia management plus cell salvage plus rational transfusion strategy. The study protocol has been registered with PROSPERO (CRD42017079217). RESULTS: Seventeen studies comprising 235,779 surgical patients were included in this meta-analysis (100,886 pre-PBM group and 134,893 PBM group). Implementation of PBM significantly reduced transfusion rates by 39% [risk ratio (RR) 0.61, 95% confidence interval (CI) 0.55-0.68, P < 0.00001], 0.43 red blood cell units per patient (mean difference -0.43, 95% CI -0.54 to -0.31, P < 0.00001), hospital length of stay (mean difference -0.45, 95% CI -0.65 to -0.25, P < 0,00001), total number of complications (RR 0.80, 95% CI 0.74-0.88, P <0.00001), and mortality rate (RR 0.89, 95% CI 0.80-0.98, P = 0.02). CONCLUSIONS: Overall, a comprehensive PBM program addressing all 3 PBM pillars is associated with reduced transfusion need of red blood cell units, lower complication and mortality rate, and thereby improving clinical outcome. Thus, this first meta-analysis investigating a multimodal approach should motivate all executives and health care providers to support further PBM activities.

Hemoglobin Optimization for Coronary Bypass: A 10-Year Canadian Multicenter Experience.

BACKGROUND: We report our 10-year experience of a multicenter hemoglobin optimization program with the aim to reduce red blood cell transfusion in patients undergoing coronary artery bypass grafting (CABG). METHODS: From 2006 to 2016, patients undergoing CABG at 10 centers in Ontario were referred to the Ontario Transfusion Coordinators (ONTraC) program. Of these, we present data on the first 60 consecutive patients per center, per year (n = 6,145). RESULTS: Overall, 45.7% patients were assessed <14 days preoperatively, 16.4% were assessed ≥14 days preoperatively, and 37.9% were not assessed by ONTraC preoperatively. Transfusion rates fell from 40.1% in 2006 to 26.2% in 2016 (p < 0.01). Patients undergoing assessment were more likely to be older (p < 0.01), female (p < 0.01), and anemic (p < 0.01) versus nonassessed patients. Those patients assessed were more likely to be treated with iron (p < 0.01) and erythropoietin (p < 0.01) preoperatively versus nonassessed patients. Transfusion rates were 26%, 28%, and 28% for patients undergoing assessment ≥14 days prior to operation, <14 days prior to operation, or not at all. After baseline covariate adjustment, patients assessed ≥14 days preoperatively had shorter length of stay (effect -0.83, 95% confidence interval [CI] -1.41 to -0.25; p < 0.01) and a trend towards lower risk of red blood cell transfusion (odds ratio [OR] 0.83, 95% CI 0.68 to 1.00; p = 0.06). Blood transfusion was independently associated with an increased risk of death (OR 1.49, 95% CI 1.37 to 1.60; p < 0.01), infection (OR 1.24, 95% CI 1.18 to 1.30; p < 0.01), and longer hospital length of stay (effect 1.49, 95% CI 1.35 to 1.62; p < 0.01). CONCLUSIONS: The results of this study suggest that preoperative hemoglobin optimization may be effective in reducing red blood cell transfusion after CABG, particularly for patients assessed ≥14 days preoperatively.

A Canadian Population-Based Cohort to the Study Cost and Burden of Surgically Resected Hidradenitis Suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic debilitating disease with long-lasting comorbidities that impose direct and indirect costs on the health care system. However, limited studies have estimated the burden of this disease in Canada, and no population-based studies have previously addressed this condition. OBJECTIVES: This work describes the characteristics of a population-based HS cohort to address the existing knowledge gap on the burden of HS for the Canadian health care system. This cohort will provide a foundation for further studies about clinical outcomes and risk factors of HS by providing opportunities for merging additional databases. METHODS: Data on demographic information, morbidities, relative resource use, and the cost of sectorial services were obtained from the Institute for Clinical Evaluative Sciences (ICES). All residents of Ontario covered by the Ontario Health Insurance Plan (OHIP) between April 1, 2002, and March 31, 2013, who underwent surgery for HS, defined by OHIP billing codes, were included. RESULTS: A total of 6244 cases were included in the analysis, following quality control procedures. Twice as many females were treated surgically relative to males. The majority of individuals treated were under the age of 64, with more than half having a moderate level of morbidity (according to Resource Utilization Bands defined by the Johns Hopkins Adjusted Clinical Group Classification System). CONCLUSIONS: This cohort study is the first population-based resource about HS in Canada. Administrative population-based databases provide essential information to assess the burden of chronic diseases and identify factors associated with higher cost.

Sleep stage distribution in persons with mild traumatic brain injury: a polysomnographic study according to American Academy of Sleep Medicine standards.

OBJECTIVE AND BACKGROUND: Sleep stage disruption in persons with mild traumatic brain injury (mTBI) has received little research attention. We examined deviations in sleep stage distribution in persons with mTBI relative to population age- and sex-specific normative data and the relationships between such deviations and brain injury-related, medical/psychiatric, and extrinsic factors. PATIENTS AND METHODS: We conducted a cross-sectional polysomnographic investigation in 40 participants diagnosed with mTBI (mean age 47.54 ± 11.30 years; 56% males). MEASUREMENTS: At the time of investigation, participants underwent comprehensive clinical and neuroimaging examinations and one full-night polysomnographic study. We used the 2012 American Academy of Sleep Medicine recommendations for recording, scoring, and summarizing sleep stages. We compared participants' sleep stage data with normative data stratified by age and sex to yield z-scores for deviations from available population norms and then employed stepwise multiple regression analyses to determine the factors associated with the identified significant deviations. RESULTS: In patients with mTBI, the mean duration of nocturnal wakefulness was higher and consolidated sleep stage N2 and REM were lower than normal (p < 0.0001, p = 0.018, and p = 0.010, respectively). In multivariate regression analysis, several covariates accounted for the variance in the relative changes in sleep stage duration. No sex differences were observed in the mean proportion of non-REM or REM sleep. CONCLUSIONS: We observed longer relative nocturnal wakefulness and shorter relative N2 and REM sleep in patients with mTBI, and these outcomes were associated with potentially modifiable variables. Addressing disruptions in sleep architecture in patients with mTBI could improve their health status.

Community- and Healthcare-Associated Methicillin-Resistant Staphylococcus aureus Strains: An Investigation Into Household Transmission, Risk Factors, and Environmental Contamination.

OBJECTIVE To measure transmission frequencies and risk factors for household acquisition of community-associated and healthcare-associated (HA-) methicillin-resistant Staphylococcus aureus (MRSA). DESIGN Prospective cohort study from October 4, 2008, through December 3, 2012. SETTING Seven acute care hospitals in or near Toronto, Canada. PARTICIPANTS Total of 99 MRSA-colonized or MRSA-infected case patients and 183 household contacts. METHODS Baseline interviews were conducted, and surveillance cultures were collected monthly for 3 months from household members, pets, and 8 prespecified high-use environmental locations. Isolates underwent pulsed-field gel electrophoresis and staphylococcal cassette chromosome mec typing. RESULTS Overall, of 183 household contacts 89 (49%) were MRSA colonized, with 56 (31%) detected at baseline. MRSA transmission from index case to contacts negative at baseline occurred in 27 (40%) of 68 followed-up households. Strains were identical within households. The transmission risk for HA-MRSA was 39% compared with 40% (P=.95) for community-associated MRSA. HA-MRSA index cases were more likely to be older and not practice infection control measures (P=.002-.03). Household acquisition risk factors included requiring assistance and sharing bath towels (P=.001-.03). Environmental contamination was identified in 78 (79%) of 99 households and was more common in HA-MRSA households. CONCLUSION Household transmission of community-associated and HA-MRSA strains was common and the difference in transmission risk was not statistically significant. Infect Control Hosp Epidemiol 2016;1-7.

Cancer screening barriers and facilitators for under and never screened populations: A mixed methods study.

BACKGROUND: Cancer screening is below targets in Ontario, Canada. Our objective was to identify and quantify the barriers and facilitators for breast, cervical and colorectal cancer screening for under and never screened (UNS) residents living in Ontario between 2011 and 2013. METHODS: We used a multi-phased mixed methods study design. Results from thematic analysis of focus group discussions with health care providers and UNS community members were used to develop an on-line, province-wide, cross-sectional survey to estimate the prevalence of barriers and facilitators for the provincial population. Adjusted prevalence odds ratios and 95% confidence intervals were estimated for UNS compared to regularly screened participants using logistic regression. RESULTS: Four focus groups were held with health service providers and sixteen with UNS community members. Top barriers and facilitators themed around provider-patient communication, fear and embarrassment, history of physical or sexual abuse, social determinants of health (including low literacy, lack of awareness, and health insurance), symptoms appearing, and family and friends. 3075 participants completed the online survey. Compared to regularly screened participants, UNS had significantly higher odds of reporting: no regular health care provider; not feeling comfortable talking about screening; or the Doctor or Nurse Practitioner not suggesting screening. UNS also had significantly higher odds of reporting the facilitators: the test being less scary/painful or uncomfortable; friend/family insisting on getting screened; starting to have symptoms; or an easier test that could be done at home. CONCLUSIONS: Interventions addressing fear through individual, interpersonal and structural facilitators may increase cancer screening.

Return to work after work-related traumatic brain injury.

BACKGROUND: Work-related traumatic brain injury (wrTBI) comprises up to 24% of TBIs, yet relatively little is known about it even though wrTBI incurs high costs to employers, insurers, and injured. OBJECTIVES: To compare demographic, clinical, and occupation-related factors following mild-to-moderate TBI of those who successfully returned to work (RTW) versus those who did not, and to determine perceived facilitators of and barriers to RTW. METHODS: Retrospective cohort study from a consecutive sample of persons with TBI seen in an outpatient assessment clinic. Surveys were mailed to eligible potential participants. Consenting participants were interviewed by telephone or returned a completed survey via mail. RESULTS: Fifty of 116 eligible individuals participated in the study. Half of the participants returned to work. Participants in this group were significantly younger and had more years of education than the no-RTW group. The most common factors perceived to assist the RTW group were support of family and friends (92%) and of treatment providers (80%), and employers who provided accommodations (76%). Difficulty thinking and concentrating (94%) and fatigue (94%) were the most common barriers to RTW. CONCLUSIONS: This study highlights the importance of support from family, friends and employers as RTW facilitators. These factors merit further investigation in TBI rehabilitation studies.

Rehospitalization After Traumatic Brain Injury: A Population-Based Study.

OBJECTIVE: To examine, from a Canadian population-based perspective, the incidence and etiology of long-term hospital utilization among persons living with traumatic brain injury (TBI) by age and sex. DESIGN: Retrospective cohort study. SETTING: Acute care hospitals. PARTICIPANTS: Index cases of TBI (N=29,269) were identified from the Discharge Abstract Database for fiscal years 2002/2003 through 2009/2010 and were followed-up until 36 months after injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehospitalization was defined as admission to an acute care facility that occurred up to 36 months after index injury. Diagnoses associated with subsequent rehospitalization were examined by age and sex. RESULTS: Of the patients with TBI, 35.5% (n=10,390) were subsequently hospitalized during the 3-year follow-up period. Multivariable logistic regression (controlling for index admission hospital) identified men, older age, mechanism of injury being a fall, greater injury severity, rural residence, greater comorbidity, and psychiatric comorbidity to be significant predictors of rehospitalization in a 3-year period postinjury. The most common causes for rehospitalization differed by age and sex. CONCLUSIONS: Rehospitalization after TBI is common. Factors associated with rehospitalization can inform long-term postdischarge planning. Findings also support examining causes for rehospitalization by age and sex.

Bicycling crash circumstances vary by route type: a cross-sectional analysis.

BACKGROUND: Widely varying crash circumstances have been reported for bicycling injuries, likely because of differing bicycling populations and environments. We used data from the Bicyclists' Injuries and the Cycling Environment Study in Vancouver and Toronto, Canada, to describe the crash circumstances of people injured while cycling for utilitarian and leisure purposes. We examined the association of crash circumstances with route type. METHODS: Adult cyclists injured and treated in a hospital emergency department described their crash circumstances. These were classified into major categories (collision vs. fall, motor vehicle involved vs. not) and subcategories. The distribution of circumstances was tallied for each of 14 route types defined in an earlier analysis. Ratios of observed vs. expected were tallied for each circumstance and route type combination. RESULTS: Of 690 crashes, 683 could be characterized for this analysis. Most (74%) were collisions. Collisions included those with motor vehicles (34%), streetcar (tram) or train tracks (14%), other surface features (10%), infrastructure (10%), and pedestrians, cyclists, or animals (6%). The remainder of the crashes were falls (26%), many as a result of collision avoidance manoeuvres. Motor vehicles were involved directly or indirectly with 48% of crashes. Crash circumstances were distributed differently by route type, for example, collisions with motor vehicles, including "doorings", were overrepresented on major streets with parked cars. Collisions involving streetcar tracks were overrepresented on major streets. Collisions involving infrastructure (curbs, posts, bollards, street furniture) were overrepresented on multiuse paths and bike paths. CONCLUSIONS: These data supplement our previous analyses of relative risks by route type by indicating the types of crashes that occur on each route type. This information can guide municipal engineers and planners towards improvements that would make cycling safer.

Diisocyanate and non-diisocyanate sensitizer-induced occupational asthma frequency during 2003 to 2007 in Ontario, Canada.

OBJECTIVE: To investigate proportions and outcomes of isocyanate and other causes of occupational asthma (OA) claims in Ontario, Canada, 2003 to 2007. METHODS: New accepted workers' compensation claims for OA compensated by the Ontario Workplace Safety and Insurance Board were retrospectively reviewed. RESULTS: There were 112 allowed claims for OA-30 (26.8%) from diisocyanates (ISO) and 82 (73.2%) from other causes (non-diisocyanates [N-ISO]). The most common occupations for ISO OA were production workers (50%). The most common agents in the N-ISO group were flour (13%) and metal dusts/fumes (10%). At a median time of 8 months postdiagnosis, 55% of ISO and 56.4% of N-ISO workers, respectively, were unemployed. CONCLUSIONS: Diisocyanates OA compensation claims in Ontario are recognized at a lower absolute number and proportion of all OA claims than those in earlier periods. More than half from all causes were unemployed at a median of 8 months postdiagnosis.

Comparing the effects of infrastructure on bicycling injury at intersections and non-intersections using a case-crossover design.

BACKGROUND: This study examined the impact of transportation infrastructure at intersection and non-intersection locations on bicycling injury risk. METHODS: In Vancouver and Toronto, we studied adult cyclists who were injured and treated at a hospital emergency department. A case-crossover design compared the infrastructure of injury and control sites within each injured bicyclist's route. Intersection injury sites (N=210) were compared to randomly selected intersection control sites (N=272). Non-intersection injury sites (N=478) were compared to randomly selected non-intersection control sites (N=801). RESULTS: At intersections, the types of routes meeting and the intersection design influenced safety. Intersections of two local streets (no demarcated traffic lanes) had approximately one-fifth the risk (adjusted OR 0.19, 95% CI 0.05 to 0.66) of intersections of two major streets (more than two traffic lanes). Motor vehicle speeds less than 30 km/h also reduced risk (adjusted OR 0.52, 95% CI 0.29 to 0.92). Traffic circles (small roundabouts) on local streets increased the risk of these otherwise safe intersections (adjusted OR 7.98, 95% CI 1.79 to 35.6). At non-intersection locations, very low risks were found for cycle tracks (bike lanes physically separated from motor vehicle traffic; adjusted OR 0.05, 95% CI 0.01 to 0.59) and local streets with diverters that reduce motor vehicle traffic (adjusted OR 0.04, 95% CI 0.003 to 0.60). Downhill grades increased risks at both intersections and non-intersections. CONCLUSIONS: These results provide guidance for transportation planners and engineers: at local street intersections, traditional stops are safer than traffic circles, and at non-intersections, cycle tracks alongside major streets and traffic diversion from local streets are safer than no bicycle infrastructure.

High uptake of HIV testing in pregnant women in Ontario, Canada.

In 1999, Ontario implemented a policy to offer HIV counseling and testing to all pregnant women and undertook measures to increase HIV testing. We evaluated the effectiveness of the new policy by examining HIV test uptake, the number of HIV-infected women identified and, in 2002, the HIV rate in women not tested during prenatal care. We analyzed test uptake among women receiving prenatal care from 1999 to 2010. We examined HIV test uptake and HIV rate by year, age and health region. In an anonymous, unlinked study, we determined the HIV rate in pregnant women not tested. Prenatal HIV test uptake in Ontario increased dramatically, from 33% in the first quarter of 1999 to 96% in 2010. Test uptake was highest in younger women but increased in all age groups. All health regions improved and experienced similar test uptake in recent years. The HIV rate among pregnant women tested in 2010 was 0.13/1,000; in Toronto, the rate was 0.28 per 1,000. In the 2002 unlinked study, the HIV rate was 0.62/1,000 among women not tested in pregnancy compared to 0.31/1,000 among tested women. HIV incidence among women who tested more than once was 0.05/1,000 person-years. In response to the new policy in Ontario, prenatal HIV testing uptake improved dramatically among women in all age groups and health regions. A reminder to physicians who had not ordered a prenatal HIV test appeared to be very effective. In 2002, the HIV rate in women who were not tested was twice that of tested women: though 77% of pregnant women had been tested, only 63% of HIV-infected women were tested. HIV testing uptake was estimated at 98% in 2010.

Route infrastructure and the risk of injuries to bicyclists: a case-crossover study.

OBJECTIVES: We compared cycling injury risks of 14 route types and other route infrastructure features. METHODS: We recruited 690 city residents injured while cycling in Toronto or Vancouver, Canada. A case-crossover design compared route infrastructure at each injury site to that of a randomly selected control site from the same trip. RESULTS: Of 14 route types, cycle tracks had the lowest risk (adjusted odds ratio [OR] = 0.11; 95% confidence interval [CI] = 0.02, 0.54), about one ninth the risk of the reference: major streets with parked cars and no bike infrastructure. Risks on major streets were lower without parked cars (adjusted OR = 0.63; 95% CI = 0.41, 0.96) and with bike lanes (adjusted OR = 0.54; 95% CI = 0.29, 1.01). Local streets also had lower risks (adjusted OR = 0.51; 95% CI = 0.31, 0.84). Other infrastructure characteristics were associated with increased risks: streetcar or train tracks (adjusted OR = 3.0; 95% CI = 1.8, 5.1), downhill grades (adjusted OR = 2.3; 95% CI = 1.7, 3.1), and construction (adjusted OR = 1.9; 95% CI = 1.3, 2.9). CONCLUSIONS: The lower risks on quiet streets and with bike-specific infrastructure along busy streets support the route-design approach used in many northern European countries. Transportation infrastructure with lower bicycling injury risks merits public health support to reduce injuries and promote cycling.

Preventive health practices and behavioral risk factors in women surviving traumatic brain injury.

Traumatic brain injury (TBI) affects millions globally and is considered a universal public health concern. Our study addresses a considerable knowledge gap about the health of female survivors of TBI. Using a retrospective cohort study design, we examined behavioral risk factors, access to health screenings, and primary care services among women with a history of moderate to severe TBI. We compared findings with a general female population. Female survivors (n = 75) appeared to have comparable use of primary care services with the general population. Significantly more women reported poor mental health postinjury; reported alcohol consumption was also greater.

Mycoplasma genitalium presence, resistance and epidemiology in Greenland.

OBJECTIVES: Greenland reports the highest rates of chlamydial infection and gonorrhea in the Arctic. Our objective was to determine the presence, and describe the basic epidemiology, of Mycoplasma genitalium for Greenland. STUDY DESIGN: Cross-sectional study. METHODS: 314 residents from Nuuk and Sisimiut, between the ages of 15 and 65 years, participated in "Inuulluataarneq" (the Greenland Sexual Health Project) between July 2008 and November 2009. Participants provided self-collected samples for sexually transmitted infection (STI) testing and completed a sexual health survey. Descriptive statistics and logistic regression were used to summarize the basic characteristics of STI cases overall and M. genitalium and Chlamydia trachomatis specifically. Clinically relevant characteristics in each full model were gender (male or female), age (in years), age at sexual debut (in years), number of sexual partners in the past 3 months (continuous) and history of forced sex and community. RESULTS: The overall prevalence of STIs was 19.0%, specifically: 9.8% for M. genitalium and 9.4% for C. trachomatis; 100% of M. genitalium-positive cases carried macrolide resistance determinants. Being female [OR = 3.2; 95% confidence interval (CI): 1.1-9.8] and younger age (OR = 0.9; 95% CI: 0.9-1.0) were associated with M. genitalium positivity. Age was also associated with C. trachomatis (OR = 0.9; 95% CI: 0.8-0.9) and STI positivity overall (OR = 0.9; 95% CI: 0.9-0.9). CONCLUSIONS: We observed a high prevalence of M. genitalium and macrolide resistance in this study. A better understanding of M. genitalium sequelae is needed to inform policy around testing, treatment, control and antibiotic use.

Using geographical information systems mapping to identify areas presenting high risk for traumatic brain injury.

BACKGROUND: The aim of this study is to show how geographical information systems (GIS) can be used to track and compare hospitalization rates for traumatic brain injury (TBI) over time and across a large geographical area using population based data. RESULTS & DISCUSSION: Data on TBI hospitalizations, and geographic and demographic variables, came from the Ontario Trauma Registry Minimum Data Set for the fiscal years 1993-1994 and 2001-2002. Various visualization techniques, exploratory data analysis and spatial analysis were employed to map and analyze these data. Both the raw and standardized rates by age/gender of the geographical unit were studied. Data analyses revealed persistent high rates of hospitalization for TBI resulting from any injury mechanism between two time periods in specific geographic locations. CONCLUSIONS: This study shows how geographic information systems can be successfully used to investigate hospitalizaton rates for traumatic brain injury using a range of tools and techniques; findings can be used for local planning of both injury prevention and post discharge services, including rehabilitation.

Hospitalizations and emergency department visits for TBI in Ontario.

OBJECTIVE: The aim of this study was to determine the number of annual hospitalizations and overall episodes of care that involve a traumatic brain injury (TBI) by age and gender in the province of Ontario. To provide a more accurate assessment of the prevalence of TBI, episodes of care included visits to the emergency department (ED), as well as admissions to hospital. Mechanisms of injury for overall episodes were also investigated. METHODS: Traumatic brain injury cases from fiscal years 2002/03-2006/07 were identified by means of ICD-10 codes. Data were collected from the National Ambulatory Care Reporting System and the Discharge Abstract Database. RESULTS: The rate of hospitalization was highest for elderly persons over 75 years-of-age. Males generally had higher rates for both hospitalizations and episodes of care than did females. The inclusion of ED visits to hospitalizations had the greatest impact on the rates of TBI in the youngest age groups. Episodes of care for TBI were greatest in youth under the age of 14 and elderly over the age of 85. Falls (41.6%) and being struck by or against an object (31.1%) were the most frequent causes for a TBI. CONCLUSIONS: The study provides estimates for TBI from the only Canadian province that has systematically captured ED visits in a national registry. It shows the importance of tracking ED visits, in addition to hospitalizations, to capture the burden of TBI on the health care system. Prevention strategies should include information on ED visits, particularly for those at younger ages.

Experience of a network of transfusion coordinators for blood conservation (Ontario Transfusion Coordinators [ONTraC]).

BACKGROUND: The experiences of the development of a provincial program to promote blood conservation are herein reported. STUDY DESIGN AND METHODS: Transfusion coordinators were placed in 23 Ontario hospitals. Anonymized laboratory and clinical information was collected in a defined number of all consecutive patients admitted for three designated procedures: knee arthroplasty, abdominal aortic aneurysm (AAA), and coronary artery bypass graft (CABG) surgery (n approximately 1100, 300, and 300 at each time period, respectively). RESULTS: Considerable interinstitutional variation was observed in the proportion of patients who received transfusions. At 12 months, and over the 24-month period of the project, most hospitals demonstrated decreased use of allogeneic blood; at 12 months an approximate 24 percent reduction in patients undergoing knee surgery, 14 percent in AAA, and 23 percent in CABG was obtained. In addition, patients who received transfusions received less allogeneic blood. Patients who did not receive allogeneic transfusions had lower postoperative infection rates (p < 0.05) and length of stay (p < 0.0001); allogeneic transfusion was an independent predictor of increased length of stay. The main blood conservation measures employed during this time were education, preoperative autologous donation, erythropoietin, and cell salvage. CONCLUSION: The implementation of a provincial network of transfusion coordinators was feasible and allogeneic transfusion rates declined over the period the program has been in place.

Discharge destination from acute care after traumatic brain injury.

OBJECTIVE: To identify the impact of private insurance coverage on discharge disposition after a traumatic brain injury (TBI) using injury in a motor vehicle accident (MVA) as a proxy for private insurance, controlling for age and severity of injury. METHOD: Cross-sectional study. PATIENTS: Patients with TBI discharged between 1993-1994 and 2000-2001 (n = 9,703). MAIN OUTCOME MEASURE: Discharge destination from acute care; controlled odds ratio (OR) and confidence interval (CI) for type of injury. RESULTS: Type of injury, age, and length of stay are significantly associated with discharge destination. However, the motor vehicle accident patients are 56% more likely to be discharged to home with support services than patients with similar injuries from falls. CONCLUSION: Even in a system with universal coverage, availability of private insurance type is a potential independent determinant of post-acute care services. More research is required to determine the effect this relationship has on the cost and outcomes of care for TBI patients.