Internal and external validation of an updated ICD-10-CA to AIS-2005 update 2008 algorithm.

BACKGROUND: Administrative data are a powerful tool for population-level trauma research but lack the trauma-specific diagnostic and injury severity codes needed for risk-adjusted comparative analyses. The objective of this study was to validate an algorithm to derive Abbreviated Injury Scale (AIS-2005 update 2008) severity scores from Canadian International Classification of Diseases (ICD-10-CA) diagnostic codes in administrative data. METHODS: This was a retrospective cohort study using data from the 2009 to 2017 Ontario Trauma Registry for the internal validation of the algorithm. This registry includes all patients treated at a trauma center who sustained a moderate or severe injury or were assessed by a trauma team. It contains both ICD-10-CA codes and injury scores assigned by expert abstractors. We used Cohen's kappa (𝜅) coefficient to compare AIS-2005 Update 2008 scores assigned by expert abstractors to those derived using the algorithm and the intraclass correlation coefficient to compare assigned and derived Injury Severity Scores. Sensitivity and specificity for detection of a severe injury (AIS score, ≥ 3) were then calculated. For the external validation of the algorithm, we used administration data to identify adults who either died in an emergency department or were admitted to hospital in Ontario secondary to a traumatic injury (2009-2017). Logistic regression was used to evaluate the discriminative ability and calibration of the algorithm. RESULTS: Of 41,869 patients in the Ontario Trauma Registry, 41,793 (99.8%) had at least one diagnosis matched to the algorithm. Evaluation of AIS scores assigned by expert abstractors and those derived using the algorithm demonstrated a high degree of agreement in identification of patients with at least one severe injury (𝜅 = 0.75; 95% confidence interval [CI], 0.74-0.76). Likewise, algorithm-derived scores had a strong ability to rule in or out injury with AIS ≥ 3 (specificity, 78.5%; 95% CI, 77.7-79.4; sensitivity, 95.1; 95% CI, 94.8-95.3). There was strong correlation between expert abstractor-assigned and crosswalk-derived Injury Severity Score (intraclass correlation coefficient, 0.80; 95% CI, 0.80-0.81). Among the 130,542 patients identified using administrative data, the algorithm retained its discriminative properties. CONCLUSION: Our ICD-10-CA to AIS-2005 update 2008 algorithm produces reliable estimates of injury severity and retains its discriminative properties with administrative data. Our findings suggest that this algorithm can be used for risk adjustment of injury outcomes when using population-based administrative data. LEVEL OF EVIDENCE: Diagnostic Tests/Criteria; Level II.

Injury outcomes across Canadian trauma systems: a historical cohort study.

PURPOSE: Most North American trauma systems have designated trauma centres (TCs) including level I (ultraspecialized high-volume metropolitan centres), level II (specialized medium-volume urban centres), and/or level III (semirural or rural centres). Trauma system configuration varies across provinces and it is unclear how these differences influence patient distributions and outcomes. We aimed to compare patient case mix, case volumes, and risk-adjusted outcomes of adults with major trauma admitted to designated level I, II, and III TCs across Canadian trauma systems. METHODS: In a national historical cohort study, we extracted data from Canadian provincial trauma registries on major trauma patients treated between 2013 and 2018 in all designated level I, II, or III TCs in British Columbia, Alberta, Quebec, and Nova Scotia; level I and II TCs in New Brunswick; and four TCs in Ontario. We used multilevel generalized linear models to compare mortality and intensive care unit (ICU) admission and competitive risk models for hospital and ICU length of stay (LOS). Ontario could not be included in outcome comparisons because there were no population-based data from this province. RESULTS: The study sample comprised 50,959 patients. Patient distributions in level I and II TCs were similar across provinces but we observed significant differences in case mix and volumes for level III TCs. There was low variation in risk-adjusted mortality and LOS across provinces and TCs but interprovincial and intercentre variation in risk-adjusted ICU admission was high. CONCLUSIONS: Our results suggest that differences in the functional role of TCs according to their designation level across provinces leads to significant variations in the distribution of patients, case volumes, resource use, and clinical outcomes. These results highlight opportunities to improve Canadian trauma care and underline the need for standardized population-based injury data to support national quality improvement efforts.

RéSUMé: OBJECTIF: La plupart des systèmes de traumatologie nord-américains disposent de centres de traumatologie (CT) désignés, y compris de niveau I (centres métropolitains ultraspécialisés à volume élevé), de niveau II (centres urbains spécialisés à volume moyen) et/ou de niveau III (centres semi-ruraux ou ruraux). La configuration des systèmes de traumatologie varie d'une province à l'autre et nous ne savons pas comment ces différences influent sur la répartition de la patientèle et sur les issues. Notre objectif était de comparer le mélange de cas des patient·es, le volume de cas et les issues ajustées en fonction du risque des adultes ayant subi un traumatisme majeur admis·es dans des CT désignés de niveaux I, II et III dans l'ensemble des systèmes de traumatologie canadiens. MéTHODE: Dans une étude de cohorte historique nationale, nous avons extrait des données des registres provinciaux canadiens de traumatologie sur les patient·es ayant subi un traumatisme majeur traité·es entre 2013 et 2018 dans tous les CT désignés de niveau I, II ou III en Colombie-Britannique, en Alberta, au Québec et en Nouvelle-Écosse, les CT de niveau I et II au Nouveau-Brunswick, et dans quatre CT en Ontario. Nous avons utilisé des modèles linéaires généralisés à plusieurs niveaux pour comparer la mortalité, les admissions en unité de soins intensifs (USI) et les modèles de risque compétitif pour la durée du séjour à l'hôpital et à l'USI. L'Ontario n'a pas pu être inclus dans les comparaisons des devenirs parce qu'il n'y avait pas de données démographiques pour cette province. RéSULTATS: L'échantillon de l'étude comptait 50 959 patient·es. La répartition des patient·es dans les CT de niveaux I et II était similaire d'une province à l'autre, mais nous avons observé des différences significatives dans le mélange des cas et les volumes pour les CT de niveau III. Il y avait une faible variation de la mortalité ajustée en fonction du risque et des durées de séjour entre les provinces et les CT, mais la variation interprovinciale et intercentre des admissions à l'USI ajustées en fonction du risque était élevée. CONCLUSION: Nos résultats suggèrent que les différences dans le rôle fonctionnel des CT selon leur niveau de désignation d'une province à l'autre entraînent des variations importantes dans la répartition des patient·es, le nombre de cas, l'utilisation des ressources et les issues cliniques. Ces résultats mettent en évidence les possibilités d'amélioration des soins de traumatologie au Canada et soulignent la nécessité de disposer de données normalisées sur les blessures dans la population pour appuyer les efforts nationaux d'amélioration de la qualité.

An International Survey of Approaches to Chair Restraint of Nonhuman Primates.

Specifically designed restraint chairs are the preferred method of restraint for research studies that require NHP to sit in place for sustained periods of time. In light of increasing emphasis on refinement of restraint to improve animal wellbeing, it is important to have a better understanding of this potentially stressful procedure. Although chair restraint is used internationally, very little published information is available on this subject. We developed a survey to obtain an overview of equipment, procedures, and plans for improvement regarding chair restraint. We received 101 responses from people working in academic, government, contract research, and pharmaceutical laboratories within the Americas, Europe and Asia. Findings indicate that the majority of laboratories using restraint chairs work with macaque species. Restraint chairs are used for a wide range of procedures, including cognitive testing, recording neuronal activity, functional MRI, intravenous infusion, and blood sampling. Approximately 2/3 of laboratories use an enclosed 'box chair,' which the animal is trained to enter and then to extend its head through an opening on the top of the chair; the remaining one third of laboratories use an 'open chair' design, in which manual handling or the pole-and-collar system is used to transfer and secure the animal into the chair. Respondents reported that when selecting the type of chair to use, they considered comfort for the animal, ease of use, and the ability to adjust fit between animals of different sizes. Various training methods and timeframes are used to prepare macaques for restraint chair procedures. Several laboratories are incorporating greater use of positive reinforcement training. The community that uses these restraint procedures needs to work together to define best practice; our survey results can help in that effort.

Positive reinforcement methods to train chimpanzees to cooperate with urine collection.

Positive reinforcement training can be used in many ways to enhance the welfare of captive primates. Training for biologic sample collection is one application of positive reinforcement training. In this study, 35 adult female chimpanzees were trained to cooperate with the collection of urine samples needed to facilitate a research study. A median of 35 training sessions was required for the subjects to reach reliable performance (4 of 5 sequential attempts successful) of the urine collection behavior. Adult age had no effect on the speed of learning as indicated by a rank order correlation. Individual differences in the rate of learning were pronounced but did not vary with the age of the chimpanzees. Approximately 2 y after the initial training, and with continual sample collection taking place twice weekly, we assessed the reliability of their performance and found that the chimpanzees cooperated 100% of the time and that collection of a urine sample required about 5 min. Positive reinforcement training can markedly reduce staff time, particularly for studies such as this that require frequent biologic sample collection over long durations. Similar approaches could be used to train other laboratory primates to cooperate with urine collection procedures. Animal training programs that emphasize positive reinforcement training are an important refinement in the care of laboratory primates.

Participatory health research within a prison setting: a qualitative analysis of 'Paragraphs of passion'.

The purpose of this research was to engage, empower and enhance the health and well-being of incarcerated women. The integration of primary health care, community-based participatory research, a settings approach to health promotion, and transformative action research guided the design of this study. A partnership between incarcerated women who became peer-researchers, correctional staff, and academic researchers facilitated the equitable contribution of expertise and decision-making by all partners. The study was conducted in a short sentence (two years or less), minimum/medium security Canadian women's correctional centre. Of the approximately 200 women that joined the research team, 115 participated in writing a 'paragraph of passion' while incarcerated between November, 2005 and August, 2007. Participatory, inductive qualitative, narrative and content analysis were used to illuminate four themes: expertise, transformation, building self-esteem, as well as access and support. The women organized monthly health forums in the prison to share their new knowledge and life experience with other incarcerated women, correctional staff, academics, and community members, and in doing so have built bridges and relationships, some of which have lasted to the present day.

Refining the pole-and-collar method of restraint: emphasizing the use of positive training techniques with rhesus macaques (Macaca mulatta).

The pole-and-collar method is one of several techniques that enable the safe transfer of a nonhuman primate from its home environment into a restraint chair without the need for sedation. It has been used within the scientific community for decades. Traditional methods to train animals for pole-and-collar use rely primarily on aspects of negative reinforcement, with very little incorporation of positive-reinforcement techniques. With increasing emphasis on animal training and welfare, research facilities are incorporating positive-reinforcement training into husbandry and experimental procedures. Here we demonstrate the feasibility of training rhesus macaques (Macaca mulatta; n = 8) to cooperate for pole-and-collar transfer to a primate restraint chair. By using predominantly positive-reinforcement techniques, with supplemental elements of negative reinforcement, macaques were trained in a mean of 85 training sessions (a mean of 1085 min of training time). We also provide tools for investigators using the pole-and-collar method to help them successfully incorporate positive-reinforcement training into their procedures. This refinement has the potential to improve animal welfare and enhance the value of nonhuman primate models in research.

Positive reinforcement training to enhance the voluntary movement of group-housed sooty mangabeys (Cercocebus atys atys).

Positive reinforcement training (PRT) has successfully been used to train diverse species to execute behaviors helpful in the everyday care and wellbeing of the animals. Because little information is available about training sooty mangabeys (Cercocebus atys atys), we analyzed PRT with a group of 30 adult males as they were trained to shift from 1 side of their enclosure to the other. Over a 4-mo period we conducted 57 training sessions totaling 26.5 h of training and recorded compliance information. During training, compliance increased from 76% of the animals during the first 5 training sessions to 86% of the animals shifting during the last 5 sessions. This result indicated progress but fell short of our goal of 90% compliance. After 25 training sessions, problem-solving techniques were applied to help the consistently noncompliant animals become more proficient. The techniques included reducing social stress by shifting animals so that noncompliant monkeys could shift into an unoccupied space, using more highly preferred foods, and 'jackpot'-sized reinforcement. To determine whether social rank affected training success, animals were categorized into high, medium, and low dominance groups, based on 7 h of behavioral observations. A Kruskal-Wallis test result indicated a significant difference in compliance according to the category of dominance. Although training a group this large proved challenging, the mangabeys cooperated more than 90% of the time during follow-up sessions. The training program improved efficiency in caring for the mangabeys.

Temperament correlates with training success in adult rhesus macaques.

In recent years there has been a marked increase in awareness of issues involving the psychological well-being of nonhuman primates (NHPs) used in biomedical research. As a result, many facilities are starting to train primates to voluntarily cooperate with veterinary, husbandry, and research procedures, such as remaining still for blood draws or injections. Such training generally reduces the stress associated with these procedures, resulting in calmer animals and, ultimately, better research models. However, such training requires great investments in time, and there can be vast individual differences in training success. Some animals learn tasks quickly, while others make slower progress in training. In this study, we examined whether temperament, as measured by response to a novel food object, correlated with the amount of time it took to train 20 adult female rhesus macaques to perform a simple task. The monkeys were categorized as "exploratory" (i.e., inspected a novel object placed in the home cage within 10 sec), "moderate" (i.e., inspected the object within 10-180 sec), or "inhibited" (i.e., did not inspect the object within 3 min). We utilized positive reinforcement techniques to train the monkeys to touch a target (PVC pipe shaped like an elbow) hung on their cage. Temperament correlated with training success in this study (Pearson chi2=7.22, df=2, P=0.03). We easily trained over 75% of the animals that inspected the novel food (i.e., exploratory or moderate individuals) to touch the target. However, only 22% of the inhibited monkeys performed the task. By knowing which animals may not respond to conventional training methods, we may be able to develop alternate training techniques to address their specific needs. In addition, these results will allow us to screen monkeys to be assigned to research projects in which they will be trained, with the goal of obtaining the best candidates for those studies.