Noninvasive techniques for blood pressure measurement are not a reliable alternative to direct measurement: a randomized crossover trial in ICU.

INTRODUCTION: Noninvasive blood pressure (NIBP) monitoring methods are widely used in critically ill patients despite poor evidence of their accuracy. The erroneous interpretations of blood pressure (BP) may lead to clinical errors. OBJECTIVES: To test the accuracy and reliability of aneroid (ABP) and oscillometric (OBP) devices compared to the invasive BP (IBP) monitoring in an ICU population. MATERIALS AND METHODS: Fifty adult patients (200 comparisons) were included in a randomized crossover trial. BP was recorded simultaneously by IBP and either by ABP or by OBP, taking IBP as gold standard. RESULTS: Compared with ABP, IBP systolic values were significantly higher (mean difference ± standard deviation 9.74 ± 13.8; P < 0.0001). Both diastolic (-5.13 ± 7.1; P < 0.0001) and mean (-2.14 ± 7.1; P=0.0033) IBP were instead lower. Compared with OBP, systolic (10.80 ± 14.9; P < 0.0001) and mean (5.36 ± 7.1; P < 0.0001) IBP were higher, while diastolic IBP (-3.62 ± 6.0; P < 0.0001) was lower. Bland-Altman plots showed wide limits of agreement in both NIBP-IBP comparisons. CONCLUSIONS: BP measurements with different devices produced significantly different results. Since in critically ill patients the importance of BP readings is often crucial, noninvasive techniques cannot be regarded as reliable alternatives to direct measurements.

Cross-sectional investigation of HEMS activities in Europe: a feasibility study.

OBJECTIVES: To gather information on helicopter emergency medical services (HEMSs) activities across Europe. METHODS: Cross-sectional data-collection on daily (15 November 2013) activities of a sample of European HEMSs. A web-based questionnaire with both open and closed questions was used, developed by experts of the European Prehospital Research Alliance (EUPHOREA). RESULTS: We invited 143 bases from 11 countries; 85 (60%) reported base characteristics only and 73 (51%) sample-day data too. The variety of base characteristics was enormous; that is, the target population ranged from 94.000 to 4.500.000. Of 158 requested primary missions, 62 (0.82 per base) resulted in landing. Cardiac aetiology (36%) and trauma (36%) prevailed, mostly of life-threatening severity (43%, 0.64 per mission). Had HEMS been not dispatched, patients would have been attended by another physician in 67% of cases, by paramedics in 24%, and by nurses in 9%. On-board physicians estimated to have caused a major decrease of death risk in 47% of missions, possible decrease in 22%, minor benefit in 17%, no benefit in 11%, and damage in 3%. Earlier treatment and faster transport to hospital were the main reasons for benefit. The most frequent therapeutic procedure was drug administration (78% of missions); endotracheal intubation occurred in 25% of missions and was an option hardly offered by ground crews. CONCLUSIONS: The study proved feasible, establishing an embryonic network of European HEMS. The participation rate was low and limits the generalizability of the results. Fortunately, because of its cross-sectional characteristics and the handy availability of the web platform, the study is easily repeatable with an enhanced network.

A population based study on the night-time effect in trauma care.

BACKGROUND: The so-called off hour effect-that is, increased mortality for patients admitted outside normal working hours-has never been demonstrated in trauma care. However, most of the studies excluded transferred cases. Because these patients are a special challenge for trauma systems, we hypothesised that their processes of care could be more sensitive to the off hour effect. METHODS: The study design was retrospective, cohort and population based. We compared the mortality of all patients by daytime and night-time admittance to hospitals in an Italian region, with 4.5 million inhabitants, following a major injury in 2011. Logistic regression was used, adjusted for demographics and severity of injury (TMPM-ICD9), and stratified by transfer status. RESULTS: 1940 major trauma cases were included; 105 were acutely transferred. Night-time admission had a significant pejorative effect on mortality in the adjusted analysis (OR=1.49; 95% CI 1.05 to 2.11). This effect was most evident in transferred cases (OR=3.71; 95% CI 1.11 to 12.43). CONCLUSIONS: The night-time effect in trauma care was demonstrated for the first time and was maximal in transferred cases. This may explain why it was not found in previous studies where these patients were mostly excluded. Also, the use of population based data-whereby patients not accessing trauma centre care and presumably receiving poorer care were included-may have contributed to the findings.

Collecting core data in severely injured patients using a consensus trauma template: an international multicentre study.

INTRODUCTION: No worldwide, standardised definitions exist for documenting, reporting and comparing data from severely injured trauma patients. This study evaluated the feasibility of collecting the data variables of the international consensus-derived Utstein Trauma Template. METHODS: Trauma centres from three different continents were invited to submit Utstein Trauma Template core data during a defined period, for up to 50 consecutive trauma patients. Directly admitted patients with a New Injury Severity Score (NISS) equal to or above 16 were included. Main outcome variables were data completeness, data differences and data collection difficulty. RESULTS: Centres from Europe (n = 20), North America (n = 3) and Australia (n = 1) submitted data on 965 patients, of whom 783 were included. Median age was 41 years (interquartile range (IQR) 24 to 60), and 73.1% were male. Median NISS was 27 (IQR 20 to 38), and blunt trauma predominated (91.1%). Of the 36 Utstein variables, 13 (36%) were collected by all participating centres. Eleven (46%) centres applied definitions of the survival outcome variable that were different from those of the template. Seventeen (71%) centres used the recommended version of the Abbreviated Injury Scale (AIS). Three variables (age, gender and AIS) were documented in all patients. Completeness > 80% was achieved for 28 variables, and 20 variables were > 90% complete. CONCLUSIONS: The Utstein Template was feasible across international trauma centres for the majority of its data variables, with the exception of certain physiological and time variables. Major differences were found in the definition of survival and in AIS coding. The current results give a clear indication of the attainability of information and may serve as a stepping-stone towards creation of a European trauma registry.

[Assessment of the regional Emergency Medical Service of Friuli-Venezia-Giulia based on the Mattoni SSN Quality Indicators]. / Applicazione degli indicatori di qualità del progetto Mattoni SSN per la valutazione del Sistema 118 Friuli Venezia Giulia.

OBJECTIVES: The need for shared definitions and evidence based quality-indicators is widely perceived among Emergency Medical Services (EMS). In the region Friuli Venezia Giulia (FVG), Italy, both an EMS and a data collection system were established several years ago, but a comprehensive assessment of their quality had never been attempted and is the purpose of this study. DESIGN: Analysis of data regarding EMS emergency activities in the period January - September 2009. The quality indicators proposed by the national project entitled «Progetto Mattoni¼ were used. SETTING: 79 915 records were included, corresponding to 68 340 calls, 78 158 missions, 50 168 patients. RESULTS: The database has poor accuracy and accessibility. Only 20/64 indicators could be applied. Some of their definitions limit the applicability and/or reproducibility. The distribution of resources among the 4 operative centres of the region is uneven, as well as their performances in terms of call-to arrival interval. The standard recommended by the national guidelines for urban areas (8 minutes) is respected in only 56%of cases.The rescue intervals are shorter in operative centers with more resources per capita. CONCLUSIONS: There is considerable scope for improvement in both the data collection system and EMS.The indicators themselves should be partly revised.

A case-crossover study of sleep and work hours and the risk of road traffic accidents.

STUDY OBJECTIVES: Sleepiness, prolonged wakefulness, and extended work hours have been associated with increased risk of injuries and road accidents. The authors' objective was to study the relation between those factors and road accidents using a case-crossover design, effective in estimating the risk of acute events associated with transient, short effect exposures. DESIGN: Five hundred seventy-four injured drivers presenting for care after road accidents to the Emergency Room of Udine, Italy, were enrolled in the study from March 2007 to March 2008. Sleep, work, and driving patterns in the 48 h before the accident were assessed through an interview. MEASUREMENTS AND RESULTS: The relative risk (RR) of accident associated with each exposure was estimated using the case-crossover matched pair interval approach. Sleeping > or = 11 h daily was associated with a decrease of the RR, as was sleeping less than usual. Being awake > or = 16 h and, possibly, working > 12 h daily were associated with increases in the RR. CONCLUSIONS: Extended work hours and prolonged wakefulness increase the risk of road accidents and suggest that awareness should be raised among drivers. The findings regarding acute sleep amount are less clear, possibly due to an effect of chronic sleep loss.

Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED.

OBJECTIVES: The aim of this study is to assess the ability of bedside lung ultrasound (US) to confirm clinical suspicion of pneumonia and the feasibility of its integration in common emergency department (ED) clinical practice. METHODS: In this study we performed lung US in adult patients admitted in our ED with a suspected pneumonia. Subsequently, a chest radiograph (CXR) was carried out for each patient. A thoracic computed tomographic (CT) scan was made in patients with a positive lung US and a negative CXR. In patients with confirmed pneumonia, we performed a follow-up after 10 days to evaluate clinical conditions after antibiotic therapy. RESULTS: We studied 49 patients: pneumonia was confirmed in 32 cases (65.3%). In this group we had 31 (96.9%) positive lung US and 24 (75%) positive CXR. In 8 (25%) cases, lung US was positive with a negative CXR. In this group, CT scan always confirmed the US results. In one case, US was negative and CXR positive. Follow-up turned out to be always consistent with the diagnosis. CONCLUSION: Considering that lung US is a bedside, reliable, rapid, and noninvasive technique, these results suggest it could have a significant role in the diagnostic workup of pneumonia in the ED, even if no sensitivity nor specificity can be inferred from this study because the real gold standard is CT, which could not be performed in all patients.

A case-crossover study of alcohol consumption, meals and the risk of road traffic crashes.

BACKGROUND: The case-crossover (CC) design has proved effective to investigate the association between alcohol use and injuries in general, but has never been applied to study alcohol use and road traffic crashes (RTCs) specifically. This study aims at investigating the association between alcohol and meal consumption and the risk of RTCs using intrapersonal comparisons of subjects while driving. METHODS: Drivers admitted to an Italian emergency room (ER) after RTCs in 2007 were interviewed about personal, vehicle, and crash characteristics as well as hourly patterns of driving, and alcohol and food intake in the 24 hours before the crash. The odds ratio (OR) of a RTC was estimated through a CC, matched pair interval approach. Alcohol and meal consumption 6 and 2 hours before the RTC (case exposure window) were compared with exposures in earlier control windows of analogous length. RESULTS: Of 574 patients enrolled, 326 (56.8%) reported previous driving from 6 to 18 hours before the RTC and were eligible for analysis. The ORs (mutually adjusted) were 2.25 (95%CI 1.11-4.57) for alcohol and 0.94 (0.47-1.88) for meals. OR for alcohol was already increased at low (1-2 units) doses - 2.17 (1.03-4.57) and the trend of increase for each unit was significant - 1.64 (95%CI 1.05-2.57). In drivers at fault the OR for alcohol was 21.22 (2.31-194.79). The OR estimate for meal consumption seemed to increase in case of previous sleep deprivation, 2.06 (0.25-17.00). CONCLUSION: Each single unit of acute alcohol consumption increases the risk of RTCs, in contrast with the 'legal' threshold allowed in some countries. Meal consumption is not associated with RTCs, but its combined effects with sleepiness need further elucidation.

A comparison of European Trauma Registries. The first report from the EuroTARN Group.

UNLABELLED: Trauma management systems have grown in response to regional variations in trauma population, geographical conditions and the provisions of care. National Trauma Registries are being established to improve patient outcomes. However international comparisons could provide the potential to record regional performance, identify and share examples of best practice. To assess whether it was possible to compare data currently being collected by a number of trauma services across Europe, a group was established to develop a common core dataset and to assess the feasibility of collecting anonymised data. METHOD: A series of meetings with European collaborators led to the creation of a group entitled EuroTARN. A website was developed in 2002 and interested parties were invited to submit suggestions for a European dataset using an online version of the Delphi technique. A core dataset was created in 2003 and in 2004 participants were invited to submit a summary of past cases online via the EuroTARN Website. RESULTS: Representatives from 14 countries met and corresponded to create the core dataset. During a trial data collection phase 14 institutions from 11 countries submitted unadjusted mortality data for over 21,500 cases with injury severity Scores of over 15 including information on multiply injured and head injured patients. The results demonstrated that there were observed differences in trauma outcome for similar groups of patients. CONCLUSION: It is possible to collect and collate outcome data from established trauma registries across Europe with minimal additional infrastructure using a web-based system. Initial analysis of the results reveals significant international variations. The network has potential as a source of data for epidemiological and clinical research and for optimal trauma system design across Europe.

The first Italian trauma registry of national relevance: methodology and initial results.

OBJECTIVE: To describe and discuss the ongoing endeavor to establish a multiregional trauma registry in Italy. DESIGN: Prospective observational analysis by description and cohort comparison. SETTING: Three Italian hospitals, referral centers for severely traumatized patients. PATIENTS: trauma victims admitted between 1 July 2004 and 28 February 2005 with an Injury Severity Score >15 or requiring early admission to intensive care. INTERVENTIONS: None. MEASURES: Compilation rates for some 'sentry' variables. Total number of patients and Injury Severity Score. Ten widely used descriptive variables (type of trauma, mechanism of injury, age, gender, Injury Severity Score, Revised Trauma Score, Prognostic Severity Index, 'call-to-hospital' and 'admission-to-ward' intervals, and outcome at 30 days) measured in the subgroup with Injury Severity Score>15, in general and by hospital. RESULTS: A trauma registry has been established that fit the present organization of trauma care in Italy. It seems to compare well with the references available in the literature. Five hundred and forty-nine patients have been enrolled so far. The compilation rate has been well above 70% for all variables in all hospitals, except pre-hospital times in two hospitals. A substantial homogeneity exists among the hospitals in the general characteristics of the patients with Injury Severity Score>15. CONCLUSIONS: The project has achieved its goals so far. The previous estimates on the number of cases (about 300/year/hospital) are confirmed and major shortcomings in methodology seem unlikely. Therefore, positive future developments are possible: usage for quality improvement and research, linkage to other European registries and participation of other hospitals.

Emergency medical service treated out-of-hospital cardiac arrest: Identification of weak links in the chain-of-survival through an epidemiological study.

BACKGROUND: In-depth analysis of emergency medical services (EMSs) performances in out-of-hospital cardiac arrest (OHCA) promotes quality improvement. AIMS: The purpose of this study was to identify the improvable factors of the EMS response to OHCA through the description and analysis of OHCA incidence, characteristics, management and outcome. METHODS: This was a retrospective cohort study on all OHCA patients treated by the EMSs of the district of Trieste, Italy (236,556 inhabitants) in 2011. RESULTS: A total of 678 OHCAs occurred and 142 (20.1%) underwent cardiopulmonary resuscitation (CPR), with a respective incidence of 287/100,000/year and 60/100,000/year. The incidence of shockable rhythms in the CPR group was 13/100,000. OHCAs occurred mainly during daytime, though the proportion of patients receiving CPR was significantly higher by night-time (p=0.01). Thirty-four CPR patients (23.9%) restored spontaneous circulation on scene; 12 (8.5%) survived to hospital discharge (11 with good neurological recovery). Survival was not correlated with age, while was significantly higher for patients with shockable rhythms (32.3%; p<0.001). Mean response time was 8 min. Direct intervention of physician-staffed units did not improve the outcome when compared with two-tiered activation. Patients immediately identified as OHCA by dispatch nurses and those undergoing therapeutic hypothermia showed a non-significant trend towards improved survival (p=0.09 and 0.07, respectively). CONCLUSIONS: OHCA identification by dispatch nurses and reduction of response time were the factors most susceptible to improvement.

Adherence to agents acting on the renin-angiotensin system in secondary prevention of non-fatal myocardial infarction: a self-controlled case-series study.

AIMS: In accordance with current guidelines, patients discharged after acute myocardial infarction (AMI) are usually prescribed agents acting on the renin-angiotensin system (ACE-I/ARB). However, adherence to prescribing medications is a recognized problem and most studies demonstrating the value of adherence were limited by their non-randomized design and by 'healthy-adherer' bias. Herein we sought to evaluate the relationship between adherence to ACE-I/ARB and risk of subsequent AMIs, by using the self-controlled case-series design which virtually eliminates interpersonal confounding, being based on intrapersonal comparisons. METHODS AND RESULTS: We linked data from three longitudinal registries containing information about hospitalizations, drug prescriptions, and vital status of all residents in an Italian region. From 30 089 patients hospitalized for AMI in the years 2009-11, we enrolled the 978 with non-fatal re-AMIs at Days 31-365 after discharge, receiving at least one ACE-I/ARB prescription collected at any of the regional pharmacies. Using information on prescriptions, each individual's observation time was then divided into periods exposed or unexposed to ACE-I/ARB. The relative re-AMI incidence rate ratios (IRRs) of ACE-I/ARB exposure were estimated by conditional Poisson regression. During drug-covered periods, the risk of AMI recurrence was ∼20% lower, i.e. the IRR (rate of recurrent AMI in exposed versus unexposed periods) was 0.79 (95% CI 0.66-0.96, P = 0.001). The benefit of ACE-I/ARB was confirmed also by sensitivity analyses considering only first recurrences, excluding cases with AMI within previous 3 years, or with long, not AMI, hospital re-admission. CONCLUSIONS: Poor adherence to ACE-I/ARB prescription medication was associated with a 20% increased risk of recurrent AMI. This was consistent with previous research, but the SCSS study design, even if not randomized, eased previous concerns about healthy-adherer bias.

Self-controlled case-series study to verify the effect of adherence to Beta-blockers in secondary prevention of myocardial infarction.

BACKGROUND: Beta-blockers (BB) are recommended in secondary prevention of acute myocardial infarction (AMI), but adherence to prescription medication is a recognized problem. Most literature on the consequences of poor adherence to prescribed BB is limited by the possibility of "healthy adherer bias" and better-designed studies have been advocated. METHODS AND RESULTS: We investigated the association between adherence to BB prescription and risk of subsequent AMIs using the self-controlled case series design, which allows improved control of interpersonal confounding, being based on intrapersonal comparisons. From all the 30 089 patients hospitalized for AMI in the years 2009-2011 in an Italian region we selected those that suffered subsequent AMIs at days 31 to 365 from discharge (1328), and then the 1207 that had at least one BB prescription collected at any of the regional pharmacies. Using information on prescriptions, each individual's observation time was then divided into periods exposed or unexposed to BB and the relative AMI incidence rate ratios (IRR) of BB exposure were estimated by conditional Poisson regression. The IRR (rate of recurrent AMI in exposed versus unexposed periods) was 0.79 (95% CI 0.69 to 0.90, P=0.001). Various sensitivity analyses confirmed the robustness to possible failure of assumptions, ie, considering only first recurrences (IRR 0.76, 95% CI 0.66 to 0.88, P<0.001), excluding cardiovascular fatalities (IRR 0.76, 95% CI 0.65 to 0.89, P<0.001), and excluding individuals with long hospital admissions (IRR 0.60, 95% CI 0.43 to 0.83, P=0.002). CONCLUSIONS: Adherence to recommended BB therapy was associated with a 20% reduction of recurrent AMIs, consistently with previous research, but with decreased concerns about healthy-adherer bias.

[Quality indicators for the assessment of ST-segment elevation acute myocardial infarction (STEMI) networks. How hospital discharge records could be integrated with Emergency medical services data: the Emilia-Romagna STEMI network experience]. / Indicatori per la valutazione dei percorsi di rete dell'infarto miocardico acuto con sopraslivellamento del tratto ST: integrazione dei dati amministrativi provenienti dalle schede di dimissione ospedaliera e dal flusso emergenza-urgenza. Esperienza della Regione Emilia-Romagna.

BACKGROUND: The assessment of the regional network for ST-segment elevation acute myocardial infarction (STEMI) is fundamental for quality assurance. Since 2011 all Italian Health Authorities, in addition to hospital discharge records (HDR), must provide a standardized information flow (ERD) about emergency department (ED) and emergency medical system (EMS) activities. The aim of this study was to evaluate whether data integration of ERD with HDR may allow the development of appropriate quality indicators. METHODS: Patients admitted to coronary care units (CCU) for STEMI between January 1 to December 31, 2013, were identified from the regional HDR database. All data were linked to those of the regional ERD database. Four quality indicators were defined: 1) rates of EMS activation, 2) rates of EMS direct transfer to the catheterization laboratory (Cath-lab), 3) transfer rates from a Spoke to a Hub hospital with angioplasty facilities, and 4) median time spent in ED. RESULTS: In 2013, 2793 patients with STEMI were admitted to the CCU. Of these, 1684 patients (60%) activated EMS and were transported to Spoke or Hub hospitals; 955 (57%) entered directly in CCU/Cath-lab; 677 were transferred directly to a Hub hospital ED without being admitted to a Spoke hospital. The median ED time in Hub hospital was 47 min (IQR 24-136) and in Spoke hospital 53 min (IQR 30-131). CONCLUSIONS: The integration among administrative data banks (i.e., HDR with ERD) allowed the assessment of the regional STEMI network and the identification of potentially useful quality indicators. Their easy availability should enable comparisons with local, national and international standards, and may favor quality improvement.

Inadequate ventilation of patients with severe brain injury: a possible drawback to prehospital advanced trauma care?

OBJECTIVES: To assess the appropriateness of arterial carbon dioxide tension control in a group of 92 patients with traumatic brain injury who, despite receiving advanced prehospital care, showed no improved outcome in comparison with a group homogeneous but for a lower level of prehospital care. METHODS: A retrospective registration of the early in-hospital arterial carbon dioxide tension of the patients intubated and ventilated on scene. Patients were excluded if the arterial carbon dioxide tension did not reflect prehospital ventilation or its alteration might have been intentional or unavoidable. RESULTS: Arterial carbon dioxide tension was normal (35-45 mmHg) in only six of the 16 suitable cases (37.5%), was elevated (>45 mmHg) in three cases (18.75%), low (25-35 mmHg) in five cases (31.25%), and extremely low (<25 mmHg) in two cases (12.5%). CONCLUSION: Potentially dangerous alterations in capnia occurred in the majority of patients analysed. The possible consequences and causes are discussed. Further studies are needed to assess the consequences of any deviation from ideal standards, and to set realistic standards of arterial carbon dioxide tension control during prehospital ventilation.

Evaluation of the survival benefit of Trauma-Centre care in the Italian setting.

BACKGROUND: Trauma Centres (TC) are expected to have a lower mortality - after controlling for injury-severity - than non-designated hospitals in order to justify their funding. This benefit has been demonstrated in the USA not long ago, while the evidence from other settings is still limited. We evaluated the mortality benefit of TC care in an Italian setting, where the first Trauma System with designated TCs was instituted six years ago. MATERIALS AND METHODS: We compared 30-day mortality among 4059 severely injured patients treated in the three TCs and in 12 other hospitals of the region Emilia-Romagna, Italy between 2007 and 2011. We used propensity-score weighting to adjust for differences in potential confounders. RESULTS: In the overall population there was no difference in the adjusted mortality - OR (95% CI) 1.02 (0.81-1.29). However, an interaction existed between TC care and injury severity. Subgroup analyses showed that the benefit of TC care was significant for the patients with a TMPM-ICD9 severity score>0.12 - OR (95% CI) 0.70 (0.52-0.97). These patients comprised about one-third of the study population. Further subgroup investigations showed that this effect was concentrated in the patients with less than 45 years. CONCLUSIONS: The risk of death for patients with particularly severe injuries is significantly lower when they are treated in TCs as compared to Non-Trauma Centres, especially if they are younger than 45 years. TC care should be provided to a larger number of patients than currently done.

Effects of anticoagulant and antiplatelet drugs on the risk for hospital admission for traumatic injuries: a case-control and population-based study.

BACKGROUND: The current cardiovascular literature advocates an overall beneficial balance between the advantages of oral anticoagulants and antiplatelet drugs in preventing and treating thromboembolic events and their disadvantages in promoting hemorrhage. However, traumatic injuries have usually received little attention despite several studies from the surgical literature showing worse outcomes in anticoagulated trauma registry patients. To quantify at population level too this seemingly deleterious impact, we investigated the effects of anticoagulants and antiplatelet use on the risk for hospital admission for acute traumatic causes. METHODS: A population-based, case-control study in an Italian region with 4.5 million inhabitants was conducted. Cases were all the 59,348 adult residents admitted to the hospital for traumatic injuries in the years 2010 and 2011. Controls were age- and sex-matched residents selected by incidence density sampling. By conditional logistic regression adjusted for comorbidities, we estimated the risk for traumatic hospital admission while on anticoagulant, antiplatelet, and combined medications. RESULTS: The odds ratios (ORs) for anticoagulation and combined medications were 1.21 (95% confidence interval [CI], 1.15-1.28) and 1.39 (95% CI, 1.21-1.62). These effects were generally consistent across subgroups of demographic and clinical characteristics and particularly important in the head injured (e.g., OR for anticoagulation, 2.00; 95% CI, 1.77-12.27). Antiplatelets alone had no overall effect (OR, 1.02; 95% CI, 0.99-1.05). The number-needed-to-harm of anticoagulation was 595. CONCLUSION: Oral anticoagulation increased the population risk for traumatic hospital admission, with a further increase in case of concurrent antiplatelet use. Because this effect is most likely to derive from the prohemorrhagic properties of these drugs, injured patients should be included in the future evaluations of the cost-benefit profiles of these medications. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Coronary artery bypass grafting vs percutaneous coronary intervention in a 'real-world' setting: a comparative effectiveness study based on propensity score-matched cohorts.

OBJECTIVES: Most studies comparing coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) showed that fewer patients who had undergone CABG required repeat revascularizations , but no difference in survival, with the exception of some subgroups of patients. However, long-term real-world evidence on patients in whom both procedures are technically feasible is yet not available. The aim of this study was to compare 5-year rates of death, myocardial infarction (MI), target vessel revascularization (TVR) and stroke in a large cohort of patients with left main coronary artery (LMCA) or multivessel disease, treated with CABG or PCI (with or without DES) or PCI with DES only. METHODS: Two propensity score (PS)-matched cohorts of patients undergoing revascularization procedures at the regional public and private centres of Emilia-Romagna over the period July 2002-December 2008 were used to compare long-term outcomes of PCI (6246 patients) and CABG (5504 patients). RESULTS: PCI was associated with higher risk of death (HR = 1.6; 95% CI 1.4-1.8, P < 0.0001), MI (HR = 3.3; 95% CI 2.7-4.0, P < 0.0001) and TVR (HR = 4.5; 95% CI 3.8-5.2, P < 0.0001) at 5 years. No significant difference was shown for stroke (HR = 1.1; 95% CI 0.9-1.4, P = 0.43). CABG benefit was more evident in the risk of death in patients with two-vessel disease plus LMCA and in those with three-vessel disease, LVEF <35%, congestive heart failure and diabetes. Adjusted comparison with PS between PCI with DES only and CABG confirmed significant differences in favour of CABG for mortality, MI and TVR rates. Competing risk analysis showed that the difference in the mortality rate was due to higher rate of MI in PCI. CONCLUSIONS: In the 'real-world' setting of this study, CABG was associated with significantly lower rates of death, MI and TVR in patients with LMCA or multivessel disease, so it remains the standard of care, particularly for patients with more extensive coronary disease and diabetes.