Maternal and child health after injuries: a two-year follow-up of a nationally representative sample.

OBJECTIVE: The objective of this study was to examine the association between childhood injury and health outcomes among survivors and their mothers using a national survey in the United States (US). STUDY DESIGN: This was a longitudinal analysis of a nationally representative sample. METHODS: Secondary analysis of the 1997-2013 Medical Expenditure Panel Survey (MEPS) was performed. Children (aged 2-18 years) with or without injuries were followed up for two years. Injuries captured in the study were those associated with at least one hospitalization, emergency department visit, or office-based visit. Outcome measures were child and maternal general and mental health status. Multiple mixed-logistic regressions were used with suboptimal health defined as the response of poor or fair health versus good, very good, or excellent health. RESULTS: Of the 63,422 children analyzed, 3251 (4.9%) were injured, representing 3.6 million US children. Injured children were more likely to be male, white, and older than those without injuries (P < 0.01). About a fifth of injured children suffered head injuries. Injuries were strongly associated with suboptimal general and mental health status in children (adjusted odds ratios [AORs], 1.35 and 1.36, respectively, P < 0.05). Mothers of children with injuries were also more likely to report suboptimal mental health (AOR, 1.30, P < 0.05). CONCLUSION: Injuries among children are associated with lasting adverse effects in general and mental health. To improve health outcomes of pediatric injuries, further follow-up care may be needed to ensure that they return to pre-injury health levels. These results highlight the importance of primary prevention and the long-term impact of injuries on the health of children and their mothers.

Linked Records of Children with Traumatic Brain Injury. Probabilistic Linkage without Use of Protected Health Information.

OBJECTIVE: Record linkage may create powerful datasets with which investigators can conduct comparative effectiveness studies evaluating the impact of tests or interventions on health. All linkages of health care data files to date have used protected health information (PHI) in their linkage variables. A technique to link datasets without using PHI would be advantageous both to preserve privacy and to increase the number of potential linkages. METHODS: We applied probabilistic linkage to records of injured children in the National Trauma Data Bank (NTDB, N = 156,357) and the Pediatric Health Information Systems (PHIS, N = 104,049) databases from 2007 to 2010. 49 match variables without PHI were used, many of them administrative variables and indicators for procedures recorded as International Classification of Diseases, 9th revision, Clinical Modification codes. We validated the accuracy of the linkage using identified data from a single center that submits to both databases. RESULTS: We accurately linked the PHIS and NTDB records for 69% of children with any injury, and 88% of those with severe traumatic brain injury eligible for a study of intervention effectiveness (positive predictive value of 98%, specificity of 99.99%). Accurate linkage was associated with longer lengths of stay, more severe injuries, and multiple injuries. CONCLUSION: In populations with substantial illness or injury severity, accurate record linkage may be possible in the absence of PHI. This methodology may enable linkages and, in turn, comparative effectiveness studies that would be unlikely or impossible otherwise.

The utility of imputed matched sets. Analyzing probabilistically linked databases in a low information setting.

OBJECTIVE: To compare results from high probability matched sets versus imputed matched sets across differing levels of linkage information. METHODS: A series of linkages with varying amounts of available information were performed on two simulated datasets derived from multiyear motor vehicle crash (MVC) and hospital databases, where true matches were known. Distributions of high probability and imputed matched sets were compared against the true match population for occupant age, MVC county, and MVC hour. Regression models were fit to simulated log hospital charges and hospitalization status. RESULTS: High probability and imputed matched sets were not significantly different from occupant age, MVC county, and MVC hour in high information settings (p > 0.999). In low information settings, high probability matched sets were significantly different from occupant age and MVC county (p < 0.002), but imputed matched sets were not (p > 0.493). High information settings saw no significant differences in inference of simulated log hospital charges and hospitalization status between the two methods. High probability and imputed matched sets were significantly different from the outcomes in low information settings; however, imputed matched sets were more robust. CONCLUSIONS: The level of information available to a linkage is an important consideration. High probability matched sets are suitable for high to moderate information settings and for situations involving case-specific analysis. Conversely, imputed matched sets are preferable for low information settings when conducting population-based analyses.

Segmental cherry angiomas associated with extragenital lichen sclerosus: a report of two cases.

Cherry angiomas (Campbell de Morgan spots) are common acquired red skin papules composed of dilated capillary loops, usually of unknown aetiology. Extragenital lichen sclerosus (LS) presents as porcelain-white scaly atrophic lesions with or without genital involvement. We report two cases of segmental multiple cherry angiomas in association with extragenital LS. Two unrelated women, aged 46 and 66 years, presented with extragenital LS affecting their axillae and lower abdomen. During the examination, both patients were noted to have several hundred red skin papules in a segmental distribution, affecting the left thigh and flank of one woman, and the right abdomen and back of the other. Clinically and histologically, the papules were consistent with cherry angiomas. The striking segmental distribution of multiple cherry angiomas may be due to genetic mosaicism; however, segmental Fabry disease was excluded by sequence analysis of the α-galactosidase A gene. Any causal link between cherry angiomas and LS remains uncertain.

Involution of infantile haemangiomas after imiquimod 5% cream.

Infantile haemangioma is a common childhood condition, which usually resolves spontaneously and is managed expectantly. In a small percentage of complex cases, haemangiomas may be associated with complications such as persistent bleeding, ulceration, feeding difficulties or visual impairment. Active treatment is often necessary in such cases. Current interventions include surgical, laser and immunomodulatory treatments. Imiquimod 5% cream is a novel alternative topical treatment that may have a potential role in management of these patients. We present our experience of imiquimod 5% cream in the treatment of five children with difficult haemangiomas. We discuss its efficacy and some of the side effects that may be encountered, which have not previously been reported.

Solasodine glycoalkaloids: a novel topical therapy for basal cell carcinoma. A double-blind, randomized, placebo-controlled, parallel group, multicenter study.

OBJECTIVE: To assess the safety and efficacy of a 0.005% mixture of solasodine glycosides (Zycure) in the treatment of basal cell carcinoma. Design Double-blind, randomized, and vehicle-controlled, parallel group study. SETTING: Ten centers in the United Kingdom. Participants Male, n = 50; female, n = 44; age range, 32-95 years (Table 1). INTERVENTION: Ninety-four patients were randomized on a 2 : 1 ratio (n = 62, Zycure; n = 32, vehicle). Histologically confirmed lesions were treated double blinded, twice daily under occlusion with Zycure or vehicle for 8 weeks. Patients were reviewed fortnightly for adverse effects and overall response. Successfully treated patients were followed up at six-month intervals for a year. MAIN OUTCOME MEASURES: The primary efficacy endpoint was histologically confirmed clearance of the basal cell carcinoma (2-mm punch biopsy) at the end of 8-week treatment. RESULTS: Efficacy (intention-to-treat population) at 8 weeks was 66% (41/62) in the Zycure group, compared to 25% (8/32) in the vehicle group (P < 0.001; Cochran-Mantel-Haenszel test). Ninety percent (37/41) of the Zycure group completed follow-up at six-month intervals for 1 year, of whom 78% (29/37) had no recurrence. There were no major treatment-related adverse effects, although 10 patients in Zycure group did not complete the treatment protocol for various reasons. CONCLUSION: We conclude that the solasodine glycoside cream Zycure is a safe therapy for basal cell carcinoma, with a cure rate of 66% at 8 weeks and 78% at 1 year follow-up.

MRSA enteritis causing a high stoma output in the early postoperative phase after bowel surgery.

INTRODUCTION: Nosocomial MRSA infection has become an important healthcare issue. We present 6 cases of MRSA enteritis, acquired following bowel surgery and ileostomy formation. PATIENTS AND METHODS: The data set was obtained from the experience of one consultant surgeon over 6 years in one medical centre. The clinical features and course of six patients that developed MRSA enteritis postoperatively were obtained through review of case notes and laboratory data. RESULTS: Four male and two female patients (age range, 22-80 years) developed a clinical syndrome postoperatively requiring treatment within the high dependency unit. Three developed respiratory distress syndrome, and one died from multi-organ failure. Exploratory laparotomy carried out in three patients was negative. All patients were MRSA-negative on admission but had swabs positive for MRSA from ileostomy site postoperatively. All of the three patients who had ileostomy effluent cultured for MRSA had positive results. DISCUSSION: Fever, abdominal pain, distension and high stoma output in the early postoperative period following bowel surgery should alert the clinician to the possibility of MRSA enteritis. Patients require aggressive resuscitation and culture of ileostomy effluent for MRSA. Exploratory laparotomy has no obvious benefits. As MRSA enteritis has the potential to be a lethally effective disseminator of MRSA, such clinical features should prompt early instigation of appropriate infection control practices.

The fast and the fatal: street racing fatal crashes in the United States.

The objective of this study was to determine the annual incidence of fatal motor vehicle crashes involving street racing and to describe the characteristics of these crashes compared to other fatal crashes in the United States. The National Highway Traffic Safety Administration Fatality Analysis Reporting System data for 1998-2001 were used for the analyses. There were 149 568 fatal crashes and 315 (0.21%) involved street racing and 399 fatalities occurred in these crashes. In contrast to other fatal crashes, street racing fatal crashes were more likely to occur on urban roadways and were nearly six times more likely to occur at travel speeds> or = 65 mph. Compared with other drivers involved in fatal crashes, street racers were more likely to be teenagers, male, and have previous crashes and driving violations. Street racing involves risky driving behaviors and warrants further attention.

Genetic and functional analyses of FH mutations in multiple cutaneous and uterine leiomyomatosis, hereditary leiomyomatosis and renal cancer, and fumarate hydratase deficiency.

Germline mutations of the fumarate hydratase (FH, fumarase) gene are found in the recessive FH deficiency syndrome and in dominantly inherited susceptibility to multiple cutaneous and uterine leiomyomatosis (MCUL). We have previously reported a number of germline FH mutations from MCUL patients. In this study, we report additional FH mutations in MCUL and FH deficiency patients. Mutations can readily be found in about 75% of MCUL cases and most cases of FH deficiency. Some of the more common FH mutations are probably derived from founding individuals. Protein-truncating FH mutations are functionally null alleles. Disease-associated missense FH changes map to highly conserved residues, mostly in or around the enzyme's active site or activation site; we predict that these mutations severely compromise enzyme function. The mutation spectra in FH deficiency and MCUL are similar, although in the latter mutations tend to occur earlier in the gene and, perhaps, are more likely to result in a truncated or absent protein. We have found that not all mutation-carrier parents of FH deficiency children have a strong predisposition to leiomyomata. We have confirmed that renal carcinoma is sometimes part of MCUL, as part of the variant hereditary leiomyomatosis and renal cancer (HLRCC) syndrome, and have shown that these cancers may have either type II papillary or collecting duct morphology. We have found no association between the type or site of FH mutation and any aspect of the MCUL phenotype. Biochemical assay for reduced FH functional activity in the germline of MCUL patients can indicate carriers of FH mutations with high sensitivity and specificity, and can detect reduced FH activity in some patients without detectable FH mutations. We conclude that MCUL is probably a genetically homogeneous tumour predisposition syndrome, primarily resulting from absent or severely reduced fumarase activity, with currently unknown functional consequences for the smooth muscle or kidney cell.

Snowmobile injuries in Utah.

OBJECTIVE: To describe the epidemiology of snowmobile injuries in Utah. METHODS: Analysis of probabilistically linked statewide emergency department (ED), hospital admission, and death certificate data for 1996 and 1997. RESULTS: There were 625 cases of snowmobile-related injuries. The majority (83%) were evaluated in the ED only. Median ED patient age was 29 years (range 3-74 years), and 66% were male. The leading diagnoses were open wounds to the head (7.8%), back strains (5.4%), and contusions of the trunk and lower extremities (5.2% and 5.0%, respectively). An Injury Severity Score (ISS) of > or = 4 (range 1-75) was found in 37% of the ED patients. The median charge was $373 per patient, with two-year cumulative charges of $266,283. One hundred seven patients required inpatient hospital care. Median inpatient age was 32 years (range 4-92 years), and 60% were male. Leading inpatient diagnoses were fracture of the vertebral column (9.3%), lower extremity fracture (9.3%), upper extremity fracture (6.5%), and pelvis fracture (3.7%). An ISS of > or = 4 (range 1-38) was found in 70% of the hospitalized patients. Average length of stay was 3 days, with a range of 1 to 68 days. Median inpatient charge was $6,003 per patient, with two-year cumulative charges of $1,333,218. Ten inpatients required transfer for rehabilitation or skilled nursing care. There were a total of six fatalities, three of which occurred in the ED, one in the inpatient population, and two identified from the death certificate database. CONCLUSIONS: By combining ED, inpatient, and death certificate data sets, probabilistic linkage provides a comprehensive description of snowmobile-related injuries and a baseline evaluation of morbidity, mortality, and financial burden.

A population-based assessment of pediatric all-terrain vehicle injuries.

OBJECTIVE: To describe the types of injuries sustained by children who ride all-terrain vehicles (ATVs), to estimate the hospital charges associated with these injuries, and to determine adherence to existing rules and regulations governing ATV use. METHODS: Analysis of statewide hospital admissions (1992-1996) and emergency department (ED) visits (1996) in Utah. All patients who were younger than 16 years and had an external cause of injury code for ATV use were included. RESULTS: In 1996, 268 ED visits by children involved an ATV. Boys were twice as commonly injured as girls (male:female ratio: 2.1:1), and skin and orthopedic injuries were most frequent. The median ED charge was $368, and ED charges for these patients totaled $138 000. From 1992 to 1996, 130 children were hospitalized as a result of injuries sustained during ATV use, with median charges of $4240 per admission. Male to female ratio was 2.7:1, and the average age was 11.2 +/- 3.6 years. Mean injury severity score was 8.0 +/- 6.0, and median length of stay was 2 days (range: 0-43 days). Orthopedic injuries were most frequent, but 25% (n = 32) of children sustained head or spinal cord injury. Most children (94%) were discharged from the hospital, but 8 children died as a result of their injuries. Utah regulations prohibit children who are younger than 8 years from driving an ATV and advise against carrying passengers on ATVs. However, 25% (n = 15) of all injured children who were younger than 8 were driving the ATV when injured, and 15% (n = 60) of injured children were passengers on ATVs. Four of the 8 fatally injured children were younger than 8, and all were driving the ATV at the time of the crash. Finally, the estimated injury rate per 100 registered ATVs is significantly higher for children than for adults (3.41 vs 1.71). CONCLUSIONS: ATV use results in significant injuries to children. Efforts to educate parents regarding the risks of ATV use, proper supervision, and use of safety equipment are warranted. Manufacturers of ATVs should continue to improve the safety profile of these inherently unstable vehicles.

Probabilistic record linkage: relationships between file sizes, identifiers and match weights.

This study investigates relationships between file sizes, amounts of information contained in commonly used record linkage variables, and the amount of information needed for a successful probabilistic linkage project. We present an equation predicting the amount of information needed for a successful linkage project. Match weights for variables commonly used in record linkage are measured using artificially created databases. Linkage algorithms were successful when the sum of minimum weights for variables used in a linkage exceeded the predicted cutoff. Linkage results were acceptable when this sum was near the predicted cutoff. This technique enables researchers to determine if enough information exists to perform a successful probabilistic linkage.

A population-based study of crashes involving 16- and 17-year-old drivers: the potential benefit of graduated driver licensing restrictions.

OBJECTIVE: To evaluate the potential effectiveness of graduated driver licensing programs using population-based linked data for motor vehicle crashes (MVCs) that involved teenaged drivers (TDs). METHODS: Utah crash, inpatient hospital discharge, and emergency department databases were analyzed and probabilistically linked. We computed hospital charges and compared violations, contributing factors, seatbelt use, and passengers for TDs (16-17 years old) relative to adult drivers (18-59 years old). RESULTS: TDs comprised 5.8% of the study population, but were involved in 19.0% of MVCs. TD crashes resulted in $11 million in inpatient hospital charges and 158 fatalities. TD crashes were 1.70 times (95% confidence interval [CI]: 1.34, 2.04) less likely to result in fatal injury to drivers than were crashes that involved adult drivers, but TDs were 2.20 times (95% CI: 1.96, 2.47) more likely to receive citations. The following were findings of the study: 1) 11% of all TD crashes but 19% of fatal TD crashes occurred between 2200 and 0600 hours; 2) TDs used seatbelts less often than did adult drivers (79.1% vs 84.4%) and less often with passengers present (81.9% vs 75.0%; 3) TDs were 1.72 times (95% CI: 1.38, 2.14) more likely to be involved in crashes that resulted in seriously or fatally injured occupants when driving with passengers than when driving alone. CONCLUSIONS: TDs are overrepresented in MVCs. TD crashes have a higher fatality rate at night, and TDs wear seatbelts less often than do adult drivers. Passengers affect TD crash characteristics. Graduated driver licensing programs that target state-specific characteristics of TDs may decrease morbidity and mortality.

Shoulder belts in motor vehicle crashes: a statewide analysis of restraint efficacy.

The purpose of our study was to evaluate the impact of shoulder belt use on motor vehicle crash ejection, morbidity and mortality. We analyzed motor vehicle crash records linked to hospital inpatient data for front seat occupants of passenger cars in Utah between 1994 and 1996 (n = 103,035). Stochastic simulations were used to adjust for possible seatbelt misclassification. There were 276 (0.3%) occupants coded as using only a shoulder belt. The adjusted odds of ejection for shoulder only belted occupants was higher compared to lap-shoulder belted (odds ratio (OR) = 18.9; 95% confidence interval (CI) = 15.1, 25.1) and lap only belted occupants (OR = 4.3; 95% Cl = 2.9, 7.7). There was no difference in the odds of ejection for an occupant using a shoulder belt only and an occupant using no seatbelt (OR = 1.1; 95% CI = 1.0, 1.3). Occupants using a shoulder belt only were more likely to sustain a fatal or hospitalizing injury than lap-shoulder belted (OR = 2.3; 95% Cl = 1.9, 3.0), and lap only belted occupants (OR = 1.8; 95% CI = 1.3, 2.7), while controlling for other covariates. Occupants using only a shoulder belt had the same odds of a fatal or hospitalizing injury as unbelted occupants (OR = 1.1; 95% Cl = 0.9, 1.4). Average hospital inpatient length of stay, charges and injury severity scores were similar for all restraint types. These results stress the need for the use of a lap belt in conjunction with the shoulder belt.

Adults and children in severe motor vehicle crashes: a matched-pairs study.

STUDY OBJECTIVE: Many articles report seat belt injuries to children. This study examines the effect of child versus adult age and seat belt use on outcome in severe motor vehicle crashes. METHODS: A population-based data set of all motor vehicle crashes statewide was analyzed by using matched-pairs logistic regression. Subjects were participants in motor vehicle crashes in which at least one occupant was killed or hospitalized and at least one was a child (age <15 years). Only passengers in cars, vans, and the front of light trucks were considered. Unique matched pairs were formed of one adult and one child from the same vehicle. The main outcome measure was death or hospitalization. Covariates were seat belt use and front or back seat position. RESULTS: Overall, 413 pairs were analyzed. Seat belt use in these severe crashes was low for children and adults (40% versus 45%). Children more often sat in the back seat (74% versus 31% for adults). Risk of death was similar (7% for children and 8% for adults), but the percentage killed or hospitalized differed (13% for children and 28% for adults; odds ratio [OR] 2.5; 95% confidence interval [CI] 1.8 to 3.7). After controlling for seat belt use and seat position, adults remained at a similarly increased risk compared with children (OR 2.6; 95% CI 1.6 to 4.2). The back seat was much safer than the front seat (OR 5.5; 95% CI 3.7 to 8.1). An adult's nonuse of restraints was strongly predictive of a child's nonuse. CONCLUSION: Seat belts were at least as protective for children as for adults, but only 40% of the children in these severe crashes were restrained.

Motor vehicle crash characteristics and medical outcomes among older drivers in Utah, 1992-1995.

STUDY OBJECTIVE: We sought to compare the characteristics and medical outcomes of motor vehicle crashes for drivers 70 years and older with those of drivers between the ages of 30 and 39 years. METHODS: We probabilistically linked statewide motor vehicle crash and hospital discharge data between the years of 1992 and 1995 for the state of Utah. We calculated the odds of older drivers exhibiting certain motor vehicle crash characteristics compared with younger drivers. Adjusting for nighttime crash, high-speed crash, and seatbelt use, we calculated the odds of an older driver being killed or hospitalized compared with those of a younger driver. RESULTS: During the study years, there were 14,466 drivers older than 69 years and 68,706 drivers between the ages of 30 and 39 years involved in motor vehicle crashes in Utah. Older drivers were less likely to have crashes involving drug or alcohol use (odds ratio [OR] 0.1; 95% confidence interval [CI] 0.1 to 0.2) and less likely to have crashes at high speed (OR 0.6; 95% CI 0.6 to 0.7). Although older drivers were no more likely to have a crash involving a right-hand turn (OR 1.0; 95% CI 0.9 to 1.1) than younger drivers, they were over twice as likely to have a crash involving a left-hand turn (OR 2.3; 95% CI 2.2 to 2.5). Also, older drivers were more likely to be killed or hospitalized than younger drivers (OR, 3.5; P <.001). Among belted drivers, an older driver was nearly 7 times more likely to be killed or hospitalized than a younger driver (OR 6. 9; 95% CI 5.4 to 8.9). CONCLUSION: Older drivers do have distinctive motor vehicle crash patterns. Interventions must be taken to reduce the number of left-hand turn crashes involving older drivers. In addition, further research is needed to design, implement, and evaluate countermeasures that may enable older drivers to continue driving while keeping public safety in the forefront.

Identification of three genes expressed primarily during development in Physarum polycephalum.

During the life cycle of Physarum polycephalum, uninucleate amoebae develop into multinucleate syncytial plasmodia. These two cell types differ greatly in cellular organisation, behaviour and gene expression. Classical genetic analysis has identified the mating-type gene, matA, as the key gene controlling the initiation of plasmodium development, but nothing is known about the molecular events controlled by matA. In order to identify genes involved in regulating plasmodium formation, we constructed a subtracted cDNA library from cells undergoing development. Three genes that have their highest levels of expression during plasmodium development were identified: redA, redB (regulated in development) and mynD (myosin). Both redA and redB are single-copy genes and are not members of gene families. Although redA has no significant sequence similarities to known genes, redB has sequence similarity to invertebrate sarcoplasmic calcium-binding proteins. The mynD gene is closely related to type II myosin heavy-chain genes from many organisms and is one of a family of type II myosin genes in P. polycephalum. Our results indicate that many more red genes remain to be identified, some of which may play key roles in controlling plasmodium formation.

Physarum amoebae express a distinct fragmin-like actin-binding protein that controls in vitro phosphorylation of actin by the actin-fragmin kinase.

Amoebae and plasmodia constitute the two vegetative growth phases of the Myxomycete Physarum. In vitro and in vivo phosphorylation of actin in plasmodia is tightly controlled by fragmin P, a plasmodium-specific actin-binding protein that enables actin phosphorylation by the actin-fragmin kinase. We investigated whether amoebal actin is phosphorylated by this kinase, in spite of the lack of fragmin P. Strong actin phosphorylation was detected only following addition of recombinant actin-fragmin kinase to cell-free extracts of amoebae, suggesting that amoebae contain a protein with properties similar to plasmodial fragmin. We purified the complex between actin and this protein to homogeneity. Using an antibody that specifically recognizes phosphorylated actin, we demonstrate that Thr203 in actin can be phosphorylated in this complex. A full-length amoebal fragmin cDNA was cloned and the deduced amino acid sequence shows 65% identity with plasmodial fragmin. However, the fragmins are encoded by different genes. Northern blots using RNA from a developing Physarum strain demonstrate that this fragmin isoform (fragmin A) is not expressed in plasmodia. In situ localization showed that fragmin A is present mainly underneath the plasma membrane. Our results indicate that Physarum amoebae express a fragmin P-like isoform which shares the property of binding actin and converting the latter into a substrate for the actin-fragmin kinase.

The implications of protocol-based care on dental services in the military.

Downsizing, limited resources, and increasing costs provide challenges to the military health system. Variations in the diagnosis and treatment of dental disease add to the demands on the delivery system to provide access and ensure quality for uniformed personnel. Evidence-based dentistry is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. An evidence-based practice combines individual clinical expertise with the best external evidence available from systematic review of research findings. It provides a scientific basis for patient care, planning and implementation of health services, and development of health policy. Practice guidelines formulated on scientific evidence can reduce variations in the diagnosis and treatment of various dental conditions. A risk assessment protocol for treating dental caries can reduce operative dental treatment recommended at the initial examination and decrease the need for restorative care during a military career.