Cognitive remediation in residential substance use treatment: A randomized stepped-wedge trial.

ABSTRACTExecutive dysfunction is common in individuals with substance use disorder (SUD) and presents a barrier to treatment engagement. The study aimed to investigate the effectiveness of cognitive remediation (CR) for improving executive functioning and treatment retention in patients with SUD, using a stepped-wedge cluster randomized controlled trial. The sample included 527 adults enrolled across ten residential SUD treatment providers in NSW, Australia. The intervention consisted of 12 hours of CR delivered over six weeks in a group format. The comparator was treatment-as-usual (TAU). Primary outcomes included self-reported executive functioning and proportion of treatment completed (PoTC), measured as the number of days in treatment divided by the planned treatment duration. Intention-to-treat analysis did not find significant differences for self-reported executive functioning (mean difference = -2.49, 95%CI [-5.07, 0.09], p = .059) or PoTC (adjusted mean ratio = 1.09, 95%CI [0.88, 1.36], p = .442). Due to high dropout from the intention-to-treat sample (56%) a post-hoc analysis was conducted using a per-protocol approach, in which CR was associated with improved self-reported executive functioning (mean difference = -3.33, 95%CI [-6.10, -0.57], p = .019) and improved likelihood of treatment graduation (adjusted odds ratio = 2.43, 95%CI [1.43, 4.11], p < .001). More research is required to develop a CR approach that results in service-wide treatment effectiveness.

Prehospital times and outcomes of patients transported using an ambulance trauma transport protocol: A data linkage analysis from New South Wales Australia.

INTRODUCTION: Prehospital trauma systems are designed to ensure optimal survival from critical injuries by triaging and transporting such patients to the most appropriate hospital in a timely manner. OBJECTIVES: We sought to evaluate whether prehospital time and location (metropolitan versus non-metropolitan) were associated with 30-day mortality in a cohort of patients transported by road ambulance using a trauma transport protocol. METHODS: Data linkage analysis of routinely collected ambulance and hospital data across all public hospitals in New South Wales (NSW). The data linkage cohort included adult patients (age ≥ 16years) transported by NSW Ambulance, where a T1 Major Trauma Transport Protocol was documented by paramedic crews and transported by road to a public hospital emergency department in NSW for two years between January 2019 and December 2020. The outcomes of interest were prehospital times (response time, scene time and transport time) and 30-day mortality due to injury. RESULTS: 9012 cases were identified who were transported to an emergency department with T1 protocol indication. Median prehospital transport times were longer in non-metropolitan road transports [n = 3,071, 98 min (71-126)] compared to metropolitan transports [n = 5,941, 65 min (53-80), p < 0.001]. There was no significant difference in 30-day mortality between the two groups (1.24% vs 1.65%, p = 0.13). In the subgroup of patients with abnormal vital signs, the only predictors of mortality were increasing age, presence of severe injury (OR 24.87, 95%CI 11.02, 56.15, p < 0.001), and arrival at a non-trauma facility (OR 3.01, 95%CI 1.26, 7.20, p < 0.05). Increasing transport times were not found to increase the odds of 30-day mortality. DISCUSSION: In the context of an inclusive trauma system and an established prehospital major trauma protocol, increasing prehospital transport times and scene location were not associated with increased mortality.

Evaluation of the New South Wales ambulance T1 major trauma transport protocol: A state-wide data linkage study.

INTRODUCTION: Prehospital triage and transport protocols are critical components of the trauma systems. Still, there have been limited studies evaluating the performance of trauma protocols in New South Wales, such as the NSW ambulance major Trauma transport protocol (T1). OBJECTIVES: Determine the performance of a major trauma transport protocol in a cohort of ambulance road transports METHODS: A data-linkage study using routine ambulance and hospital datasets across New South Wales Australia. Adult patients (age > 16 years) where any trauma protocol was indicated by paramedic crews and transported to any emergency department in the state were included. Major injury outcome was defined as an Injury Severity Score >8 based on coded in-patient diagnoses, or admission to intensive care unit or death within 30 days due to injury. Multivariable logistic regression was used to determine ambulance predictors of major injury outcome. RESULTS: There were 168,452 linked ambulance transports analysed. Of the 9,012 T1 protocol activations, 2,443 cases had major injury [positive predictive value (PPV) = 27.1%]. There were 16,823 major injuries in total giving a sensitivity of the T1 protocol of 2,443/16,823 (14.5%), specificity of 145,060/151,629 (95.7%) and a negative predictive value (NPV) of 145,060/159,440 (91%). Overtriage rate associated with T1 protocol was 5,697/9,012 (63.2%) and undertriage rate was 5,509/159,440 (3.5%). The most important predictor of major injury was the activation of more than one trauma protocol by ambulance paramedics. DISCUSSION: Overall, the T1 was associated with low undertriage and high specificity. The protocol may be improved by considering age and the number of trauma protocols activated by paramedics for any given patient.

Incidence of multiple organ failure in adult polytrauma patients: A systematic review and meta-analysis.

BACKGROUND: Postinjury multiple organ failure (MOF) is the leading cause of late death in trauma patients. Although MOF was first described 50 years ago, its definition, epidemiology, and change in incidence over time are poorly understood. We aimed to describe the incidence of MOF in the context of different MOF definitions, study inclusion criteria, and its change over time. METHODS: Cochrane Library, EMBASE, MEDLINE, PubMed, and Web of Science databases were searched for articles published between 1977 and 2022 in English and German. Random-effects meta-analysis was performed when applicable. RESULTS: The search returned 11,440 results, of which 842 full-text articles were screened. Multiple organ failure incidence was reported in 284 studies that used 11 unique inclusion criteria and 40 MOF definitions. One hundred six studies published from 1992 to 2022 were included. Weighted MOF incidence by publication year fluctuated from 11% to 56% without significant decrease over time. Multiple organ failure was defined using four scoring systems (Denver, Goris, Marshall, Sequential Organ Failure Assessment [SOFA]) and 10 different cutoff values. Overall, 351,942 trauma patients were included, of whom 82,971 (24%) developed MOF. The weighted incidences of MOF from meta-analysis of 30 eligible studies were as follows: 14.7% (95% confidence interval [CI], 12.1-17.2%) in Denver score >3, 12.7% (95% CI, 9.3-16.1%) in Denver score >3 with blunt injuries only, 28.6% (95% CI, 12-45.1%) in Denver score >8, 25.6% (95% CI, 10.4-40.7%) in Goris score >4, 29.9% (95% CI, 14.9-45%) in Marshall score >5, 20.3% (95% CI, 9.4-31.2%) in Marshall score >5 with blunt injuries only, 38.6% (95% CI, 33-44.3%) in SOFA score >3, 55.1% (95% CI, 49.7-60.5%) in SOFA score >3 with blunt injuries only, and 34.8% (95% CI, 28.7-40.8%) in SOFA score >5. CONCLUSION: The incidence of postinjury MOF varies largely because of lack of a consensus definition and study population. Until an international consensus is reached, further research will be hindered. LEVEL OF EVIDENCE: Systematic Review and Meta-analysis; Level III.

Falls from ladders in New South Wales: A data-linkage study.

INTRODUCTION: Fall from ladders is increasingly identified as a significant cause of injury and mortality, yet large-scale research into ladder fall outcomes and trends is limited. OBJECTIVES: To explore the nature and severity of injuries resulting from ladder falls and to determine predictors of Injury Severity Score (ISS) and 6-month mortality. METHODS: Data were obtained from the New South Wales (NSW) Trauma Registry, Admitted Patient Data Collection and Registry of Births, Deaths, and Marriages on patients aged 15 and over who had major trauma from a ladder fall and were admitted to hospital between January 1st, 2012, and July 31st, 2019. Data linkage and descriptive statistics were carried out alongside bivariate and multivariable regression analysis. RESULTS: 963 patients injured after ladder falls were identified. The mean age was 61.9 years (SD 14.2), 91.0% were male, and 489 (50.8%) were born in Australia. The height of fall was between one and five meters in 827 (86.2%) patients, and the place of fall was home and residential places in 27.5%. The most common body areas injured were the head (26.5%), spine (21.2%) and thorax (20.6%), and the median injury severity score was 17. The median length of stay of patients' in-hospital and intensive care unit was six days and two days, respectively. Six months post-discharge mortality was 6.4%. The unadjusted association between the presence of comorbidities or socio-economic class and ISS or mortality was not statistically significant. Increasing ISS was found to be associated with increasing age (Estimate (Est), 15.2; 95% Confidence Interval (CI), 12.3-18.1) and a fall height greater than five metres (Est, 5.8; CI, 3.2-8.4). Mortality was found to be associated with increasing age (Odds ratio (OR), 1.06; CI, 1.03-1.08) and increasing ISS (OR, 1.19; CI, 1.15-1.24). CONCLUSION: People presenting to the hospital after falling from a ladder were predominately male, aged over 60 and had fallen in a residential setting. Increasing age and fall height are associated with more severe injuries.

Review article: Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation in the emergency department: A systematic review.

The use of cricoid pressure (CP) to prevent aspiration during rapid sequence induction (RSI) has become controversial, although CP is considered central to the practice of RSI. There is insufficient research to support its efficacy in reducing aspiration, and emerging concerns it reduces the first-pass success (FPS) of intubation. This systematic review aims to assess the safety and efficacy of CP during RSI in EDs by investigating its effect on FPS and the incidence of complications, including gastric regurgitation and aspiration. A systematic review of four databases was performed for all primary research investigating CP during RSI in EDs. The primary outcome was FPS; secondary outcomes included complications such as gastric regurgitation, aspiration, hypoxia, hypotension and oesophageal intubation. After screening 4208 citations, three studies were included: one randomised controlled trial (n = 54) investigating the incidence of aspiration during the application of CP and two registry studies (n = 3710) comparing the rate of FPS of RSI with and without CP. The results of these individual studies are not sufficient to draw concrete conclusions but do suggest that aspiration occurs regardless of the application of CP, and that FPS is not reduced by the application of CP. There is insufficient evidence to conclude whether applying CP during RSI in EDs affects the rate of FPS or the incidence of complications such as aspiration. Further research in the ED, including introducing CP usage into other existing airway registries, is needed.

Prehospital activation of a coordinated multidisciplinary hospital response in preparation for patients with severe hemorrhage: A statewide data linkage study of the New South Wales "Code Crimson" pathway.

BACKGROUND: Hemorrhage is a leading cause of preventable death in trauma. Prehospital medical teams can streamline access to massive transfusion and definitive hemorrhage control by alerting in-hospital trauma teams of suspected life-threatening bleeding in unstable patients. This study reports the initial experience of an Australian "Code Crimson" (CC) pathway facilitating early multidisciplinary care for these patients. METHODS: This data-linkage study combined prehospital databases with a trauma registry of patients with an Injury Severity Score greater than 12 between 2017 and 2019. Four groups were created; prehospital CC activation with and without in-hospital links and patients with inpatient treatment consistent with CC, without one being activated. Diagnostic accuracy was estimated using capture-recapture methodology to replace the missing cell (no prehospital CC and Injury Severity Score < 12). RESULTS: Of 72 prehospital CC patients, 50 were linked with hospital data. Of 154 potentially missed patients, 42 had a prehospital link. Most CC patients were young men who sustained blunt trauma and required more prehospital interventions than non-CC patients. Code Crimson patients had more multisystem trauma, especially complex thoracic injuries (80%), while missed CC patients more frequently had single organ injuries (59%). Code Crimson patients required fewer hemorrhage control procedures (60% vs. 86%). Lower mortality was observed in CC patients despite greater hospital and intensive care unit length of stay. Despite a low sensitivity (0.49; 95% confidence interval [CI], 0.38-0.61) and good specificity (0.92; 95% CI, 0.86-0.96), the positive likelihood ratio was acceptable (6.42; 95% CI, 3.30-12.48). CONCLUSION: The initiation of a statewide CC process was highly specific for the need for hemorrhage control intervention in hospital, but further work is required to improve the sensitivity of prehospital activation. Patients who had a CC activation sustained more multisystem trauma but had lower mortality than those who did not. These results guide measures to improve this pathway. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Predictors of mortality in older patients with isolated severe head injury: a data linkage study from New South Wales, Australia.

Objective This study aimed to identify factors associated with 90-day mortality in older patients with a severe head injury. Methods A data linkage study was performed with the New South Wales Trauma Registry, Admitted Patient Data Collection and Registry of Births Deaths and Marriages to identify patients aged ≥75 years with isolated severe head injury presenting to trauma hospitals between 2012 and 2016. The primary outcome was all-cause mortality at 90 days. Results In all, 2045 patients were included in the analysis. The mean (±s.d.) age was 84.5 ± 5.6 years. Falls accounted for 93.7% of this cohort. In-hospital mortality was 28.2% and 90-day mortality was 60.7%. Clinical variables associated with increased 90-day mortality were a Glasgow Coma Scale (GCS) score P = 0.03) and systolic blood pressure ≥180 mmHg on arrival (aOR 1.39; 95%CI 1.05-1.83; P = 0.02). The most important predictor of 90-day mortality was the presence of severe intracranial injury based on computed tomography (CT) imaging. Increasing age and comorbidities were not associated with increased mortality in this cohort. Conclusions A GCS score What is known about the topic? Older adults with severe injury generally have higher mortality, worse functional outcomes and a greater need for prolonged rehabilitation than younger people. What does this paper add? Reduced GCS score, severe hypertension on arrival and severe intracranial injury on CT were predictive of mortality after isolated severe head injury in patients aged ≥75 years. There was no association between increasing age or comorbidities and mortality in this cohort. What are the implications for practitioners? CT scan results and initial observations should play a role in discussions around prognosis and appropriateness of care in older patients with isolated severe head injury.

Determinants of long-term unplanned readmission and mortality following self-inflicted and non-self-inflicted major injury: a retrospective cohort study.

PURPOSE: To describe the characteristics of major injury and identify determinants of long-term unplanned readmission and mortality after self-inflicted and non-self-inflicted injury to inform potential readmission screening. METHOD: A retrospective cohort study of 11,269 individuals aged ≥ 15 years hospitalised for a major injury during 2013-2017 in New South Wales, Australia. Unplanned readmission and mortality up to 27-month post-injury were examined. Logistic regression was used to examine predictors of unplanned readmission. RESULTS: During the 27-month follow-up, 2700 (24.8%) individuals with non-self-inflicted and 98 (26.1%) with self-inflicted injuries had an unplanned readmission. Individuals with an anxiety-related disorder and a non-self-inflicted injury who were discharged home were three times more likely (OR: 3.27; 95%CI 2.28-4.69) or if they were discharged to a psychiatric facility were four times more likely (OR: 4.11; 95%CI 1.07-15.80) to be readmitted. Compared to individuals aged 15-24 years, individuals aged ≥ 65 years were 3 times more likely to be readmitted (OR 3.12; 95%CI 2.62-3.70). Individuals with one (OR 1.60; 95%CI 1.39-1.84) or ≥ 2 (OR 1.88; 95%CI 1.52-2.32) comorbidities, or who had a drug-related dependence (OR 1.88; 95%CI 1.52-2.31) were more likely to be readmitted. The post-discharge age-adjusted mortality rate following a self-inflicted injury (35.6%; 95%CI 29.9-41.8) was higher than for individuals with a non-self-inflicted injury (11.0%; 95%CI 10.4-11.8). CONCLUSIONS: Unplanned readmission after injury is associated with injury intent, age, and comorbid health. Screening for anxiety and drug-related dependence after major injury, accompanied by service referrals and post-discharge follow-up, has potential to prevent readmission.

Description and prediction of outcome of drowning patients in New South Wales, Australia: protocol for a data linkage study.

INTRODUCTION: Despite being a preventable cause of death, drowning is a global public health threat. Australia records an average of 288 unintentional drowning deaths per year; an estimated annual economic burden of $1.24 billion AUD ($2017). On average, a further 712 hospitalisations occur due to non-fatal drowning annually. The Australian state of New South Wales (NSW) is the most populous and accounts for 34% of the average fatal drowning burden. This study aims to explore the demographics and outcome of patients who are admitted to hospitals for drowning in NSW and also investigates prediction of patients' outcome based on accessible data. METHODS AND ANALYSIS: This protocol describes a retrospective, cross-sectional data linkage study across secondary data sources for any person (adult or paediatric) who was transferred by NSW Ambulance services and/or admitted to a NSW hospital for fatal or non-fatal drowning between 1/1/2010 and 31/12/2019. The NSW Admitted Patient Data Collection will provide data on admitted patients' characteristics and provided care in NSW hospitals. In order to map patients' pathways of care, data will be linked with NSW Ambulance Data Collection and the NSW Emergency Department Data Collection. Finally patient's mortality will be assessed via linkage with NSW Mortality data, which is made up of the NSW Register of Births, Deaths and Marriages and a Cause of Death Unit Record File. Regression analyses will be used to identify predicting values of independent variables with study outcomes. ETHICS AND DISSEMINATION: This study has been approved by the NSW Population & Health Services Research Ethics Committee. Results will be disseminated through peer-reviewed publications, mass media releases and at academic conferences. The study will provide outcome data for drowning patients across NSW and study results will provide data to deliver evidence-informed recommendations for improving patient care, including updating relevant guidelines.

Correlating injury severity scores and major trauma volume using a state-wide in-patient administrative dataset linked to trauma registry data-A retrospective analysis from New South Wales Australia.

INTRODUCTION: Trauma registries are used to analyse and report activity and benchmark quality of care at designated facilities within a trauma system. These capabilities may be enhanced with the incorporation of administrative and electronic medical record datasets, but are currently limited by the use of different injury coding systems between trauma and administrative datasets. OBJECTIVES: Use an Abbreviated Injury Scale to International Classification of Disease (AIS-ICD) mapping tool to correlate estimated injury severity scores and major trauma volume based on administrative data collections with trauma registry data. METHODS: Adult trauma cases were identified from the New South Wales Trauma Registry between 2012 and 2016 and linked probabilistically using age, facility and date of facility arrival to the Admitted Patient Data Collection (APDC). Estimated Injury Severity Scores (ISS) were derived using the AIS-ICD mapping tool applied to diagnoses contained in the APDC. RESULTS: A total of eligible 13,439 cases were analysed. The overall correlation between trauma registry ISS and ISS estimated from APDC using the AIS-ICD mapping tool was low to moderate (Spearman Rho 0.41 95%CI 0.40, 0.43). Based on an estimated ISS cut-off value of 8, there was high correlation between estimated trauma volume and the number of major trauma cases at each facility (Spearman Rho 0.98, 95%CI 0.95, 0.99). Trauma Revised Injury Severity Score (TRISS) was associated with only slightly higher mortality prediction performance compared to estimated ISS (AUROC 0.76 95%CI 0.75, 0.78 versus AUROC 0.74 95%CI 0.73, 0.76). CONCLUSION: A low to moderate correlation exists between individual patient ISS scores based on AIS to ICD mapping of in-patient data collection, but a high correlation for overall major trauma volume using the AIS-ICD mapping at facility level with comparable TRISS mortality prediction.

A stepped wedge cluster randomised trial of a cognitive remediation intervention in alcohol and other drug (AOD) residential treatment services.

BACKGROUND: Executive functioning impairment is common in substance use disorder and is a major risk factor for poor treatment outcomes, including treatment drop-out and relapse. Cognitive remediation interventions seek to improve executive functioning and offer a promising approach to increase the efficacy of alcohol and other drug (AOD) treatments and improve long-term therapeutic outcomes. This protocol describes a study funded by the NSW Agency for Clinical Innovation that assesses the effectiveness of delivering a six-week group-based intervention of cognitive remediation in an ecologically valid sample of people attending residential AOD treatment services. We primarily aim to investigate whether cognitive remediation will be effective in improving executive functioning and treatment retention rates. We will also evaluate if cognitive remediation may reduce long-term AOD use and rates of health service utilisation, as well as improve personal goal attainment, quality of life, and client satisfaction with treatment. In addition, the study will involve an economic analysis of the cost of delivering cognitive remediation. METHODS/DESIGN: The study uses a stepped wedge cluster randomised design, where randomisation will occur at the cluster level. Participants will be recruited from ten residential AOD treatment services provided by the non-government sector. The intervention will be delivered in 12 one-hour group-based sessions over a period of six weeks. All participants who are expected to receive treatment for the duration of the six-week intervention will be asked to participate in the study. The clusters of participants who are randomly assigned to the treatment condition will complete cognitive remediation in addition to treatment as usual (TAU). Primary and secondary outcome assessments will be conducted at pre-cognitive remediation/TAU phase, post-cognitive remediation/TAU phase, two-month follow-up, four-month follow-up, six-month follow-up, and eight-month follow-up intervals. DISCUSSION: This study will provide comprehensive data on the effect of delivering a cognitive remediation intervention within residential AOD treatment services. If shown to be effective, cognitive remediation may be incorporated as an adjunctive intervention in current treatment programs. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Register (ANZCTR): ACTRN12618001190291 . Prospectively registered 17th July 2018.

External benchmarking of trauma services in New South Wales: Risk-adjusted mortality after moderate to severe injury from 2012 to 2016.

BACKGROUND: Trauma centres and systems have been associated with improved morbidity and mortality after injury. However, variability in outcomes across centres within a given system have been demonstrated. Performance improvement initiatives, that utilize external benchmarking as the backbone, have demonstrated system-wide improvements in outcomes. This data driven approach has been lacking in Australia to date. Recent improvement in local data quality may provide the opportunity to engage in data driven performance improvement. Our objective was to generate risk-adjusted outcomes for the purpose of external benchmarking of trauma services in New South Wales (NSW) based on existing data standards. METHODS: Retrospective cohort study of the NSW Trauma Registry. We included adults (>16 years), with an Injury Severity Score >12, that received definitive care at either Major Trauma Services (MTS) or Regional Trauma Services (RTS) between 2012-2016. Hierarchical logistic regression models were then used to generate risk-adjusted outcomes. Our outcome measure was in-hospital death. Demographics, vital signs, transfer status, survival risk ratios, and injury characteristics were included as fixed-effects. Median odds ratios (MOR) and centre-specific odds ratios with 95% confidence intervals were generated. Centre-level variables were explored as sources of variability in outcomes. RESULTS: 14,452 patients received definitive care at one of seven MTS (n = 12,547) or ten RTS (n = 1905). Unadjusted mortality was lower at MTS (9.4%) compared to RTS (11.2%). After adjusting for case-mix, the MOR was 1.33, suggesting that the odds of death was 1.33-fold greater if a patient was admitted to a randomly selected centre with worse as opposed to better risk-adjusted mortality. Definitive care at an MTS was associated with a 41% lower likelihood of death compared to definitive care at an RTS (OR 0.59 95%CI 0.35-0.97). Similar findings were present in the elderly and isolated severe brain injury subgroups. CONCLUSIONS: The NSW trauma system exhibited variability in risk-adjusted outcomes that did not appear to be explained by case-mix. A better understanding of the drivers of the described variation in outcomes is crucial to design targeted locally-relevant quality improvement interventions.

Factors predicting outcome in whiplash injury: a systematic meta-review of prognostic factors.

BACKGROUND: Whiplash injuries are among the leading injuries related to car crashes and it is important to determine the prognostic factors that predict the outcome of patients with these injuries. This meta-review aims to identify factors that are associated with outcome after acute whiplash injury. MATERIALS AND METHODS: A systematic search for all systematic reviews on outcome prediction of acute whiplash injury was conducted across several electronic databases. The search was limited to publications in English, and there were no geographical or time of publication restrictions. Quality appraisal was conducted with A Measurement Tool to Assess Systematic Reviews. RESULTS: The initial search yielded 207 abstracts; of these, 195 were subsequently excluded by topic or method. Twelve systematic reviews with moderate quality were subsequently included in the analysis. Post-injury pain and disability, whiplash grades, cold hyperalgesia, post-injury anxiety, catastrophizing, compensation and legal factors, and early healthcare use were associated with continuation of pain and disability in patients with whiplash injury. Post-injury magnetic resonance imaging or radiographic findings, motor dysfunctions, or factors related to the collision were not associated with continuation of pain and disability in patients with whiplash injury. Evidence on demographic and three psychological factors and prior pain was conflicting, and there is a shortage of evidence related to the significance of genetic factors. CONCLUSIONS: This meta-review suggests an association between initial pain and anxiety and the outcome of acute whiplash injury, and less evidence for an association with physical factors. LEVEL OF EVIDENCE: Level 1.

Spine surgery outcome in patients who sought compensation after a motor vehicle accident: a retrospective cohort study.

BACKGROUND: Back and neck pain are common after road traffic injury and are treated by spine surgery in some cases. This study aimed to describe the outcomes of spine surgery in people who made an insurance claim after road traffic accidents without an associated spinal fracture or dislocation. METHODS: This study was a retrospective cohort based on insurers' data of Compulsory Third Party (CTP) claims. File audit and data extraction were undertaken using a study-specific proforma. Primary outcomes were ongoing pain and symptoms, complications, return to work and pre-injury duties, and ongoing treatment 2 years following spine surgery. Secondary outcomes were health care costs based on data provided by the insurers. RESULTS: After screening 766 files, 90 cases were included (female: 48; mean age: 46 years). Among the subjects who were working prior the injury, the rate of return to work was 37% and return to pre-injury duties was 23% 2 years following the surgery. The average number of appointments with health care professionals in the 1 year after surgery was 21, compared to 10 for the 1 year prior to surgery (p = 0.03). At 2 years following the initial surgery, 21% of claimants had undergone revision spine surgery; 68% reported ongoing back pain and 41% had ongoing radicular symptoms. The difference between costs 1 year before and after surgery (excluding surgical costs) was statistically significant (p = 0.04). Fusions surgery was associated with higher total costs than decompression alone. After adjusting for surgery type, lumbar surgery was associated with higher costs in the 1 year after surgery and total surgical costs compared to cervical surgery. CONCLUSIONS: The majority of claimants continued having clinical symptoms, continued using health care and did not return to work despite undertaking spine surgery.

A systematic review on the effectiveness of back protectors for motorcyclists.

BACKGROUND: Motorcyclists are a vulnerable road-user population who are overrepresented in traffic injuries. Utilisation of back protectors may be an effective preventive measure for spine injuries in motorcyclists. Since use of back protectors is increasing it is important that clinical evidence supports their use. The study aimed to investigate the current evidence on the ability of back protectors to reduce the rate of back injuries and patient mortality in motorcycle crashes. METHODS: A systematic literature search was conducted using various electronic databases. Systematic reviews, randomised controlled trials, controlled clinical trials, cohort studies, case series and case reports were included Opinion pieces and laboratory or biomechanical studies were excluded. Back protectors and spine protectors were included as the intervention; neck braces and speed humps were excluded. The target outcomes were any injuries to the back or death. Only English language studies were included. RESULTS: The search strategy yielded 185 studies. After excluding 183 papers by title and abstract and full-text evaluation, only two small cross-sectional studies were included. Foam inserts in motorcycle jackets and non-standard clothing may possibly be associated with higher risk of injuries, while hard shell and standard back protectors may possibly be associated with a reduced rate of back and spinal injury. CONCLUSION: This systematic review highlighted lack of appropriate evidence on efficacy of back protectors. Based on limited information, we are uncertain about the effects of back protectors on spinal injuries. Further research is required to substantiate the effects of back protectors on mortality and other injuries to the back.