Risk Factors Associated with Traumatic Brain Injury and Implementation of Guidelines for Requesting Computed Tomography After Head Trauma Among Children in France.

Importance: Pediatric traumatic brain injuries (TBIs) are a leading cause of death and disability. The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide a framework for requesting head computed tomography (HCT) after pediatric head trauma (PHT); however, quantitative data are lacking regarding both TBIs found on HCT and justification of the HCT request according to the PECARN guidelines. Objectives: To evaluate the types, frequencies, and risk factors for TBIs on HCT in children referred to emergency departments (EDs) who underwent HCT for PHT and to evaluate quality of HCT request. Design, Setting, and Participants: This multicenter, retrospective cohort study included patients younger than 18 years who underwent HCT for PHT who were referred to 91 EDs during on-call hours between January 1, 2020, to May 31, 2022. Data were analyzed between July and August 2022. Exposure: All radiological reports with pathologic findings were reviewed by 4 senior radiologists. Six hundred HCT requests filled by emergency physicians were randomly sampled to review the examination justification according to the PECARN guidelines. Main Outcomes and Measures: Associations between TBIs, age, sex, and Glasgow Coma Scale (GCS) were investigated using univariable χ2 and Cochrane-Armitage tests. Multivariable stepwise binary logistic regressions were used to estimate the odds ratio (ORs) for intracranial hemorrhages (ICH), any type of fracture, facial bone fracture, and skull vault fracture. Results: Overall, 5146 children with HCT for PHT were included (median [IQR] age, 11.2 [4.7-15.7] years; 3245 of 5146 [63.1%] boys). ICHs were diagnosed in 306 of 5146 patients (5.9%) and fractures in 674 of 5146 patients (13.1%). The following variables were associated with ICH in multivariable analysis: GCS score of 8 or less (OR, 5.83; 95% CI, 1.97-14.60; P < .001), extracranial hematoma (OR, 2.54; 95% CI, 1.59-4.02; P < .001), skull base fracture (OR, 9.32; 95% CI, 5.03-16.97; P < .001), upper cervical fracture (OR, 19.21; 95% CI, 1.79-143.59; P = .006), and skull vault fracture (OR, 35.64; 95% CI, 24.04-53.83; P < .001). When neither extracranial hematoma nor fracture was found on HCT, the OR for presenting ICH was 0.034 (95% CI, 0.026-0.045; P < .001). Skull vault fractures were more frequently encountered in children younger than 2 years (multivariable OR, 6.31; 95% CI, 4.16-9.66; P < .001; reference: children ≥12 years), whereas facial bone fractures were more frequently encountered in boys older than 12 years (multivariable OR, 26.60; 95% CI, 9.72-109.96; P < .001; reference: children younger than 2 years). The justification for performing HCT did not follow the PECARN guidelines for 396 of 589 evaluable children (67.2%) for requests filled by emergency physicians. Conclusion and Relevance: In this cohort study of 5146 children who underwent HCT for PHT, knowing the odds of clinical and radiological features for ICHs and fractures could help emergency physicians and radiologists improve their image analysis and avoid missing significant injuries. The PECARN rules were not implemented in nearly two-thirds of patients.

Fighting and Penalty Minutes Associated With Long-term Mortality Among National Hockey League Players, 1967 to 2022.

Importance: National Hockey League (NHL) players are exposed to frequent head trauma. The long-term consequences of repetitive brain injury, especially for players who frequently engage in fighting, remains unknown. Objective: To investigate the mortality rates and causes of death among NHL enforcers with more career fights and penalty minutes as compared with matched controls. Design, Setting, and Participants: This matched cohort study examined 6039 NHL players who participated in at least 1 game in the seasons between October 11, 1967, and April 29, 2022, using official NHL data. Cohorts designated as enforcer-fighter (E-F) and enforcer-penalties (E-P) were selected. The E-F cohort consisted of players who participated in 50 or more career fights (n = 331). The E-P cohort included players with 3 or more penalty minutes per game (n = 183). Control-matched NHL players were identified for each E-F player (control-fighter [C-F]) (n = 331) and each E-P player (control-penalties [C-P]) (n = 183). Exposures: Fighting and penalty minutes were both used as proxies for head trauma exposure. Players with significantly increased exposure to fighting and penalties (E-F and E-P cohorts) were compared with NHL players with less frequent exposure to head trauma (C-F and C-P cohorts). Main Outcomes and Measures: Mortality rates and age at death of the enforcer and control cohorts, and their causes of death using data obtained from publicly available sources such as online and national news sources, including NHL.com. Results: Among the 6039 NHL players identified (mean [SD] age, 47.1 [15.2] years), the mean (SD) number of fights was 9.7 (24.5). The mortality rates of E-F and C-F players (13 [3.9%] vs 14 [4.2%], respectively; P = .84) or E-P and C-P players (13 [7.1.%] vs 10 [5.5%]; P = .34) were not significantly different. The mean (SD) age at death was 10 years younger for E-F players (47.5 [13.8] years) and E-P players (45.2 [10.5] years) compared with C-F players (57.5 [7.1] years) and C-P players (55.2 [8.4] years). There was a difference in causes of death between the control and enforcer players (2 neurodegenerative disorders, 2 drug overdoses, 3 suicides, and 4 vehicular crashes among enforcers vs 1 motor vehicle crash among controls; P = .03), with enforcers dying at higher rates of overdose (2 of 21 [9.5%] vs 0 of 24) and suicide (3 of 21 [14.3%] vs 0 of 24) (P = .02). Conclusions and Relevance: The findings of this matched cohort study indicate that there is no difference in overall mortality rates between NHL enforcers and controls. However, being an enforcer was associated with dying approximately 10 years earlier and more frequently of suicide and drug overdose.

RISK FACTORS OF AMYOTROPHIC LATERAL SCLEROSIS IN GEORGIA.

Objective - to identify risk factors in patients diagnosed with Amyotrophic Lateral Sclerosis in Georgia directed to The First University Clinic of TSMU and P. Sarajishvili Institute of Neurology. Totally 53 patients, aged 24 to 82 years, were investigated with Amyotrophic Lateral Sclerosis (ALS), defined by "Gold Coast " criteria. We have used the Questionnaire for Environmental Exposures, Toxins, and Neurological diseases developed by Dartmouth-Hitchcock Medical center to identify risk factors, and categorized patients according to the place of settlement and environmental hazards. The control consisted of age and sex matched 50 healthy individuals. The brain was visualized by MRI (1.5T), and Electromyography (EMG) was performed on all patients. ALS risk was higher among those ever holding a job in mechanics, painting, or construction (p<0.05), head trauma or concussion that caused a "blackout" or loss of consciousness was associated with a higher risk of ALS (p<0.01). Demographically more ALS cases were found in Tbilisi and Imereti, compared to other regions (p<0.05). According to our research on Georgian ALS cases, several occupational jobs, Head trauma is associated with developing ALS in Georgia, Research is needed to identify environmental risk factors attributing to higher rates of ALS in Tbilisi and Imereti.

Outcomes of SUBGALEAL Drain Placement after two Burr-Holes Craniectomy for Chronic Subdural Hematoma.

OBJECTIVE: To evaluate the efficacy and complications of subgaleal drain placement after two burr-holes evacuation of chronic subdural hematoma (CSDH). STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: The Neurosurgical unit of the Lady Reading Hospital, Peshawar, from April to November 2021. METHODOLOGY: Sixty-four consecutive patients diagnosed with surgically significant unilateral chronic subdural hematoma were prospectively included after obtaining informed consent. All the patients underwent two burr-holes craniectomies and evacuation, followed by subgaleal drain placement. Patient demographics, pre- and postoperative clinical information including hematoma resolution and complications were collected. RESULTS: This study included 44 (69%) males and 20 (31%) females with a mean age of 70.1 ± 8 years. The most common presenting symptoms were headaches (70%) and confusion (68%). Eighteen patients (28%) were taking warfarin or other anticoagulants, whereas, 23 patients (36%) were taking antiplatelet medications at the time of presentation. Thirty-six (56.3%) patients had a history of head trauma. Warfarin use was statistically significant in the patients with no history of head injury. Fifty-five patients (85%) showed no significant recurrence on the 2 week postoperative computed tomography (CT) scan. None of the patients had intraparenchymal hematoma or contusion of iatrogenic origin on postoperative CT scans. CONCLUSION: Subgaleal drain placement after two burr-holes craniectomy led to high-resolution rates. However, no parenchymal injuries were attributed to the procedure. KEY WORDS: Chronic subdural hematoma, Subdural drain, Subperiosteal drain, Burr-hole craniostomy.

Head Injuries and Emergencies in Sports.

Head injuries are a common occurrence in sports and can involve injuries to the brain, skull, and superficial soft tissues. The most commonly discussed diagnosis is a concussion. Head and cervical spine injuries must be considered together at times, due to the overlapping nature of symptoms present during on-field evaluation. This article presents a range of head injuries, along with critical steps in evaluation and management.

Predicting Complicated Mild Traumatic Brain Injury in Adolescent Trauma to Enhance Clinical Decisions in Imaging.

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury algorithm is used to identify children at low risk of clinically significant traumatic brain injuries to reduce computed tomography (CT) exposure. Adapting PECARN rules based on population-specific risk stratification has been suggested to improve diagnostic accuracy. OBJECTIVE: This study sought to identify center-specific patient variables, beyond PECARN rules, that may enhance the identification of patients requiring neuroimaging. METHODS: This single-center, retrospective cohort study was conducted from July 1, 2016, to July 1, 2020, in a Southwestern U.S. Level II pediatric trauma center. The inclusion criteria were adolescents (10-15 years), Glasgow Coma Scale (13-15), with a confirmed mechanical blow to the head. Patients without a head CT were excluded. Logistic regression was performed to identify additional complicated mild traumatic brain injury predictor variables beyond the PECARN. RESULTS: There were 136 patients studied; 21 (15%) presented with a complicated mild traumatic brain injury. Relative to motorcycle collision or all-terrain vehicle trauma (odds ratio [OR] 211.75, 95% confidence interval, CI [4.51, 9931.41], p < .001), an unspecified mechanism (OR 42.0, 95% CI [1.30, 1350.97], p = .03) and consult activation (OR 17.44, 95% CI [1.75, 173.31], p = .01) were significantly associated with complicated mild traumatic brain injury. CONCLUSIONS: We identified additional factors associated with complex mild traumatic brain injury, including motorcycle collision and all-terrain vehicle trauma, unspecified mechanism, and consult activation that are not in the PECARN imaging decision rule. Adding these variables may aid in determining the need for appropriate CT scanning.

Rapid absorption of frontal lobe contusion and laceration with hematoma: A case report and review of literature.

RATIONALE: It is rare for a traumatic intracranial hematoma to self-absorb rapidly after conservative treatment. To the best of our knowledge, there has been no report in the relevant literature of rapid absorption of hematoma formation following cerebral contusion and laceration. PATIENT CONCERNS: A 54-year-old male was admitted to our hospital with head trauma at 3 hours prior to admission. He was alert and oriented, glasgow coma scale score of 15. Head computed tomography (CT) showed left frontal brain contusion with hematoma, however, a reexamination of CT about 29 hours following the trauma revealed that the hematoma had been absorbed. DIAGNOSES: A diagnosis of contusion and laceration of left frontal lobe with hematoma formation was made based on the CT images. INTERVENTIONS: The patient underwent conservative treatment. OUTCOMES: After treatment, dizziness and headache subsided for the patient, and no special discomfort was reported. LESSONS: It is likely that the reason for rapid absorption in this case is that the hematoma is prone to liquefaction because of abnormal platelet values and coagulation dysfunction. As the liquefaction hematoma breaks into the lateral ventricle, it is redistributed and absorbed in the lateral ventricle and subarachnoid space. Further evidence is required to support this hypothesis.

CEREBO®: A Portable Device for Non-invasive Detection of Intracranial Hematomas in Real Time.

Context: Brain injury has become a silent epidemic and has very low survival and recovery rates because of inaccurate triaging, especially in absence of symptoms. Therefore, a clinical assessment tool for quick onsite detection of intracranial hematoma is necessary. Aims: This study aims to assess the efficacy of the near infrared-based device CEREBO® for the non-invasive detection of intracranial hematomas in traumatic head injury patients. Settings and Design: Observational, prospective, cohort, single-center study. Methods and Materials: Forty-four patients recruited from the Department of Neurosurgery of Civil Hospital, Ahmedabad, between 3 and 85 years from June 2018 to March 2020 were examined by CEREBO® and computed tomography (CT) scan within 72 h post-injury or first onset of symptoms to measure the desired parameters. Statistical Analysis Used: SAS 9.4. Results: The device exhibited high sensitivity (94.87%) and specificity (76.19%) for unilateral hematomas with a positive predictive value (PPV) of 93.67% and a negative predictive value (NPV) of 80%. For bilateral hematomas, the device exhibited a sensitivity of 80%, specificity of 77.78%, PPV 83.33%, and NPV 73.68%. Conclusions: This study establishes the efficacy of CEREBO® to be used as a point-of-care medical screening device for detecting brain hematomas in patients who have had a head injury and is therefore recommended as an adjunct to CT scan. In the triaging or diagnosis phase, it allows for early treatment and thus helps to reduce the secondary injury resulting from the existing and delayed hematomas.

[Primary injuries of corpus callosum vessels in craniocerebral injuries]. / Pervichnye povrezhdeniya sosudov mozolistogo tela pri cherepno-mozgovoi travme.

The aim of the scientific work is to establish morphological characteristics of hemorrhages in the corpus callosum as a marker of primary vascular injuries in diffuse axonal injury (DAI) in relation to the goals and objectives of forensic examination. Changes in the structures of corpus callosum were analyzed in 45 corpses of persons with traumatic brain injury who died in hospital from DAI diagnosed according to clinical and instrumental data within 24 hours after the trauma. The changes were characterized by rectic hemorrhages (haemorrhagia per rhexin) in combination with successively developing vascular, tissue, and cellular post-traumatic reactions. These changes were not observed in the control group. The following morphological characteristics of hemorrhages were established: small focal, elongated, clearly contoured hemorrhages of different sizes, up to 4 mm long, up to 0.8 mm wide, unidirectional at an angle from the lower to upper surface of the sagittal corpus callosum section, at least three, grouped in limited areas sized up to 1.5 × 1.0 cm without clear borders. The detected hemorrhages and the course of changes give reason to consider them the result of primary traumatic effects, making them a diagnostic marker of DAI.

[Rare cases of head traumas incited by propeller blades of small vessels]. / Redkie sluchai travm golovy, prichinennykh lopastyami grebnykh vintov malomernykh sudov.

2 cases of death in males due to multiple head impacts by propeller blades of small vessels are given. The set of the following signs provides a basis for confirming the above-mentioned mechanism and properties of the traumatic object: multiplicity, oblong shape, parallel step-like arrangement of injury lengths, acute-angled M-shaped or Y-shaped injury ends, uneven edges, sometimes with the formation of small flaps and abrasion, lumpy wound walls, multi-fragmented nature of fractures in a limited area of the skullcap and facial skull bones, the location of damage to intracranial structures in the projection of external injuries and fractures of the cerebral skull bones.

Short Falls in Childhood Occasionally Cause Major Brain Injuries Because of Unusual Circumstances.

METHODS: Records and imaging were reviewed for children younger than 6 years, hospitalized between 2015 and 2020 for major closed head injuries following less than 4-ft falls. Major injury was defined as intensive care admission more than 2 days, neurosurgical intervention, death, or disability at hospital discharge. Subjects were identified through Seattle and Spokane, Washington abuse consultations. Harborview Medical Center's trauma registry and Seattle Children's Hospital's Hemophilia Treatment Program and Radiology were searched for subjects. RESULTS: We identified 12 young children who sustained major closed head injury due to short falls. Seven developed major space-occupying epidural hemorrhages. One child developed internal hydrocephalus after intraventricular hemorrhage. One child with prior meningomyelocele, Chiari 2 malformation, and ventriculoperitoneal shunt developed shunt decompensation after an acute-on-chronic subdural hemorrhage. One child developed an internal capsule stroke because of a previously undiagnosed calcifying angiopathy. Another child developed space-occupying subdural hemorrhage associated with previously unrecognized platelet pool disorder. Only this child had abuse concerns, which were resolved with his coagulopathy diagnosis. One child had a diastatic skull fracture leading to pseudomeningocele.At Harborview Medical Center, 140 children were seen for short falls in the emergency department or inpatient service. Among the 40 needing intensive care, 4 (12.5%) had major injuries after short falls. Our hemophilia treatment program did not see any children who had sustained major injury following a short fall in a 5½ year period. CONCLUSIONS: Although young children rarely sustain major head injury following short falls, serious head injuries do occasionally occur because of unusual injury mechanisms or preexisting conditions. It is important to fully evaluate these patients to differentiate these unintentional falls from abusive head injury.

Trauma deaths of hospitalized patients in Abu Dhabi Emirate: a retrospective descriptive study.

AIM: To study the epidemiology and pattern of trauma-related deaths of hospitalized patients in Abu Dhabi Emirate, United Arab Emirates, in order to improve trauma management and injury prevention. METHODS: The Abu Dhabi Trauma Registry prospectively collects data of all hospitalized trauma patients from seven major trauma centres in Abu Dhabi Emirate. We studied all patients who died on arrival or after admission to these hospitals from January 2014 to December 2019. RESULTS: There were 453 deaths constituting 13.5% of all trauma deaths in the Abu Dhabi Emirate. The median (IQR) age of the patients was 33 (25-45) years, and 82% were males. 85% of the deaths occurred in the emergency department (ED) and the intensive care unit (ICU). Motor vehicle collision (63.8%) was the leading cause of death. 45.5% of the patients had head injury. Two of the seven hospitals admitted around 50% of all patients but accounted for only 25.8% of the total deaths (p < 0.001). Those who died in the ward (7%) were significantly older, median (IQR) age: of 65.5 (31.75-82.25) years, (p < 0.001), 34.4% of them were females (p = 0.09). The median (IQR) GCS of those who died in the ward was 15 (5.75-15) compared with 3 (3-3) for those who died in ED and ICU (P < 0.001). CONCLUSIONS: Death from trauma predominantly affects young males with motor traffic collision as the leading cause. Over 85% of in-hospital deaths occur in the ICU and ED, mainly from head injuries. Injury prevention of traffic collisions through enforcement of law and improved hospital care in the ED and ICU will reduce trauma death.

The Impact of the COVID-19 Pandemic on Pediatric Bicycle Injury.

Bicycling is a common childhood activity that is associated with significant injury risk. This study's aim was to assess pediatric bicycle injury epidemiology and impacts of the COVID-19 pandemic. We conducted a cross-sectional evaluation of patients age < 18 years presenting with bicycle injury to a pediatric trauma center. A pre-pandemic period (1 March 2015-29 February 2020) was compared to the pandemic period (1 March 2020-28 February 2021). A total of 611 injury events for children < 18 years were included (471 pre-pandemic events and 140 pandemic events). The relative frequency of pandemic injuries was greater than pre-pandemic injuries (p < 0.001), resulting in a 48% increase in pandemic period injuries versus the pre-pandemic average (141 pandemic vs. 94.4/year pre-pandemic). Individuals of female sex represented a larger proportion of injuries in the pandemic period compared to the pre-pandemic period (37% pandemic vs. 28% pre-pandemic, p = 0.035). Injuries were more common on weekends versus weekdays (p = 0.01). Time series analysis showed a summer seasonality trend. Localizing injury events to ZIP codes showed regional injury density patterns. During COVID-19, there was an increase in bicycle injury frequency and proportional shift toward more injuries involving individuals of female sex. Otherwise, injury patterns were largely unchanged. These results demonstrate the necessity of safety interventions tailored to community needs.

Influence of surrogate scalp material and thickness on head impact responses: Toward a biofidelic head-brain physical model.

Advanced physical head models capable of replicating both global kinematics and intracranial mechanics of the human head are required for head injury research and safety gear assessment. These head surrogates require a complex design to accommodate realistic anatomical details. The scalp is a crucial head component, but its influence on the biomechanical response of such head surrogates remains unclear. This study aimed to evaluate the influence of surrogate scalp material and thickness on head accelerations and intraparenchymal pressures using an advanced physical head-brain model. Scalp pads made from four materials (Vytaflex20, Vytaflex40, Vytaflex50, PMC746) and each material with four thicknesses (2, 4, 6, and 8 mm) were evaluated. The head model attached to the scalp pad was dropped onto a rigid plate from two heights (5 and 19.5 cm) and at three head locations (front, right side, and back). While the selected materials' modulus exhibited a relatively minor effect on head accelerations and coup pressures, the effect of scalp thickness was shown to be major. Moreover, by decreasing the thickness of the head's original scalp by 2 mm and changing the original scalp material from Vytaflex 20 to Vytaflex 40 or Vytaflex 50, the head acceleration biofidelity ratings could improve by 30% and approached the considered rating (0.7) of good biofidelity. This study provides a potential direction for improving the biofidelity of a novel head model that might be a useful tool in head injury research and safety gear tests. This study also has implications for selecting appropriate surrogate scalps in the future design of physical and numerical head models.

Ondansetron Safety Regarding Prolong QTc for Children with Head Trauma.

BACKGROUND: There have been recent reports of increased QT interval after head trauma in concussed athletes and adult patients. Ondansetron, which is widely used in treatment of nausea and vomiting symptoms in head injuries, was issued a safety warning from the U.S. Food and Drug Administration regarding QT prolongation and risk of fatal dysrhythmias. OBJECTIVE: The purpose of this study was to evaluate the safety of ondansetron regarding QT prolongation for patients experiencing nausea or vomiting after head trauma. METHODS: Patients aged 1-20 years presenting to a pediatric emergency department with head trauma and who required a dose of ondansetron for nausea or vomiting were enrolled in the study. Patients received a baseline 12-lead electrocardiogram (ECG) prior to administration of either oral or IV ondansetron. A second post-ondansetron 12-lead ECG was performed after administration of ondansetron. All ECGs were reviewed and the QTc calculated manually by a board-certified pediatric cardiologist. RESULTS: Forty-two patients met enrollment criteria. Five patients received IV ondansetron and 37 received oral ondansetron. Mean QTc pre ondansetron was 387.5 ms and mean QTc post ondansetron was 400.9 ms (p = 0.120). We found no statistically significant difference in other ECG parameters pre and post ondansetron. CONCLUSIONS: Ondansetron is safe in regard to QTc prolongation in patients with head trauma. Based on this research, ondansetron should continue to be used for the treatment of nausea and vomiting in emergency department patients who present with head injury.

Ultramassive Transfusion for Trauma in the Age of Hemostatic Resuscitation: A Retrospective Single-Center Cohort From a Large US Level-1 Trauma Center, 2011-2021.

BACKGROUND: Uncontrolled bleeding is a leading cause of death in trauma. In the last 40 years, ultramassive transfusion (UMT; ≥20 units of red blood cells [RBCs]/24 hours) for trauma has been associated with 50% to 80% mortality; the question remains as to whether the increasing number of units transfused in urgent resuscitation is a marker of futility. We asked whether the frequency and outcomes of UMT have changed in the era of hemostatic resuscitation. METHODS: We performed a retrospective cohort study of all UMTs in the first 24 hours of care over an 11-year period at a major US level-1 adult and pediatric trauma center. UMT patients were identified, and a dataset was built by linking blood bank and trauma registry data, then reviewing individual electronic health records. Success in achieving hemostatic proportions of blood products was estimated as (units of plasma + apheresis-platelets-in-plasma + cryoprecipitate-pools + whole blood]/[all units given] ≥0.5. Demographics, injury type (blunt or penetrating), severity (Injury Severity Score [ISS]), severity pattern (Abbreviated Injury Scale score for head [AIS-Head] ≥4), admitting laboratory, transfusion, selected emergency department interventions, and discharge status were assessed using χ2 tests of categorical association, the Student t-test of means, and multivariable logistic regression. P <.05 was considered significant. RESULTS: Among 66,734 trauma admissions from April 6, 2011 to December 31, 2021, we identified 6288 (9.4%) who received any blood products in the first 24 hours, 159 of whom received UMT (0.23%; 154 aged 18-90 + 5 aged 9-17), 81% in hemostatic proportions. Overall mortality was 65% (n = 103); mean ISS = 40; median time to death, 6.1 hours. In univariate analyses, death was not associated with age, sex, or more RBC units transfused beyond 20 but was associated with blunt injury, increasing injury severity, severe head injury, and failure to receive hemostatic blood product ratios. Mortality was also associated with decreased pH and evidence of coagulopathy at admission, especially hypofibrinogenemia. Multivariable logistic regression showed severe head injury, admission hypofibrinogenemia and not receiving a hemostatic resuscitation proportion of blood products as independently associated with death. CONCLUSIONS: One in 420 acute trauma patients at our center received UMT, a historically low rate. A third of these patients lived, and UMT was not itself a marker of futility. Early identification of coagulopathy was possible, and failure to give blood components in hemostatic ratios was associated with excess mortality.

Determinants of motorcycle helmet availability and cost in retail outlets: outcomes of a market survey in northern Ghana.

BACKGROUND: Morbidity and mortality from road traffic crashes are steadily increasing globally and they remain a major public health challenge. This burden is disproportionately borne by low-and middle-income countries, especially Sub-Saharan Africa where motorcycle helmet use is low and where there are challenges of affordability and availability of standard helmets. We sought to assess the availability and cost of helmets in retail outlets in northern Ghana. METHODS: A market survey of 408 randomly sampled automobile-related retail outlets in Tamale, northern Ghana was conducted. Multivariable logistic regression was used to identify factors associated with helmet availability and gamma regression was used to identify factors associated with their cost. RESULTS: Helmets were available in 233 (57.1%) of surveyed retail outlets. On multivariable logistic regression, street vendors were 48% less likely and motorcycle repair shops 86% less likely to sell helmets than automobile/motorcycle shops. Outlets outside the Central Business District were 46% less likely to sell helmets than outlets inside that district. Nigerian retailers were five times more likely to sell helmets than Ghanaian retailers. Median helmet cost was 8.50 USD. Helmet cost decreased by 16% at street vendors, 21% at motorcycle repair shops, and 25% at outlets run by the owner. The cost increased by older age of retailer (1% per year of age), education level of retailer (12% higher for secondary education, 56% higher for tertiary education, compared to basic education), and sex (14% higher for male retailer). CONCLUSION: Motorcycle helmets were available in some retail outlets in northern Ghana. Efforts to improve helmet availability should address outlets in which they are less commonly sold, including street vendors, motorcycle repair shops, outlets run by Ghanaians, and outlets outside the Central Business District.