Maternal pregravid body mass index and child hospital admissions in the first 5 years of life: results from an Australian birth cohort.

OBJECTIVES: To examine the association of maternal pregravid body mass index (BMI) and child offspring, all-cause hospitalisations in the first 5 years of life. METHODS: Prospective birth cohort study. From 2006 to 2011, 2779 pregnant women (2807 children) were enrolled in the Environments for Healthy Living: Griffith birth cohort study in South-East Queensland, Australia. Hospital delivery record and self-report baseline survey of maternal, household and demographic factors during pregnancy were linked to the Queensland Hospital Admitted Patients Data Collection from 1 November 2006 to 30 June 2012, for child admissions. Maternal pregravid BMI was classified as underweight (<18.5 kg m(-)(2)), normal weight (18.5-24.9 kg m(-)(2)), overweight (25.0-29.9 kg m(-)(2)) or obese (⩾30 kg m(-)(2)). Main outcomes were the total number of child hospital admissions and ICD-10-AM diagnostic groupings in the first 5 years of life. Negative binomial regression models were calculated, adjusting for follow-up duration, demographic and health factors. The cohort comprised 8397.9 person years (PYs) follow-up. RESULTS: Children of mothers who were classified as obese had an increased risk of all-cause hospital admissions in the first 5 years of life than the children of mothers with a normal BMI (adjusted rate ratio (RR) =1.48, 95% confidence interval 1.10-1.98). Conditions of the nervous system, infections, metabolic conditions, perinatal conditions, injuries and respiratory conditions were excessive, in both absolute and relative terms, for children of obese mothers, with RRs ranging from 1.3-4.0 (PYs adjusted). Children of mothers who were underweight were 1.8 times more likely to sustain an injury or poisoning than children of normal-weight mothers (PYs adjusted). CONCLUSION: RESULTS suggest that if the intergenerational impact of maternal obesity (and similarly issues related to underweight) could be addressed, a significant reduction in child health care use, costs and public health burden would be likely.

Work/life balance and health: the Nurses and Midwives e-cohort Study.

BACKGROUND: Nursing and midwifery are demanding professions. Efforts to understand the health consequences and workforce needs of these professions are urgently needed. Using a novel electronic approach, the Nurses and Midwives e-cohort Study (NMeS) aims to investigate longitudinally Australian and New Zealand nurses' and midwives' work/life balance and health. This paper describes NMeS participation; provides key baseline demographic, workforce and health indicators; compares these baseline descriptions with external norms; and assesses the feasibility of the electronic approach. METHODS: From 1 April 2006 to 31 March 2008, nurses in Australia and New Zealand, and midwives in Australia were invited to participate. Potential participants were directed to a purpose-built NMeS Internet site, where study information was provided and consent sought. Once obtained, a range of standardized tools combined into one comprehensive electronic questionnaire was elicited. RESULTS: Overall, 7633 (2.3%) eligible nurses and midwives participated (6308 from Australia and 1325 from New Zealand) from a total pool of 334,400. Age, gender, occupational and health profiles were similar between countries and to national figures. However, some differences were noted; for instance, Queensland participants were over-represented, while Victorian and South Australian participants were under-represented, and 28.2% of Australians were in high strain positions compared with 18.8% of New Zealanders. CONCLUSIONS: Using an internationally novel web-based approach, a large cohort, which appears generally similar to population norms, has been established. Provided participant retention is adequate, the NMeS will provide insight into understanding the drivers of nurses' and midwives' workforce retention and work-related factors associated with their health.

Causes of injuries resulting in hospitalisation in Australia: assessing coder agreement on external causes.

OBJECTIVE: To assess extent of coder agreement for external causes of injury using ICD-10-AM for injury-related hospitalisations in Australian public hospitals. METHODS: A random sample of 4850 discharges from 2002 to 2004 was obtained from a stratified random sample of 50 hospitals across four states in Australia. On-site medical record reviews were conducted and external cause codes were assigned blinded to the original coded data. Code agreement levels were grouped into the following agreement categories: block level, 3-character level, 4-character level, 5th-character level, and complete code level. RESULTS: At a broad block level, code agreement was found in over 90% of cases for most mechanisms (eg, transport, fall). Percentage disagreement was 26.0% at the 3-character level; agreement for the complete external cause code was 67.6%. For activity codes, the percentage of disagreement at the 3-character level was 7.3% and agreement for the complete activity code was 68.0%. For place of occurrence codes, the percentage of disagreement at the 4-character level was 22.0%; agreement for the complete place code was 75.4%. CONCLUSIONS: With 68% agreement for complete codes and 74% agreement for 3-character codes, as well as variability in agreement levels across different code blocks, place and activity codes, researchers need to be aware of the reliability of their specific data of interest when they wish to undertake trend analyses or case selection for specific causes of interest.

Accuracy of external cause-of-injury coding in hospital records.

OBJECTIVE: To appraise the published evidence regarding the accuracy of external cause-of-injury codes in hospital records. DESIGN: Systematic review. DATA SOURCES: Electronic databases searched included PubMed, PubMed Central, Medline, CINAHL, Academic Search Elite, Proquest Health and Medical Complete, and Google Scholar. Snowballing strategies were used by searching the bibliographies of retrieved references to identify relevant associated articles. SELECTION CRITERIA: Studies were included in the review if they assessed the accuracy of external cause-of-injury coding in hospital records via a recoding methodology. METHODS: The papers identified through the search were independently screened by two authors for inclusion. Because of heterogeneity between studies, meta-analysis was not performed. RESULTS: Very limited research on the accuracy of external cause coding for injury-related hospitalisation using medical record review and recoding methodologies has been conducted, with only five studies matching the selection criteria. The accuracy of external cause coding using ICD-9-CM ranged from approximately 64% when exact code agreement was examined to approximately 85% when agreement for broader groups of codes was examined. CONCLUSIONS: Although broad external cause groupings coded in ICD-9-CM can be used with some confidence, researchers should exercise caution for very specific codes until further research is conducted to validate these data. As all previous studies have been conducted using ICD-9-CM, research is needed to quantify the accuracy of coding using ICD-10-AM, and validate the use of these data for injury surveillance purposes.

Ten-year outcomes following traumatic brain injury: a population-based cohort.

PRIMARY OBJECTIVE: To quantify the 10 year health service use (HSU) and mortality outcomes for people with a traumatic brain injury (TBI). RESEARCH DESIGN: A population-based matched cohort study using linked administrative data from Manitoba, Canada (Manitoba Injury Outcome Study). METHODS AND PROCEDURES: An inception cohort (1988-1991) of hospitalized cases with TBI aged 18-64 years (n = 1290) was identified and matched to a non-injured comparison group (n = 1290). Survival analysis, Negative binomial and Poisson regression were used to quantify associations between injury and HSU/mortality outcomes for 10 years following the TBI event. MAIN OUTCOME AND RESULTS: The majority of deaths (47.2%) occurred in the first 60 days following injury. Excluding the first 60 days, the adjusted 10 year mortality remained elevated (mortality rate ratio = 1.48, 95% CI = 1.02-2.15). After adjusting for demographic characteristics and pre-existing health status, the TBI cohort had more post-injury hospitalizations (rate ratio (RR) = 1.54, 95% CI = 1.39-1.71), greater cumulative lengths of stay (RR = 5.14, 95% CI = 3.29-8.02) and a greater post-injury physician claims rate (RR = 1.44, 95% CI = 1.35-1.53) than the non-injured cohort. CONCLUSIONS: People who sustain a TBI and survive the initial acute phase of care experience substantially increased long-term morbidity compared to the general population, regardless of the level of injury severity.

Long-term mortality following injury in working-age adults: a systematic review.

Priorities for prevention activities and planning for services depend on comprehensive knowledge of the distribution of the injury-related burden in the community. The aim of this systematic review was to quantify the effect of being injured, compared with not being injured, on long-term mortality in working age adults. Cohort studies were selected that were population-based, measured mortality post-discharge from inpatient treatment, included a non-injured comparison group and related to working-age adults. Data synthesis was in tabular and text form with a meta-analysis not being possible because of the heterogeneity between studies. Eleven studies met the inclusion criteria. All studies found an overall positive association between injury and increased mortality. While the greatest excess mortality was evident during the initial period post-injury, increased mortality was shown in some studies to persist for up to 40 years after injury. Due to the limited number of injury types studied and heterogeneity between studies, there is insufficient published evidence on which to calculate population estimates of long-term mortality, where injury is a component cause. The review does suggest there is considerable excess mortality following injury that is not accounted for in current methods of quantifying injury burden, and is not used to assess quality and effectiveness of trauma care.

Injury risk from popular childhood physical activities: results from an Australian primary school cohort.

BACKGROUND: Children engage in various physical activities that pose different injury risks. However, the lack of adequate data on exposure has meant that these risks have not been quantified or compared in young children aged 5-12 years. OBJECTIVES: To measure exposure to popular activities among Australian primary school children and to quantify the associated injury risks. METHOD: The Childhood Injury Prevention Study prospectively followed up a cohort of randomly selected Australian primary and preschool children aged 5-12 years. Time (min) engaged in various physical activities was measured using a parent-completed 7-day diary. All injuries over 12 months were reported to the study. All data on exposure and injuries were coded using the International classification of external causes of injury. Injury rates per 1000 h of exposure were calculated for the most popular activities. RESULTS: Complete diaries and data on injuries were available for 744 children. Over 12 months, 314 injuries relating to physical activity outside of school were reported. The highest injury risks per exposure time occurred for tackle-style football (2.18/1000 h), wheeled activities (1.72/1000 h) and tennis (1.19/1000 h). Overall, boys were injured more often than girls; however, the differences were non-significant or reversed for some activities including soccer, trampolining and team ball sports. CONCLUSION: Although the overall injury rate was low in this prospective cohort, the safety of some popular childhood activities can be improved so that the benefits may be enjoyed with fewer negative consequences.

Ten-year health service use outcomes in a population-based cohort of 21,000 injured adults: the Manitoba injury outcome study.

OBJECTIVE: To quantify long-term health service use (HSU) following non-fatal injury in adults. METHODS: A retrospective, population-based, matched cohort study identified an inception cohort (1988-91) of injured people who had been hospitalized (ICD-9-CM 800-995) aged 18-64 years (n = 21 032) and a matched non-injured comparison group (n = 21 032) from linked administrative data from Manitoba, Canada. HSU data (on hospitalizations, cumulative length of stay, physician claims and placements in extended care services) were obtained for the 12 months before and 10 years after the injury. Negative binomial and Poisson regressions were used to quantify associations between injury and long-term HSU. FINDINGS: Statistically significant differences in the rates of HSU existed between the injured and non-injured cohorts for the pre-injury year and every year of the follow-up period. After controlling for pre-injury HSU, the attributable risk percentage indicated that 38.7% of all post-injury hospitalizations (n = 25 183), 68.9% of all years spent in hospital (n = 1031), 21.9% of physician claims (n = 269 318) and 77.1% of the care home placements (n = 189) in the injured cohort could be attributed to being injured. CONCLUSION: Many people who survive the initial period following injury, face long periods of inpatient care (and frequent readmissions), high levels of contact with physicians and an increased risk of premature placement in institutional care. Population estimates of the burden of injury could be refined by including long-term non-fatal health consequences and controlling for the effect of pre-injury comorbidity.

The properties of the International Classification of the External Cause of Injury when used as an instrument for injury prevention research.

OBJECTIVE: To demonstrate properties of the International Classification of the External Cause of Injury (ICECI) as a tool for use in injury prevention research. METHODS: The Childhood Injury Prevention Study (CHIPS) is a prospective longitudinal follow up study of a cohort of 871 children 5-12 years of age, with a nested case crossover component. The ICECI is the latest tool in the International Classification of Diseases (ICD) family and has been designed to improve the precision of coding injury events. The details of all injury events recorded in the study, as well as all measured injury related exposures, were coded using the ICECI. This paper reports a substudy on the utility and practicability of using the ICECI in the CHIPS to record exposures. Interrater reliability was quantified for a sample of injured participants using the Kappa statistic to measure concordance between codes independently coded by two research staff. RESULTS: There were 767 diaries collected at baseline and event details from 563 injuries and exposure details from injury crossover periods. There were no event, location, or activity details which could not be coded using the ICECI. Kappa statistics for concordance between raters within each of the dimensions ranged from 0.31 to 0.93 for the injury events and 0.94 and 0.97 for activity and location in the control periods. DISCUSSION: This study represents the first detailed account of the properties of the ICECI revealed by its use in a primary analytic epidemiological study of injury prevention. The results of this study provide considerable support for the ICECI and its further use.

Long term health outcomes after injury in working age adults: a systematic review.

BACKGROUND: Estimating the contribution of non-fatal injury outcomes remains a considerable challenge and is one of the most difficult components of burden of disease analysis. The aim of this systematic review was to quantify the effect of being injured compared with not being injured on morbidity and health service use (HSU) in working age adults. METHODS: Studies were selected that were population based, had long term health outcomes measured, included a non-injured comparison group, and related to working age adults. Meta-analysis was not attempted because of the heterogeneity between studies. RESULTS: Nine studies met the inclusion criteria. In general, studies found an overall positive association between injury and increased HSU, exceeding that of the general population, which in some studies persisted for up to 50 years after injury. Disease outcome studies after injury were less consistent, with null findings reported. CONCLUSION: Because of the limited injury types studied and heterogeneity between study outcome measures and follow up, there is insufficient published evidence on which to calculate population estimates of long term morbidity, where injury is a component cause. However, the review does suggest injured people have an increased risk of long term HSU that is not accounted for in current methods of quantifying injury burden.

Long-term mortality following trauma: 10 year follow-up in a population-based sample of injured adults.

BACKGROUND: The aim of the study was to quantify trauma-related mortality in injured adults over 10 years postinjury. METHODS: A population-based matched cohort study used linked administrative data from Manitoba, Canada, to identify an inception cohort (1988-1991) of hospitalized trauma cases (ICD-9-CM 800-959.9) aged 18-64 years (n = 18,210) and a matched noninjured comparison group (n = 18,210). Mortality outcomes were obtained by linking the two cohorts with the Manitoba Population Registry for a period of 10 years postinjury. RESULTS: The adjusted all-cause mortality rate ratio (MRR) was 7.29 (95% CI 4.53-11.74) for the 60 days immediately postinjury. The MRRs ranged between 1.17 and 2.41 for the remainder of the 10 year follow-up period. The index injury was estimated to be responsible for 41% of all recorded deaths in the injured cohort. CONCLUSIONS: Estimates of the total mortality burden, based on the early inpatient period alone, substantially underestimates the true burden from injury.

Indicators of injury burden: which types are the most important?

Injury indicators are used for monitoring the impact of injury prevention initiatives on the population burden of injury. The object of the present study was to identify the types of injury responsible for the major component of the population health burden of injury in a large cohort in Manitoba, Canada. Injury cases (ICD-9-CM 800-995) aged 18-64 years were identified from all Manitoba hospital data between 1988 and 1991. Morbidity data were obtained from hospital discharge abstracts 12 months prior to date of injury and for 12 months post-injury. Outcomes for individuals were calculated as the difference pre- and post-injury in hospital inpatient days. Death outcomes in the 12 months post-injury were obtained by linking the cohort with the population registry. Summed outcomes across the population were stratified into injury types based on the International Code of Diseases (ICD) code of the index injury. Outcomes were also stratified by injury severity score categories where the injury severity score was obtained using ICDMAP-90. When ranked by contribution to the cohort's cumulative hospital inpatient days in the 12 months post-injury, the six most common ICD subchapter groups accounted for 65% of the total inpatient days. These six injury types also accounted for 62% of the total number of deaths in this cohort in 12 months after injury. The suggested injury types to use as indicators of burden include fracture of the lower limb, fracture of the head and neck, poisonings, intracranial injury, fracture of the upper limb, and fracture of skull.

How well do anatomical-based injury severity scores predict health service use in the 12 months after injury?

There is an acknowledged need for valid and reliable injury scores, suitable for use at the population level, which can accurately predict the long-term outcome of injury. The objective was to quantify the extent to which the abbreviated injury severity score (AIS) and the functional capacity index score (FCI) predict use of health services in the 12 months following an injury event. A cohort of injured people (ICD-9-CM 800-995) aged 18 - 64 years was identified from Manitoba hospital discharge abstracts from January 1988 to December 1991. For each member of the cohort whose injuries could be mapped to an abbreviated injury scale unique identifier, a maximum AIS (maxAIS) and a maximum FCI (maxFCI) were obtained. The cohort was linked with hospital discharge abstracts, physicians' claims and deaths from the population registry for the 12 months following injury. Negative binomial regression was used to model the relationships between the severity scores and the three outcome measures, while controlling for potential confounding variables. In total, 20 677 (97%) eligible cases were identified, of which 16 834 (81%) could be assigned a maxAIS and 15 823 (77%) a maxFCI. MaxAIS and maxFCI were significantly associated with total days in hospital following injury, but explained little of the variation in any of the health service use outcome variables (maxAIS, partial pseudo r2 ranging from < 0.001 to 0.041; and maxFCI, partial pseudo r2 ranging from < 0.001 to 0.018). It was concluded that anatomical damage is only partly responsible for long-term injury outcome. Additional variables would need to be included in predictive models of health outcomes of injury before these models could be reliable.

Effects of acetyl-L-carnitine and myo-inositol on high-energy phosphate and membrane phospholipid metabolism in zebra fish: a 31P-NMR-spectroscopy study.

Acetyl-L-carnitine (ALCAR) and myo-inositol are reported to enhance motor activity in animal models; modulate membrane phospholipid metabolism (ALCAR and myo-inositol) and high-energy phosphate metabolism (ALCAR) back to normal; and be effective treatments of major depression in humans. Fish in general and zebra fish in particular present unique animal models for the in vivo study of high-energy phosphate and membrane phospholipid metabolism by noninvasive in vivo 31P NMR. This 31P NMR study of free-swimming zebra fish showed that both ALCAR and myo-inositol decreased levels of phosphodiesters and inorganic orthophosphate and increased levels of PCr in the fish. These findings demonstrate both ALCAR and myo-inositol modulate membrane phospholipid and high-energy phosphate metabolism in free-swimming zebra fish.

Population based study of hospitalised fall related injuries in older people.

OBJECTIVE: This study aimed to identify the distribution of fall related injury in older people hospitalised for acute treatment of injury, in order to direct priorities for prevention. SETTING: A follow up study was conducted in the Brisbane Metropolitan Region of Australia during 1998. METHODS: Medical records of patients aged 65 years and over hospitalised with a fall related injury were reviewed. Demographic and injury data were analysed and injury rates calculated using census data as the denominator for the population at risk. RESULTS: From age 65, hospitalised fall related injury rates increased exponentially for both males and females, with age adjusted incidence rates twice as high in women than men. Fractures accounted for 89% of admissions, with over half being to the hip. Males were significantly more likely than females to have fractured their skull, face, or ribs (p<0.01). While females were significantly more likely than males to have fractured their upper or lower limbs (p<0.01), the difference between proportions of males and females fracturing their hip was not significant. Males were more likely than females (p<0.01) to have fall related head injuries (13% of admissions). Compared with hip fractures, head injuries contributed significantly to the burden of injury in terms of severity, need for intensive care, and excess mortality. CONCLUSIONS: The frequency and impact of hip fractures warrants continued emphasis in falls program interventions for both males and females to prevent this injury. However, interventions that go beyond measures to slow and protect against bone loss are also needed to prevent fall related head injuries.

Dose regimen for vancomycin not needing serum peak levels?

AIM: To determine the safety, efficacy, and need to measure peak serum vancomycin concentrations in a neonatal population using a standard vancomycin dosage regimen. METHOD: A total of 101 infants who were admitted to a regional neonatal intensive care unit and received vancomycin (15 mg/kg every 12 or 18 hours depending on postnatal age) were studied retrospectively. Infants who had been started on vancomycin before they were transferred to the unit were excluded. The proportion of infants was measured whose serum vancomycin concentrations were within a conservative therapeutic range of trough 5-10 mg/l, peak 20-40 mg/l, and a less conservative, but still safe, range of trough 5-12 mg/l, peak 15-60 mg/l. RESULTS: Trough concentrations of 5-10 mg/l were achieved by 46.5% of infants, and 5-12 mg/l by 55.4%. Peak concentrations of 20-40 mg/l were found in 83.2% of infants, and 15-60 mg/l in 99.0%. Highest peak concentration was 47.2 mg/l. Some 89.4% of infants with trough concentrations of 5-10 mg/l had a peak concentration of 20-40 mg/l. CONCLUSIONS: The vancomycin dosage regimen used in this study produces acceptable therapeutic serum vancomycin concentrations. Peak serum vancomycin concentrations do not need to be measured in neonates using this dosage regimen.

Appropriate indicators for injury control?

Indicators are valuable tools used to measure progress towards a desired health outcome. Increased awareness of the public health burden due to injury has lead to a concomitant interest in monitoring the impact of national initiatives that aim to reduce the size of the burden. Several injury indicators have now been proposed. This study examines the ability of each of the suggested indicators to reflect the nature and extent of the burden of non-fatal injury. A criterion validity, population-based, prospective cohort study was conducted in Brisbane, a sub-tropical Metropolitan City on the eastern seaboard of Australia, over a 12-month period between 1 January and 31 December 1998. Neither the presence of a long bone fracture nor the need for hospitalisation for 4 or more days were sensitive or specific indicators for 'serious' or major injury as defined by the 'Gold Standard' Injury Severity Score (ISS). Subsequent analysis, using other public health outcome measures demonstrated that the major component of the illness burden of injury was in fact due to 'minor' not serious injury. However, the suggested indicators demonstrated low sensitivity and specificity for these outcomes as well. The results of the study support the need to include at least all hospitalisations in any population-based measure of injury and not attempt to simplify the indicator to a more convenient measure aimed at identifying just those cases of 'serious' injury.

Randomized controlled study of digestive enzyme activity following trophic feeding.

UNLABELLED: A randomized, controlled, prospective study of 80 preterm infants of birthweight less than 1750 g requiring ventilatory support was performed. While ventilatory support was required group TF (39 infants) received trophic feeding (0.5-1 ml h(-1)) along with parenteral nutrition, whereas group C (41 infants) received parenteral nutrition alone. When ventilatory support was no longer required milk feeds were started in group C and then increased in both groups until full milk feeds were established. The ratio of lactase to sucrase activity (L:S ratio) was measured in aspirated proximal intestinal fluid on 3 occasions: immediately after ventilatory support was withdrawn (T0), 7 days later (T7) and 14 days later (T14). On the same 3 occasions faecal chymotrypsin activity was measured. The mean difference (95% confidence interval) L:S ratio was significantly higher in group TF at both T0 and T14, 1.8 (0.03, 3.57) and 0.78 (0.2, 1.35) U l(-1), respectively. There was no significant difference in faecal chymotrypsin concentration. CONCLUSION: Trophic feeding alters relative intestinal disaccharidase activity, probably by inducing lactase production, but has no effect on pancreatic chymotrypsin activity.