Ketone Ester Effects on Biomarkers of Brain Metabolism and Cognitive Performance in Cognitively Intact Adults ≥ 55 Years Old. A Study Protocol for a Double-Blinded Randomized Controlled Clinical Trial.

BACKGROUND: Ketone bodies have been proposed as an "energy rescue" for the Alzheimer's disease (AD) brain, which underutilizes glucose. Prior research has shown that oral ketone monoester (KME) safely induces robust ketosis in humans and has demonstrated cognitive-enhancing and pathology-reducing properties in animal models of AD. However, human evidence that KME may enhance brain ketone metabolism, improve cognitive performance and engage AD pathogenic cascades is scarce. OBJECTIVES: To investigate the effects of ketone monoester (KME) on brain metabolism, cognitive performance and AD pathogenic cascades in cognitively normal older adults with metabolic syndrome and therefore at higher risk for AD. DESIGN: Double-blinded randomized placebo-controlled clinical trial. SETTING: Clinical Unit of the National Institute on Aging, Baltimore, US. PARTICIPANTS: Fifty cognitively intact adults ≥ 55 years old, with metabolic syndrome. INTERVENTION: Drinks containing 25 g of KME or isocaloric placebo consumed three times daily for 28 days. OUTCOMES: Primary: concentration of beta-hydroxybutyrate (BHB) in precuneus measured with Magnetic Resonance Spectroscopy (MRS). Exploratory: plasma and urine BHB, multiple brain and muscle metabolites detected with MRS, cognition assessed with the PACC and NIH toolbox, biomarkers of AD and metabolic mediators in plasma extracellular vesicles, and stool microbiome. DISCUSSION: This is the first study to investigate the AD-biomarker and cognitive effects of KME in humans. Ketone monoester is safe, tolerable, induces robust ketosis, and animal studies indicate that it can modify AD pathology. By conducting a study of KME in a population at risk for AD, we hope to bridge the existing gap between pre-clinical evidence and the potential for brain-metabolic, pro-cognitive, and anti-Alzheimer's effects in humans.

Cold urticaria: a 20-year follow-up study.

BACKGROUND: Chronic cold urticaria results in significant morbidity, yet information on its natural history is limited. OBJECTIVE: We examined the natural history of chronic cold urticaria and its impact on quality of life. METHODS: We analysed the characteristics of patients diagnosed with cold urticaria at a community-based specialist allergy practice in the Australian Capital Territory (ACT) between 1995 and 2015. Follow-up data were obtained using a mailed questionnaire. Possible predictive factors of disease severity and symptom duration were evaluated. RESULTS: A total of 99 patients were assessed with a median age of 42 (range 5-81 years); 63% were female and the median age of onset of symptoms was 22 years. Of 41 questionnaire responders (14 ± 10.9 years follow-up; median 12 years), 5- and 10-year resolution rates were 17.9% ± 6.2% and 24.5% ± 7.2%, respectively. Whereas 22% reported resolution and 23% described improvement, the remaining 55% reported stable or worsening disease. Most individuals relied on lifestyle modification to ameliorate symptoms rather than medication. Risk factors for persistent disease were intercurrent atopic disease (P = 0.025) and those with longer duration of symptoms at the time of initial assessment (P < 0.001). Secondary causes of cold urticaria were identified in only two patients, both with B-cell malignancy. CONCLUSION: In a subset of patients, cold urticaria has low rates of spontaneous resolution and results in lifestyle changes and impaired quality of life.

Increases in anaphylaxis fatalities in Australia from 1997 to 2013.

BACKGROUND: Recent epidemiological studies indicate increases in Australian, UK and US hospital anaphylaxis admission rates. OBJECTIVES: The aim of this study was to determine whether Australian anaphylaxis fatalities are increasing in parallel and to examine the characteristics of fatalities recorded in the National Coronial Information System (NCIS). METHODS: Time trends in Australian anaphylaxis fatalities were examined using data derived from the Australian Bureau of Statistics (ABS) 1997-2013 and the NCIS 2000-2013, the latter providing additional information to verify cause and identify risk factors. RESULTS: The ABS recorded 324 anaphylaxis fatalities by cause: unspecified (n = 205); medication (n = 52); insect stings/tick bites (n = 41); food (n = 23); and blood products (n = 3). From 1997 to 2013, all-cause fatal anaphylaxis rates increased by 6.2%/year (95% CI: 3.8-8.6%, P < 0.0001) or from 0.054% to 0.099/10(5) population. Fatal food anaphylaxis increased by 9.7%/year (95% CI: 0.25-20%, P = 0.04) and unspecified anaphylaxis deaths by 7.8% (95% CI: 4.6-11.0, P < 0.0001). There was an insignificant change in medication-related fatalities (5.6% increase/year; 95% CI: 0.3% decrease to 11.8% increase, P = 0.06), and sting/bite fatalities remained unchanged. Hospital anaphylaxis admission rates for all-cause, food, unspecified and medication anaphylaxis increased at rates of 8%, 10%, 4.4% and 6.8%/year, respectively. A total of 147 verified NCIS deaths were examined in detail: medication- and sting/bite-related fatalities occurred predominantly in older individuals with multiple comorbidities. Upright posture after anaphylaxis was associated with risk of sudden death (all causes). Seafood (not nuts) was the most common trigger for food-related anaphylaxis deaths. CONCLUSIONS: Australian anaphylaxis fatality rates (most causes) have increased over the last 16 years, contrasting with UK- and US-based studies that describe overall lower and static overall anaphylaxis fatality rates (0.047-0.069/10(5) population).

Socio-economic status, geographic remoteness and childhood food allergy and anaphylaxis in Australia.

BACKGROUND: The risk factors for food allergy (FA) and anaphylaxis remain uncertain. OBJECTIVE: We examined the association between socio-economic status (SES), geographic remoteness and childhood FA and anaphylaxis in Australia. METHODS: Sales of infant hypoallergenic formulae (IHF; 2008-2009) and EpiPens (2006-2007) in children aged 0-4 years and hospital anaphylaxis admission rates (2002-2006) in age groups 0-4, 5-14, 15-24, 25-64 and 65+ years were used as proxy markers of FA and anaphylaxis in Australia. Government and commercially derived data were analysed by SES and geographic remoteness (very remote, remote, outer regional, inner regional and major cities). RESULTS: Annual IHF sales rates were higher in those with the greatest compared with the least socio-economic advantage (47,830 vs. 21,384 tins/100,000 population; P<0.001). EpiPen sales trends were also higher in those with the greatest socio-economic advantage in all age groups, most marked in those aged 0-4 (1713 vs. 669/100,000; P=0.002) and 5-14 years (1628 vs. 600/100,000; P=0.001). Formula sales rates were higher in major cities than remote/very remote regions (37,421 vs. 6704/100,000; P<0.001) with similar EpiPen sales trends, particularly in ages 0-4 (1166 vs. 601/100,000; P=0.045) and 5-14 years (1099 vs. 588/100,000; P<0.001). Socio-economic advantage and geographic remoteness remained statistically significant in multivariable analysis of prescription rates (P<0.01) and were unchanged by adjustment for health services access. While anaphylaxis admission rates were higher in those with the greatest compared with the least socio-economic advantage in children aged 0-4 years (129 vs. 92/100,000 population/year; P=0.03), the opposite was observed in older age groups (e.g. aged 25-64 years: 43 vs. 76, P=0.01). There was no association between geographic remoteness and anaphylaxis admissions. CONCLUSION: Socio-economic advantage and residence in major cities may be risk factors for developing childhood FA and anaphylaxis. Further study will determine the extent to which economic factors and location of residence also influence access to health services.

Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury.

OBJECTIVE: To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care. METHODS: We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18-65 years with a serious head injury (AIS > or =3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based "high therapeutic intensity" measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule. RESULTS: 504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation. CONCLUSIONS: This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.

Anaphylaxis: risk factors for recurrence.

BACKGROUND: There are few studies on the incidence or recurrence of anaphylaxis. OBJECTIVE: To examine the incidence of anaphylaxis and risk factors for recurrence. METHODS: A prospective study of 432 patients referred to a community-based specialist practice in the Australian Capital Territory with anaphylaxis, followed by a survey to obtain information on recurrence. RESULTS: Of 432 patients (48% male, 73% atopic, mean 27.4 years, SD 19.5, median 26) with anaphylaxis, 260 patients were seen after their first episode; 172 experienced 584 previous reactions. fifty-four percent of index episodes were treated in hospital. Aetiology was identified in 91.6% patients: food (61%), stinging insects (20.4%) or medication (8.3%). The minimum occurrence and incidence of new cases of anaphylaxis was estimated at 12.6 and 9.9 episodes/100,000 patient-years, respectively. Follow-up data were obtained from 304 patients (674 patient-years). One hundred and thirty experienced further symptoms (45 serious), 35 required hospitalization and 19 administered adrenaline. Accidental ingestion of peanut/tree nut caused the largest number of relapses, but the highest risk of recurrence was associated with sensitivity to wheat and/or exercise. Rates of overall and serious recurrence were 57 and 10 episodes/100 patient-years, respectively. Of those prescribed adrenaline, 3/4 carried it, 2/3 were in date, and only 1/2 patients faced with serious symptoms administered adrenaline. Five patients each developed new triggers for anaphylaxis, or re-presented with significant psychiatric symptoms. CONCLUSION: In any 1 year, 1/12 patients who have suffered anaphylaxis will experience recurrence, and 1/50 will require hospital treatment or use adrenaline. Compliance with carrying and using adrenaline is poor. Occasional patients develop new triggers or suffer psychiatric morbidity.

Influence of trauma system implementation on process of care delivered to seriously injured patients in rural trauma centers.

BACKGROUND: Statewide trauma systems are implemented by health care policy makers whose intent is to improve the process of care delivered to seriously injured patients. In Oregon, Advanced Trauma Life Support (ATLS) training was mandated for all physicians employed in the emergency department of trauma centers. The purpose of this study was to test the hypothesis that mandatory ATLS training favorably influenced processes of care. METHODS: Seriously injured patients treated at 9 rural Level 3 and Level 4 hospitals were studied before (PRE) and after (POST) implementation of Oregon's trauma system. The processes of care evaluated on the basis of chart review were 20 diagnostic and therapeutic interventions advocated in the ATLS course. A cumulative process score (CPS) between 0 and 1 was assigned on the basis of the processes of care delivered. A CPS of 1 indicated optimal process of care. RESULTS: Mean CPS for 506 PRE period patients (0.44 +/- 0.27) was significantly lower than the mean CPS for 512 POST period patients (0.57 +/- 0.27) with an unpaired t test (P <.001). For the subgroup with injury severity score of 16 to 34, the mean CPS of survivors (0.67 +/- 0.19) was significantly higher than the mean CPS of decedents (0.57 +/- 0.25). CONCLUSIONS: Process of care for seriously injured patients improved after categorization of rural trauma centers in Oregon. Evidence shows improved process of care may have benefitted patients with serious but survivable injuries. Measurement of process of care is an alternative to mortality analysis as an indication of the quality of care.

Mortality among seriously injured patients treated in remote rural trauma centers before and after implementation of a statewide trauma system.

BACKGROUND: Injury mortality in rural regions remains high with little evidence that trauma system implementation has benefited rural populations. OBJECTIVE: To evaluate risk-adjusted mortality in remote regions of Oregon before and after implementation of a statewide trauma system. RESEARCH DESIGN: A retrospective cohort study assessing injury mortality through 30 days after hospital discharge. SETTING: Nine rural Oregon hospitals serving counties with populations <18 persons per square mile. SUBJECTS: Severely injured patients presenting to four level-3 and five level-4 trauma hospitals 3 years before and 3 years after trauma system implementation. MEASURES: Interhospital transfer, hospital death, and demise within 30 days following hospital discharge. RESULTS: A total of 940 patients were analyzed. After trauma system implementation, patients presenting to level-4 hospitals were more likely transferred to level-2 facilities (P <0.001). Interhospital transfer times from level-3 hospitals lengthened significantly after system implementation (P <0.001). Overall mortality rates were higher in the postsystem period (8.3%) than the presystem period (6.7%), but not significantly. Controlling for covariates, no additional benefit to risk-adjusted mortality was associated with trauma system implementation. Additional deaths, occurring after trauma system implementation, included head-injured patients transferred from rural hospitals to nonlevel-1 trauma center hospitals. CONCLUSIONS: Increased injury survival after Oregon trauma system implementation, demonstrated in urban and statewide analyses, was not confirmed in remote regions of the state. Efforts to improve trauma systems in rural areas should focus on the processes of care for head-injured patients transferred to higher designation trauma centers.

Survival among injured geriatric patients during construction of a statewide trauma system.

BACKGROUND: Patient outcomes are presumed to vary during early implementation of a trauma system because of fluctuations in processes of care. This study estimates risk-adjusted survival for injured geriatric patients during implementation of the Washington State trauma system. METHODS: A presystem (1988-1992) versus early construction phase (1993-1995) retrospective cohort analysis of hospitalized geriatric injured patients in Washington State was conducted. Hospital data were cross-linked to death certificates, providing patient follow-up. A Cox proportional hazards model assessed survival to 60 days from hospital admission. RESULTS: A total of 77,136 geriatric patients were assessed. No difference in survival was observed (before vs. after) for all geriatric injured patients. However, among severely injured patients (Injury Severity Score > 15), survival during the implementation phase increased by 5.1% compared with patients admitted during the presystem years (p = 0.03). CONCLUSION: This study demonstrates improved survival for seriously injured geriatric trauma patients during construction of the Washington State trauma system.

Outcomes of patients using a tiered trauma response protocol.

OBJECTIVES: This study evaluated processes of care and outcome for injured patients at a Level I trauma center who had been either treated as a full trauma team activation (FULL) or managed with a modified trauma team activation (MOD). METHODS: A retrospective methodology was used to evaluate all patients entered into the regional trauma system and transported from the scene to a Level I trauma center. Patients treated during a 2-year period of exclusively FULL trauma team protocols were compared with patients managed during a subsequent 2-year period after implementation of a two-tiered response. In the later era, trauma system patients were designated before hospital arrival as either FULL or MOD trauma team responses. An additional case-control analysis was conducted on a subset of MOD trauma team response patients who were undertriaged; that is, in retrospect, they met criteria for a FULL response. The outcomes in the case-control group were compared by chi2 tests and Mann-Whitney U tests. Statistical significance was assumed for p < 0.05. RESULTS: During the presystem period, 1,740 patients were transported as trauma system entries to Oregon Health Sciences University. During the postsystem period, 2,333 patients were transported to Oregon Health Sciences University as either MOD trauma system entries (1,272 [55%]) or as FULL trauma system entries (1,061 [45%]). Postsystem patients had longer time intervals in the emergency department compared with presystem patients. Death rates for patients who died in the emergency department or before hospital discharge were similar. Among patients who were designated as MOD trauma system entries and were subsequently categorized as meeting FULL trauma team criteria, mortality rate was low. CONCLUSION: Implementation of the tiered response protocol led to a substantial change in the operational response in the emergency department. Although processes of care were nominally prolonged, adverse consequences were not identified. We concluded from this quality improvement review that implementation of a tiered response protocol was satisfactory and improved efficiency. Further work is required to improve accuracy of the categorization of trauma system patients as either MOD or FULL trauma codes.

Relationship of cerebral perfusion pressure and survival in pediatric brain-injured patients.

BACKGROUND: Adult brain injury studies recommend maintaining cerebral perfusion pressure (CPP) above 70 mm Hg. We evaluated CPP and outcome in brain-injured children. METHODS: We retrospectively reviewed the hospital courses of children at two Level I trauma centers who required insertion of intracranial pressure (ICP) monitors for management of traumatic brain injury. ICP, CPP, and mean arterial pressure were evaluated hourly, and means were calculated for the first 48 hours after injury. RESULTS: Of 188 brain-injured children, 118 had ICP monitors placed within 24 hours of injury. They suffered severe brain injury, with average admitting Glasgow Coma Scale scores of 6 +/- 3. Overall mortality rate was 28%. No patient with mean CPP less than 40 mm Hg survived. Among patients with mean CPP in deciles of 40 to 49, 50 to 59, 60 to 69, or 70 mm Hg, no significant difference in Glasgow Outcome Scale distribution existed. CONCLUSION: Low mean CPP was lethal. In children with survivable brain injury (mean CPP > 40 mm Hg), CPP did not stratify patients for risk of adverse outcome.

Weaning injured patients with prolonged pulmonary failure from mechanical ventilation in a non-intensive care unit setting.

BACKGROUND: Injured patients with pulmonary failure often require prolonged length of stay in an intensive care unit (ICU), which includes weaning from ventilatory support. In the last decade, noninvasive ventilation modes have been established as safe and effective. One method for accomplishing this mode of ventilation uses a simple bilevel ventilator. Because this ventilator has been successfully used in hospital wards, we postulated that bilevel ventilators could provide sufficient support during weaning from mechanical ventilation of injured patients in a non-ICU setting. METHODS: A retrospective review of trauma patients (August 1996-January 1999) undergoing bilevel positive pressure ventilation as the final phase of weaning was conducted. Before ward transfer with bilevel ventilation, conventionally ventilated ICU patients were changed to bilevel ventilation and were required to tolerate this mode for at least 24 hours. All patients had a tracheostomy as a secure airway. Outcomes analyzed included ICU length of stay, hospital length of stay, duration of mechanical ventilation, weaning success, complications, and survival. RESULTS: Fifty-one patients (39 men, 12 women) with a mean age of 53 received more than 24 hours of bilevel positive pressure ventilation. Mean Injury Severity Score was 29, with blunt mechanisms of injury occurring in 90%. Chest or spinal cord injuries that affected pulmonary mechanics were present in 75% of patients. Ventilator-associated pneumonia was treated in 43% of patients. Mean ICU length of stay and hospital length of stay were 21 and 34 days, respectively. Weaning was successful in 89% of patients, whereas 11% were discharged to skilled nursing facilities still receiving bilevel positive pressure ventilation. Two patients died, neither from a pulmonary nor airway complication. Of the remaining 49 patients, 12 were weaned in the ICU and 37 were transferred to the ward with bilevel ventilatory support. The average length of ward ventilation was 6.5 +/- 5.4 days (n = 37). CONCLUSIONS: Implementation of a program using bilevel ventilation to support the terminal phase of weaning seriously injured patients from mechanical ventilation was successful. After initiating this mode in the ICU, it was satisfactorily continued in standard surgical wards. Because this method enabled the withdrawal of ventilatory support in a non-ICU setting, its major advantage was reducing ICU length of stay.

A comparison of patient characteristics and survival in two trauma centres located in different countries.

INTRODUCTION: The aim of the study was to compare patient characteristics and mortality in severely injured patients in two trauma centres located in different countries, allowing for differences in case-mix. It represents a direct bench-marking exercise between the trauma centres at the North Staffordshire Hospital (NSH), Stoke-on-Trent, UK and the Oregon Health Sciences University (OHSU) Hospital, Portland, Oregon, USA. METHODS: Patients of all ages admitted to the two hospitals during 1995 and 1996 with an Injury Severity Score >15 were included, except for those who died in the emergency departments. Twenty-three factors were studied, including the Injury Severity Score, Glasgow Coma Score, mechanism of injury and anatomical site of injury. Outcome analysis was based on mortality at discharge. RESULTS: The pattern of trauma differed significantly between Stoke and Portland. Patients from Stoke tended to be older, presented with a lower conscious level and a lower systolic blood pressure and were intubated less frequently before arriving at hospital. Mortality depended on similar factors in both centres, especially age, highest AIS score, systolic blood pressure and Glasgow Coma Score.The crude analysis of mortality showed a highly significant odds-ratio of 1.64 in Stoke compared with Portland. Single-factor adjustments were made for the above four factors, which had a similar influence on mortality in both centres. Adjusting for the first three factors individually did not alter the odds-ratio, which stayed in the range 1.53-1.59 and remained highly significant. Adjusting for the Glasgow Coma Score reduced the odds-ratio to 0.82 and rendered it non-significant. In a multi-factor logistic regression model incorporating all of the factors shown to influence mortality in either centre, the odds-ratio was 1.7 but was not significant. CONCLUSION: The analysis illustrates the limitations and pitfalls of making crude outcome comparisons between centres. Highly significant differences in crude mortality were rendered non-significant by case-mix adjustments, supporting the null hypothesis that the two centres were equally effective in terms of this short-term indicator of outcome. To achieve a meaningful comparison between centres, adjustments must be made for the factors which affect mortality.

Fatal cerebroembolism from nonbacterial thrombotic endocarditis in a trauma patient: case report and review.

Nonbacterial thrombotic endocarditis (NBTE) is a rare condition that may result in an unexpected and usually fatal cerebroembolism. It occurs in a variety of clinical situations, including malignancy, immune disorders, and sepsis, but it has rarely been reported after trauma. The formation of NBTE appears to require a hypercoagulable state and changes in valvular morphology, e.g., during a hyperdynamic state. Patients with disseminated intravascular coagulation have a 21% incidence of NBTE. Although NBTE is usually found at autopsy, premorbid detection by echocardiography is currently possible and feasible. Untreated patients have a high incidence of embolic events, but anticoagulation with heparin may be life-saving. A lethal case of NBTE in a severely injured patient is reported here with the purpose of increasing awareness among medical personnel caring for trauma patients. Recommendations have been made for surveillance echocardiography in high-risk patients, e.g., critically ill patients with sepsis or disseminated intravascular coagulation.

Statewide variation in the treatment of patients hospitalized with spleen injury.

HYPOTHESIS: Surgeons' treatment decisions for patients with spleen injuries in Washington State from January 1, 1990, through December 31, 1994, were different in rural compared with urban communities. DESIGN AND SETTINGS: Retrospective cohort analyses using the Death and Illness History Database for the state of Washington, which provides a cross-linked record of an individual's sequential hospitalizations. Counties were defined as metropolitan, urban, or rural on the basis of population density. PATIENTS: A total of 1905 patients (1927 hospitalizations) with an International Classification of Diseases, Ninth Revision, Clinical Modification, discharge diagnosis code of 865. MAIN OUTCOME MEASURES: Physician management decisions (perform a celiotomy or repair the spleen) were stratified by geographic region. RESULTS: Throughout the state, there was substantial variability in the treatment of spleen-injured patients. Factors associated with higher odds of splenectomy included older age, overall severity of injury, treatment in rural hospitals, and treatment in the earlier years of study. While the frequency of splenic salvage increased over time, hospital length of stay, rehospitalization, and 30-day mortality did not increase. CONCLUSIONS: Injury to the spleen is a common problem for which management decisions vary by geographic region, indicating that a single management protocol does not universally apply. To evaluate appropriateness of care by process measures, such as splenic injury management, will require that decision makers grant some latitude in management variability based on factors such as practice setting.

A historical perspective of trauma system development in the United States.

The concept of a trauma system as public health policy has developed substantially during the 30 years since publication of Accidental Death and Disability: The Neglected Disease of Modern Society. The military experience with casualties established the public expectation that grievously injured citizens should be expected to survive if a system enables a team of experts to work smoothly together. The federal government has invested hundreds of millions of dollars in support of development of an infrastructure of emergency medical systems throughout the country, and trauma systems have benefited from timely prehospital care provided by trained professionals. State or regional metropolitan governments have initiated establishment of trauma systems as fusions of health care and the politics of health care policy. Trauma systems can be considered an experiment in health care policy because they have characteristics uncommon with other areas of medical practice. Hospitals have been categorized by means of outside review based on their capabilities to provide trauma care, which has led to designation, whereby individuals are transported to trauma centers after serious injury rather than the hospitals they might normally choose. The performance of hospitals and health providers in a trauma system is subjected to outside review and some form of public accountability. All of the effort, money, and work committed to trauma systems requires careful scrutiny to determine whether trauma systems are indeed beneficial. Have trauma systems reduced death, ameliorated disability, and successfully prevented the problems these public health policies intend to manage?