Recent trends in television tip over-related injuries among children aged 0-9 years.

OBJECTIVE: To describe recent trends in television tip over-related injuries among children aged 0-9 years, and to compare injury rates with sales of newer digital televisions. METHODS: Digital television sales data were obtained from marketing data provided by the Television Bureau of Advertising. Data regarding television tip over-related injuries among children aged 0-9 years were obtained from the 1998-2007 National Electronic Injury Surveillance System. A Wald chi(2) test, estimated from logistic analysis, was used to determine whether the distribution of injury types differed by age group. Pearson's correlation was used to estimate the association between digital television sales and television tip over-related injuries. RESULTS: An estimated 42 122 (95% CI 35 199 to 49 122) injuries from television tip-overs were treated in US emergency departments from 1998 to 2007. The injury rate was highest for children aged 1-4 years (18.6/100 000). A majority of injuries (63.9%) involved the head and neck for children under 1 year of age, while a higher proportion of injuries among children aged 1-4 involved the hip and lower extremity (42.9% and 31.0%, respectively), and shoulder and upper extremity (16.8%) for children aged 5-9. A strong, positive correlation was observed between television sales and annual injury rates (r = 0.89, p<0.001). CONCLUSION: Estimates of injury rates were similar to previously reported estimates, particularly for the increased proportion of head and neck injuries among very young children. While digital television sales were strongly correlated with increased injury rates, the lack of information regarding the type of television involved prevents inference regarding causation.

Vehicle rollover risk and electronic stability control systems.

BACKGROUND: Electronic stability control (ESC) systems were developed to reduce motor vehicle collisions (MVCs) caused by loss of control. Introduced in Europe in 1995 and in the USA in 1996, ESC is designed to improve vehicle lateral stability by electronically detecting and automatically assisting drivers in unfavorable situations. AIM: To examine the relationship between vehicle rollover risk and presence of ESC using a large national database of MVCs. METHODS: A retrospective cohort study for the period 1995 through 2006 was carried out using data obtained from the National Automotive Sampling System General Estimates System. All passenger cars and sport utility vehicles (SUVs)/vans of model year 1996 and later were eligible. Vehicle ESC (unavailable, optional, standard) was determined on the basis of make, model, and model year. Risk ratios (RRs) and 95% CIs were calculated to compare rollover risk by vehicle ESC group. RESULTS: For all crashes, vehicles equipped with standard ESC had decreased risk of rollover (RR = 0.62, 95% CI 0.50 to 0.77) compared with vehicles with ESC unavailable. The association was consistent for single-vehicle MVCs (RR = 0.61, 95% CI 0.46 to 0.82); passenger cars had decreased rollover risk (RR = 0.77, 95% CI 0.52 to 1.12), but SUVs/vans had a more dramatically decreased risk (RR = 0.40, 95% CI 0.26 to 0.61). CONCLUSIONS: This study supports previous results showing ESC to be effective in reducing the risk of rollover. ESC is more effective in SUVs/vans for rollovers related to single-vehicle MVCs.

Prevalence of transportation safety measures portrayed in primetime US television programs and commercials.

OBJECTIVE: To determine the prevalence of transportation related safety behaviors, such as seatbelt and helmet use, in primetime US television programs and commercials. DESIGN: Cross sectional study. SETTING: Top rated television programs and associated commercials from four major US television networks were reviewed for the prevalence of transportation safety related behaviors during a one month period in 2005. Programs were categorized according to the time and network of airing, program type, program rating, and--for commercials--type of product being advertised SUBJECTS: Occupants of automobiles, motorcycles, or bicycles in 507 instances in which a transportation scene was aired. RESULTS: Seatbelt use was depicted in 62% and 86% of individuals in television program and commercial automobile scenes, respectively. The prevalence of motorcycle helmet use was 47% in television programs and 100% in commercials. Bicycle helmets were used in 9% of television programs and 84% of commercials. The frequency of seatbelt use in programs and commercials varied by television rating and genre but did not differ by network, time of airing, or age of character portrayed. CONCLUSIONS: The prevalence of safety related behaviors aired on major US networks during primetime slots is higher than previous reports but still much lower than national averages. Commercials, in contrast, portray transportation safety measures with a frequency that exceeds that of US television programs or most national surveys.

Risk of injury for occupants of motor vehicle collisions from unbelted occupants.

OBJECTIVE: Unbelted occupants may increase the risk of injury for other occupants in a motor vehicle collision (MVC). This study evaluated the association between occupant restraint use and the risk of injury (including death) to other vehicle occupants. DESIGN: A population based cohort study. SETTING: United States. SUBJECTS: MVC occupants (n = 152 191 unweighted, n = 18 426 684 weighted) seated between a belted or unbelted occupant and the line of the principal direction of force in frontal, lateral, and rear MVCs were sampled from the 1991-2002 National Automotive Sampling System General Estimates System. Offset MVCs were not included in the study. MAIN OUTCOME MEASURE: Risk ratios and 95% confidence intervals for injury (including death) for occupants seated contiguous to unbelted occupants compared to occupants seated contiguous to belted occupants. Risk ratios were adjusted for at risk occupant's sex, age, seating position, vehicle type, collision type, travel speed, crash severity, and at risk occupants' own seat belt use. RESULTS: Exposure to unbelted occupants was associated with a 40% increased risk of any injury. Belted at risk occupants were at a 90% increased risk of injury but unbelted occupants were not at increased risk. Risks were similar for non-incapacitating and capacitating injuries. There was a 4.8-fold increased risk of death for exposed belted occupants but no increased risk of death for unbelted occupants. CONCLUSIONS: Belted occupants are at an increased risk of injury and death in the event of a MVC from unbelted occupants.

Site-specific delivery of acidic fibroblast growth factor stimulates angiogenic and osteogenic responses in vivo.

A major clinical problem in orthopedics is the healing of nonunion fractures. Limitations of this bone repair process include insufficient angiogenesis and mineralization. Integrating appropriate biomaterials with site-specific neovascularization and osteogenesis at the wound site has been the focus of several clinically relevant therapeutic strategies. As an extracellular protein, acidic fibroblast growth factor (FGF-1) induces, coordinates, and sustains site-specific molecular responses associated with angiogenesis and osteogenesis. To establish the ability of this growth factor to coordinate bone regenerative process in vivo, site-specific delivery of FGF-1, entrapped in a fibrin/hydroxyapatite composite, was evaluated. Kinetic analysis in vivo revealed the biocomposite was capable of delivering biologically active FGF-1. Release kinetics revealed an initial delivery of 87.5 ng/h of active FGF-1 in the first 20 h, followed by a reduced delivery of 28 ng/h during the next 20 h. In situ immunohistological analyses demonstrated that FGF-1-containing implants induced increased angiogenesis and infiltration of cells expressing osteogenic related markers (i.e., osteopontin, osteocalcin). Collectively, these efforts support that site-specific delivery of active FGF-1 in a fibrin/hydroxyapatite composite is competent to induce not only angiogenesis but also osteogenic cellular responses.

Vacuum-assisted complex wound closure with elastic vessel loop augmentation: a novel technique.

Patients with serious abdominal or soft-tissue injuries may require multistaged surgical management. The Vacuum-Assisted Closure device, used in combination with a shoelace technique, can promote fascial and soft-tissue approximation.

Fatal occupational electrocutions in the United States.

INTRODUCTION: The highest proportions of fatal occupational electrocutions have occurred among those employed in the electrical trades and in the construction and manufacturing industries. METHODS: Data from 1992 through 1999 were obtained from the Bureau of Labor Statistics Census of Fatal Occupational Injuries. RESULTS: Occupational electrocution deaths occurred almost entirely among males, with the highest rates among those aged 20-34 and among whites and American Indians. They were highest during the summer months, in the South, and in establishments employing 10 or fewer workers. The highest rates occurred in the construction, mining, and agriculture, forestry, and fishing industries and among trades associated with these industries. CONCLUSIONS: Electrocution continues to be a significant cause of occupational death. Workers need to be provided with safety training and employers, particularly smaller employers, persuaded of the need for safety training.

Occupational electrocutions in Jefferson County, Alabama.

Few studies have presented the general epidemiology of electrocution deaths using local medical examiner data. Data were obtained from coroner/medical examiner's files for electrocution deaths occurring between 1981 and 1998. All 27 occupational electrocutions were among men; 92.6% were white and 7.4% were black, with a mean age of 33.1 years. The rates of high- and low-voltage electrocution were similar. Low-voltage deaths showed a seasonal pattern, with the largest numbers in July, August and October. Deaths occurred most frequently among electricians and electrical helpers. The level of detail available from medical examiner records permits more complete evaluation of injury patterns than is possible using death certificate data; however, even more detailed studies, exploring worker activity at the time of injury, education, experience and training, are needed.

A continuum between scapulothoracic dissociation and traumatic forequarter amputation: a review of the literature.

Both traumatic forequarter amputation and scapulothoracic dissociation are rare and life-threatening injuries. We present the case of a 31-year old woman who was ejected from a car after a motor vehicle accident and sustained an apparent partial forequarter amputation. Upon examination her injury was found to share many characteristics with a scapulothoracic dissociation injury. With both injuries mortality is high and prompt diagnosis and treatment imperative. By viewing scapulothoracic dissociation and forequarter amputation as a continuum faster recognition and appropriate treatment may be implemented for these devastating injuries.

Trauma-specific intensive care units can be cost effective and contribute to reduced hospital length of stay.

Our hypothesis was that clinical outcomes are improved and cost and hospital length of stay (LOS) reduced as a result of the opening of a closed trauma intensive care unit (ICU). We conducted a cross-sectional study in a university-affiliated Level I trauma center. Our study population comprised trauma patients admitted to the ICU between June 1, 1996 and July 1, 1998 for at least 24 hours and with an Injury Severity Score (ISS) >16 (excluding those with severe brain injury). The main outcome measures were changes in LOS and number of ventilator days, prevalence of complications, changes in patient charges, and hospital costs. Two hundred four patients were included [trauma ICU (TICU) 60, surgical ICU 144]. The two groups were not statistically different in age, ISS, mechanism of injury, infection rate, and mortality; however, the TICU patients had a lower number of ventilator hours (83.1 vs 100.0; P = 0.007), lower ICU LOS (9.4 vs 12.1 days; P = 0.06), and lower total hospital LOS (15.6 vs 22.3 days; P = 0.01). Although this was not of statistical significance TICU patients had lower hospital charges ($125,383 vs $152,994; P = 0.06) and lower cost per case ($42,306 vs $47,548; P = 0.35) for a net savings of $314,520 during the first 6 months of operation of the TICU. This study suggests that improved clinical outcomes and decreases in cost and LOS are directly related to the opening of a closed trauma ICU.

Hypothermia deaths in Jefferson County, Alabama.

INTRODUCTION: Some reported characteristics associated with hypothermia mortality include older age, alcohol consumption, male sex, and black race. The purpose of this paper is to present the epidemiology of hypothermia deaths in Jefferson County, Alabama. METHODS: Autopsy reports maintained by the county coroner's office were abstracted for all cases with primary or underlying causes of death listed as "hypothermia" or "exposure to cold" between January 1983 and July 1999. RESULTS: Sixty three hypothermia deaths occurred in Jefferson County during the study period. The mean age among cases was 68 years, 63.9% were male and 70% were of black race. Rates of hypothermia death were highest among black males, followed by black females, particularly blacks aged 80 years or older. Deaths occurring indoors were more common among older persons and outdoor deaths more common among younger persons. Thirty per cent of decedents tested positive for alcohol, 75% of whom were found outdoors. Nine decedents tested positive for drugs or medications. Approximately 90% of decedents were identified as having one or more chronic medical conditions. Excluding alcoholics, 52% of decedents had one or more chronic medical conditions. CONCLUSIONS: Hypothermia in Jefferson County, Alabama is a cause of death primarily affecting two distinct groups of individuals, elderly persons who develop hypothermia inside a dwelling and middle aged males who develop hypothermia out of doors and have consumed alcohol.

Recurrent trauma in elderly patients.

HYPOTHESIS: Older patients (those aged > or = 70 years) who have experienced trauma have an increased risk of recurrent trauma. Demographic, medical, and functional factors are potential contributors to the risk of subsequent trauma among injured elderly patients. DESIGN: Retrospective follow-up study. PARTICIPANTS: Study participants were derived from the Longitudinal Study of Aging, an extension of the 1984 National Health Interview Survey focusing on persons who were aged 70 years and older in 1984. A cohort of elderly patients participating in the Longitudinal Study of Aging and hospitalized for injury in 1985 (n = 100) was identified using Medicare hospital discharge data. An uninjured cohort (n = 401) was also identified from the Longitudinal Study of Aging and matched for age (1 year) and sex. MAIN OUTCOME MEASURES: Risk of admission for trauma among the injured cohort compared with the uninjured cohort and associations between demographic, medical, and functional characteristics and trauma recurrence. RESULTS: Following adjustment for potential confounding factors, the injured cohort was 3.25 times more likely (95% confidence interval, 1.99-5.31) to be hospitalized for injury during the follow-up period compared with the uninjured cohort. Among the injured cohort, those at greatest risk of subsequent trauma included women and those with chronic medical conditions or functional impairments, the latter being the only factor independently associated with recurrence. CONCLUSIONS: Elderly patients who have experienced trauma are at increased risk of subsequent injury. Interventions to reduce the likelihood of trauma recurrence should focus on those with chronic illnesses and functional impairments.

The association between body habitus, restraint use, and fatality in motor vehicle collisions.

UNLABELLED: The purpose of this study was to determine if there is an association between body habitus, restraint use, and risk of death in motor vehicle collisions (MVC). METHODS: The 1995-1999 National Automotive Sampling System Crashworthiness Data System was utilized. RESULTS: Body habitus, when described by height and weight, is associated with fatality rates in restrained drivers. Body mass index as a descriptor of body habitus was not associated with fatality rates. CONCLUSIONS: The 50th percentile male Hybrid III Crash Dummy plays a major role in vehicular cabin interior design and crash testing. For drivers with a dissimilar body habitus, the vehicle cabin/body fit changes and the safety features perform differently which may account for these observations.

Reduction of vancomycin-resistant enterococcal infections by limitation of broad-spectrum cephalosporin use in a trauma and burn intensive care unit.

Both vancomycin and third-generation cephalosporin use are believed to contribute to a rise in vancomycin-resistant enterococci (VRE) infections. In 1998, the largest number of VRE infections in our hospital occurred in the trauma/burn intensive care unit (TBICU), accounting for nearly 20% of hospital infections. In an attempt to control the VRE infection rate, antibiotic protocols for prophylaxis, empiric, and definitive therapy were initiated during the final quarter of 1998 to minimize cephalosporin use by the introduction of piperacillin/tazobactam. Therefore, we undertook a study of the VRE infection rate for the TBICU in relation to vancomycin, piperacillin/tazobactam, piperacillin, third-generation cephalosporin, and total cephalosporin use before and after efforts to limit cephalosporins. These data were compared to those in the medical and surgical intensive care units. During 1998, seven VRE infections occurred in the TBICU. Following initiation of antibiotic protocols, one case of VRE infection occurred in the subsequent month and no cases in the 17 months since. The decrease in the VRE infection rate corresponded with a significant increase in the use of piperacillin/tazobactam and a reduction in third-generation and total cephalosporin use. In contrast, cephalosporin use in the medical and surgical intensive care units remains significantly higher than in the TBICU, and neither unit has had a reduction in their VRE infection rates.

Long-term survival in the elderly after trauma.

BACKGROUND: In the elderly, trauma has been associated with increased, long-term, all-cause mortality. Functional limitations secondary to injury may be responsible for the reduced survival rate. The objective of this study was to test this hypothesis using data from the Longitudinal Study of Aging (LSOA). METHODS: The LSOA is an extension of the 1984 National Health Interview Survey, which focused on 7,527 persons who were 70 years and older in 1984. Using data from the LSOA, a cohort of elderly patients hospitalized for injury in 1985 (N = 102) was identified from Medicare hospital discharge data. An uninjured cohort (N = 408) was also identified using the LSOA and matched by age (within 1 year) and sex. Deaths in both cohorts were identified using the National Death Index. Hazard ratios (HRs) for mortality within 6 years subsequent to injury, adjusted for demographic, health status, and functional characteristics, were calculated. RESULTS: The injured cohort had a significantly reduced rate of survival compared with the uninjured cohort (HR = 1.5; 95% confidence interval [CI] 1.1-2.2), and this relationship persisted after adjusting for demographic and health characteristics (HR = 1.4; 95% CI 1.0-2.0). After additional adjustment for measures of functional decline, the association diminished (HR = 1.2; 95% CI 0.8-1.7). Functional decline remained a strong, independent factor for the risk of mortality. CONCLUSION: Trauma in the elderly has both an acute and long-term influence on mortality; the latter seems to be mediated through a decline in function resulting from the injury. This study suggests that strategies to return the elderly patient to preinjury functional status are of paramount importance. Future research should explore the impact of these interventions on long-term survival.

The April 8, 1998 tornado: assessment of the trauma system response and the resulting injuries.

BACKGROUND: On April 8, 1998, an F5 tornado touched down in two counties of Alabama producing a wide path of destruction. The presence of a regional trauma system in this area presents an opportunity to evaluate the effectiveness of the system in responding to the victims of this natural disaster. METHODS: Emergency room logs and the regional trauma system database were searched for all patients treated for injuries sustained from the tornado, and medical records were reviewed for demographic information, mode of transportation to hospital, injuries, treatment, and outcome. Fatalities were identified by means of the coroner's office. RESULTS: A total of 224 patients were evaluated at nine area hospitals, of whom 63 (28%) required admission. There were 32 deaths: 30 persons were dead at the scene, and 2 patients subsequently died at Level I trauma centers. Among patients with nonfatal injuries, 39% were managed at Level I facilities, 46% at Level III facilities, and 15% at nontrauma facilities. Forty patients (55%) seen at Level I facilities required admission compared with 15 patients (17%) at Level III facilities and 8 patients (29%) at nontrauma facilities; Level I facilities also had the highest Injury Severity Score. Of patients requiring admission, 83% were transported by emergency medical services; these patients also had the highest Injury Severity Score. CONCLUSION: The regional trauma system facilitated appropriate and efficient triage to system hospitals, routing the most severely injured patients to the Level I centers without overwhelming them with the more numerous, less severely injured patients.

CT cystography: radiographic and clinical predictors of bladder rupture.

OBJECTIVE: Our goal was to identify radiographic and clinical variables that correlate with bladder rupture that may then be used as selection criteria for CT cystography in trauma patients. SUBJECTS AND METHODS: Hemodynamically stable trauma patients with hematuria were examined under standardized protocol with dynamic oral and i.v. contrast-enhanced CT of the abdomen and pelvis, followed immediately by CT cystography. CT cystography consisted of contiguous 5-mm axial scans of the pelvis after retrograde distention of bladder with 300-400 ml of 4% iodinated contrast material. Radiographic and clinical variables (pelvic fracture, pelvic fluid, intraabdominal visceral injury, degree of hematuria, hematocrit, units of blood transfused, base deficit, injury mechanism, seat belt use, sex, age) were assessed and statistically analyzed using the two-tailed Fisher's exact test and Wilcoxon's rank sum test. Positive and negative individual and multivariate predictors were analyzed. RESULTS: Of the 157 patients entered in our study, 12 (eight males and four females) had bladder rupture. One or more pelvic fractures were present in nine (75%) of the 12 patients (p < 0.001). Pubic symphysis diastasis, sacroiliac diastasis, and sacral, iliac, and pubic rami fractures were statistically associated with bladder rupture. Isolated acetabular fractures did not correlate with rupture. Eight (67%) of the 12 patients with bladder rupture revealed on CT cystography had gross hematuria (p < 0.001). No ruptures were seen in patients with <25 RBC/HPF (red blood cells per high-power field). All patients with rupture had pelvic fluid revealed on standard contrast-enhanced CT (p < 0.001). CONCLUSION: Gross hematuria, pelvic fluid, and specific pelvic fractures were highly correlated with bladder rupture; identification of these findings may help in selection of trauma patients for CT cystography.

Prognostic factors in patients with inferior vena cava injuries.

Inferior vena cava (IVC) injuries are potentially devastating insults that continue to be associated with high mortality despite advances in prehospital and in-hospital critical care. Between 1987 and 1996, 37 patients (32 males and 5 females; average age, 30 years) were identified from the trauma registry as having sustained IVC trauma. Overall mortality was 51 per cent (n = 19), with 13 intraoperative deaths and five patients dying within the first 48 hours. Blunt IVC injuries (n = 8) had a higher associated mortality than penetrating wounds (63% versus 48%). Of the 29 patients with penetrating IVC trauma, the wounding agent influenced mortality (shotgun-100% versus gunshot-43% versus stab-0%). Anatomical location of injury was also predictive of death [suprahepatic (n = 3)-100% versus retrohepatic (n = 9)-78% versus suprarenal (n = 6)-33% versus juxtarenal (n = 2)-50% versus infrarenal (n = 15)-33%]. A direct relationship existed between outcome and the number of associated injuries: nonsurvivors averaged four and survivors averaged three. Eighty per cent of patients sustaining four or more associated injuries died, by contrast to a 33 per cent mortality in those suffering less than four injuries. Physiological factors were also predictive of outcome. Patients in shock (systolic blood pressure < 80) on arrival had a higher mortality than those who were hemodynamically stable (76% versus 30%). Preoperative lactate levels were of prognostic value for death (> or = 4.0-59% versus < 4.0-0%), as was base deficit (< 4-22%, > or = 4, and < 10-36%, > or = 10-73%). Interestingly, neither time from injury to hospital arrival (47.4 minutes versus 33.0 minutes) nor time in the emergency department before surgery (45.6 minutes versus 42.6 minutes) differed between survivors and fatalities. Mortality remained high in the 34 patients who had operative control of their IVC injuries [lateral repair (n = 27)-44% versus ligation (n = 6)-66% versus Gortex graft (n = 1)-0%]. As wounding agent, anatomical location, associated injuries, and physiological status seem to most directly impact mortality, future efforts must focus both on establishing prevention programs directed at reducing the incidence of this injury, as well as on advancing the management of those who do survive to hospitalization, if we are to improve on the outcome of these devastating injuries.

Combined blunt cardiac and pericardial rupture: review of the literature and report of a new diagnostic algorithm.

The spectrum of blunt cardiac injury varies from the asymptomatic cardiac concussion to the immediately fatal cardiac rupture. Although the majority of victims sustaining blunt cardiac rupture die before receiving medical attention, some survive to evaluation. The diagnosis of cardiac rupture, if established, typically results from the signs and symptoms of pericardial tamponade. However, some patients may have remarkably few signs and symptoms suggestive of cardiac injury and represent a significant diagnostic challenge. We provide two cases of cardiac rupture in which the diagnosis was delayed by the presence of an associated pericardial tear with decompression into the mediastinum and pleural space. In neither of the cases did existing institutional algorithms for blunt cardiac injury assist in establishing the diagnosis before the acute demise of the patient. The presence of a coexisting pericardial injury in these patients with blunt cardiac rupture obscured the diagnosis, leading to the deaths of these patients. A discussion of these two cases and review of the literature is provided with recommendations for diagnostic algorithms in patients sustaining blunt thoracic trauma with possible cardiac and pericardial injury.