Colorectal Cancer Screening Challenges in the Recent Afghan Refugee Population: A Comprehensive Review Article.

Colorectal cancer (CRC) is more prevalent in south-central Asian countries, particularly the Afghan population. Screening for CRC in the Afghan population has always been challenging, primarily due to the tribal and social cultures, lack of facilities, and lack of education. The United States (US) will soon face a significantly massive influx of Afghan refugees. It becomes imperative to initiate and implement effective measures regarding CRC screening in these refugee populations. The current review article aims to identify the most likely challenges faced for CRC screening in this Afghan refugee population in the US and address the possible measures to overcome these challenges.

Arterial Bullet Embolization Secondary to Direct Cardiac Injury in Penetrating Chest Trauma: A Rare Challenging Case Report.

Severe thoracic injury secondary to penetrating trauma requires prompt resources and rapid decision-making by trauma centers and teams. Implementing trauma systems has significantly impacted medical and critical care quality and outcomes, including managing rare trauma injuries. We describe a report of a rare case of a 21-year-old man with a gunshot wound to the chest with injuries to the right pulmonary hilum requiring pneumonectomy and to the left atrium with bullet embolism to the right common iliac artery. In addition, the systematic approach where each phase of the individual's treatment -- prehospital, emergency room, running room, and intensive care -- was positively affected by the implementation, development, and progressive maturation of a trauma system is also explained.

Prehospital airway and ventilation management: a trauma score and injury severity score-based analysis.

BACKGROUND: Emergent endotracheal intubation (ETI) is considered the standard of care for patients with severe traumatic brain injury (TBI). However, recent evidence suggests that the procedure may be associated with increased mortality, possibly reflecting inadequate training, suboptimal patient selection, or inappropriate ventilation. OBJECTIVE: To explore prehospital ETI in patients with severe TBI using a novel application of Trauma Score and Injury Severity Score methodology. METHODS: Patients with moderate-to-severe TBI (head Abbreviated Injury Scale score 3+) were identified from our county trauma registry. Demographic information, pre-resuscitation vital signs, and injury severity scores were used to calculate a probability of survival for each patient. The relationship between outcome and prehospital ETI, provider type (air vs. ground), and ventilation status were explored using observed survival-predicted survival and the ratio of unexpected survivors/deaths. RESULTS: A total of 11,000 patients were identified with complete data for this analysis. Observed and predicted survivals were similar for both intubated and nonintubated patients. The ratio of unexpected survivors/deaths increased and observed survival exceeded predicted survival for intubated patients with lower predicted survival values. Both intubated and nonintubated patients transported by air medical crews had better outcomes than those transported by ground. Both hypo- and hypercapnia were associated with worse outcomes in intubated but not in nonintubated patients. CONCLUSIONS: Prehospital intubation seems to improve outcomes in more critically injured TBI patients. Air medical outcomes are better than predicted for both intubated and nonintubated TBI patients. Iatrogenic hyper- and hypoventilations are associated with worse outcomes.

Control of lipids at baseline in the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial.

In order to examine lipids, a major treatment parameter in those with diabetes and heart disease, the authors analyzed baseline data from the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D) trial. The study consisted of 2368 participants with type 2 diabetes and coronary artery disease from 49 sites in 6 countries (2295 provided lipid measurements). Fifty-nine percent of participants had a low-density lipoprotein (LDL) cholesterol level < 100 mg/dL. Levels of total, LDL, and non-high-density lipoprotein (HDL) cholesterol and triglycerides differed by age group (younger than 55, 55-64, and 65 years and older); they were lowest in those aged 65 years. Women had higher total, LDL, and non-HDL cholesterol values. Education was associated with lower total, LDL, and non-HDL cholesterol levels. LDL cholesterol and triglyceride values were lower in the United States and Canada. Adjustment for age, sex, education level, randomization year, and medication did not eliminate these differences. Geographic variation was seen and was not fully accounted for by demographic or treatment characteristics (all P values < .05).

Preinjury factors and 3-month outcomes following emergency department diagnosis of mild traumatic brain injury.

OBJECTIVE: To investigate the sequelae of mild traumatic brain injury (MTBI) by comparing selected outcomes of emergency department-diagnosed patients with mild head injuries to those with non-head injuries. SETTING: Five emergency departments in southern California. PARTICIPANTS: Two cohorts, one with MTBI (n = 689 at initial assessment) and another with non-head injuries (n = 1318). MAIN MEASURES: Rivermead Post-Concussion Symptoms Questionnaire and Pittsburgh Sleep Quality Index at 3 months postinjury. RESULTS: Postconcussion symptom rates and summary Rivermead Post-Concussion Symptoms Questionnaire scores were significantly higher for persons with MTBI than for the comparison cohort. Women reported significantly more symptoms than men. Complaints about sleep quality overall (and also sleep latency and daytime dysfunction subcomponents) were significantly more frequent among those with MTBI. CONCLUSION: Patients with MTBI have significantly more negative outcomes than patients in the comparison cohort and should be clinically managed with these prevalent outcomes in mind. Further study of follow-up medical management and the development of treatment guidelines for this group of patients are both warranted.

Air medical response to traumatic brain injury: a computer learning algorithm analysis.

BACKGROUND: The role of air medicine in traumatic brain injury (TBI) has been studied extensively using trauma registries but remains unclear. Learning algorithms, such as artificial neural networks (ANN), support vector machines (SVM), and decision trees, can identify relationships between data set variables but are not empirically useful for hypothesis testing. OBJECTIVE: To use ANN, SVM, and decision trees to explore the role of air medicine in TBI. METHODS: Patients with Head Abbreviated Injury Score 3+ were identified from our county trauma registry. Predictive models were generated using ANN, SVM, and decision trees. The three best-performing ANN models were used to calculate differential survival values (actual and predicted outcome) for each patient. In addition, predicted survival values with transport mode artificially input as "air" or "ground" were calculated for each patient to identify those who benefit from air transport. For SVM analysis, chi was used to compare the ratio of unexpected survivors to unexpected deaths for air- and ground-transported patients. Finally, decision tree analysis was used to explore the indications for various transport modes in optimized survival algorithms. RESULTS: A total of 11,961 patients were included. All three learning algorithms predicted a survival benefit with air transport across all patients, especially those with higher Head Abbreviated Injury Score or Injury Severity Score values, lower Glasgow Coma Scale scores, or hypotension. CONCLUSION: Air medical response in TBI seems to confer a survival advantage, especially in more critically injured patients.

The influence of vehicle damage on injury severity of drivers in head-on motor vehicle crashes.

Data from crashes investigated through the Crash Injury Research and Engineering Network (CIREN) Program were used to assess differences in injury patterns, severity, and sources for drivers, protected by safety belts and deploying steering wheel air bags, in head-on frontal impacts. We studied whether exterior vehicle damage with a different distribution (wide vs. narrow) across the front vehicle plane influenced injury characteristics. Drivers from both impact types were similar on the basis of demographic characteristics (except age), restraint use, and vehicle characteristics. There were significant differences in the type of object contacted and intrusion into the passenger compartment at the driver's seat location. The mean delta V (based on the kilometers per hour change in velocity during the impact) was similar for drivers in both (wide vs. narrow) impact types. There were no significant differences in injury patterns and sources except that drivers in wide impacts were almost 4 times more likely (odds ratio (OR)=3.81, 95% confidence limits (CL) 1.26, 11.5) to have an abbreviated injury scale (AIS) 3 serious or greater severity head injury. Adjusted odds ratios showed that drivers in wide impacts were less likely (OR=0.54, 95% CI 0.37, 0.79) to have severe injury (based on injury severity score (ISS)>25) when controlling for intrusion, vehicle body type, vehicle curb weight, age, proper safety belt use, and delta V. Drivers with intrusion into their position or who were driving a passenger vehicle were almost twice more likely to have severe injury, regardless of whether the frontal plane damage distribution was wide or narrow. Our study supports that the type of damage distribution across the frontal plane may be an important crash characteristic to consider when studying drivers injured in head-on motor vehicle crashes.

The influence of damage distribution on serious brain injury in occupants in frontal motor vehicle crashes.

In spite of improvements in motor vehicle safety systems and crashworthiness, motor vehicle crashes remain one of the leading causes of brain injury. The purpose of this study was to determine if the damage distribution across the frontal plane affected brain injury severity of occupants in frontal impacts. Occupants in "head on" frontal impacts with a Principal Direction of Force (PDOF) equal to 11, 12, or 1o'clock who sustained serious brain injury were identified using the Crash Injury Research Engineering Network (CIREN) database. Impacts were further classified based on the damage distribution across the frontal plane as distributed, offset, and extreme offset (corner). Overall, there was no significant difference for brain injury severity (based on Glasgow Coma Scale<9, or brain injury AIS>2) comparing occupants in the different impact categories. For occupants in distributed frontal impacts, safety belt use was protective (odds ratio (OR)=0.61) and intrusion at the occupant's seat position was four times more likely to result in severe (Glasgow Coma Scale (GCS)<9) brain injury (OR=4.35). For occupants in offset frontal impacts, again safety belt use was protective against severe brain injury (OR=0.25). Possibly due to the small number of brain-injured occupants in corner impacts, safety belts did not significantly protect against increased brain injury severity during corner impacts. This study supports the importance of safety belt use to decrease brain injury severity for occupants in distributed and offset frontal crashes. It also illustrates how studying "real world" crashes may provide useful information on occupant injuries under impact circumstances not currently covered by crash testing.

Motor vehicle-related cardiac and aortic injuries differ from other thoracic injuries.

BACKGROUND: Traumatic cardiac and thoracic aortic injuries are hypothesized to result from rapid deceleration of occupants during a motor vehicle crash. The purpose of this study was to identify potential risk factors for motor vehicle-related cardiac and thoracic aortic (HTA) injury using the Crash Injury Research Engineering Network (CIREN) database. METHODS: CIREN data were used to test the hypothesis that there is no difference between occupants with HTA injury and occupants with thoracic injury other than the heart or aorta (non-HTA). Occupant variables (restraint use, airbag deployment, Glasgow Coma Scale score, Injury Severity Score, concomitant injuries, driver versus passenger status, height, and comorbidity) and crash variables (principal direction of force, change in velocity, vehicle crush, intrusion, and vehicle type) were compared for these two groups. Odds ratios were used to quantify the potential risk factors for HTA injury compared with non-HTA injury. RESULTS: There were 168 occupants with an HTA injury and 731 with a non-HTA injury. Greater crash severity (based on vehicle crush and change in velocity), improper safety belt use, and lack of safety belt use were significantly associated with HTA injury. Unrestrained occupants had almost three times the chance of having an HTA injury (odds ratio = 2.86; p < 0.05). For restrained drivers, 41.4% of HTA injuries were caused by vehicle interior components. When not protected by both safety belts and air bags, 45.7% of driver HTA injuries were caused by the steering wheel. For passengers, the vehicle interior (armrests, side interior, and B-pillars) accounted for most HTA injuries regardless of safety system status. More than half of all occupants wearing safety belts who sustained an HTA injury were improperly wearing their safety belts. CONCLUSION: The high mortality associated with cardiac and aortic injuries supports the need to prevent these injuries from occurring during motor vehicle crashes. These results suggest proper use of safety belts is necessary to prevent cardiac and thoracic aortic injuries. However, other important potential risk factors, such as motor vehicle size and crash severity, might continue to present a challenge to motor vehicle safety professionals.

The impact of safety belt use on liver injuries in motor vehicle crashes: the importance of motor vehicle safety systems.

BACKGROUND: Liver injuries (LIs) are one of the most serious and common consequences of motor vehicle crashes (MVCs). In the unstable patient, early detection of LI based on clinical suspicion will improve acute trauma care and outcomes. The specific objectives of this analysis are to identify crash scene and occupant risk factors for LI from MVC. METHODS: Crash Injury Research and Engineering Network data were used to identify risk factors for LI; age, sex, safety belt use, air bag deployment, DeltaV (change in velocity), principal direction of force, vehicle crush, and intrusion. Occupants with LI were compared with four control groups without LI; (1) no abdominal (ABD) injury (NO_ABD), (2) any ABD (ANY_ABD), (3) ABD Abbreviated Injury Scale score of 1 to 2 (ABD_1-2), and (4) ABD Abbreviated Injury Scale score of 3 or more (ABD_3+). LI occupants were compared with each control group and odds ratios (OR) for risk of LI were computed. RESULTS: There were 311 Crash Injury Research and Engineering Network subjects aged 5 or more years with LI. The total mean Injury Severity Score was 37.6. LI was strongly and significantly associated with safety belt restraint use without air bag deployment, compared with each control group: Liver injury - restrained + air bag not deployed versus (1) NO_ABD, N = 1,519; OR = 4.4, (2) ANY_ABD, N = 317; OR = 2.6, (3) ABD_1 to 2, N = 155; OR = 3.1, (4) ABD_3+, N = 217; OR = 2.4 (p < 0.001). This association was independent of driver or passenger status and principal direction of force. LIs were also strongly and significantly associated with greater vehicle interior intrusion. CONCLUSIONS: LIs were strongly associated with a safety belt restraint in use in the absence of air bag deployment during MVC. This data may have profound importance to the trauma surgeon as an early indicator for LI during resuscitation. These findings also have important implications for future research efforts to improve safety systems in motor vehicles and reduce morbidity and mortality from MVCs in the United States.

Calcaneal fractures in occupants involved in severe frontal motor vehicle crashes.

The calcaneous is the largest tarsal bone in the foot and plays an important role in walking and running. Motor vehicle crashes and falls from elevation have been associated with calcaneal fractures. Although not life-threatening, these injuries may result in permanent disability. This study used the Crash Injury Research and Engineering Network (CIREN) database to describe calcaneal fractures and concomitant lower extremity skeletal injury patterns for occupants involved in motor vehicle crashes. Sixty-three drivers and 7 front row passengers with calcaneal fractures were identified in the CIREN database during 1997-2005. Almost all these occupants were involved in severe (based on the delta V and vehicle crush) frontal or off-set frontal crashes with toe pan intrusion. Eighty-four percent of the calcaneal fractures were intra-articular or partially articular. Overall, 93% of occupants also had injury to other body regions with 84% having other lower extremity fractures. One year after the crash, most occupants had not returned to their prior level of physical functioning. Surgically managing patients with calcaneal fractures for an optimal outcome remains a challenge for orthopedic surgeons. Because lower extremity injuries, including calcaneal fractures, may cause permanent disability, it is important to prevent these injuries through structural improvements in motor vehicle design.

Traumatic brain injury outcomes in pre- and post- menopausal females versus age-matched males.

Gender differences in outcomes from major trauma have been described previously, and exogenous female hormone administration appears to be neuroprotective following traumatic brain injury (TBI). This analysis explored outcomes in pre- and post-menopausal females versus age-matched males. A total of 13,437 patients (n = 3,178 females, n = 10,259 males) with moderate-to-severe TBI (head AIS > or = 3) were identified from our county trauma registry. Overall mortality was similar between males and females (22% for both). Logistic regression was used to compare gender outcome differences, with a separate analysis performed for premenopausal (< 50 years) versus postmenopausal (> or = 50 years) patients, and after stratification by decade of life. No statistically significant difference in outcomes was observed for pre-menopausal females versus males (odds ratio [OR] 1.06; 95% confidence interval [CI] 0.83, 1.35; p = 0.633), but outcomes were significantly better in postmenopausal females versus males (OR 0.63, 95% CI 0.48-0.81, p < 0.001) after adjusting for age, mechanism of injury, Glasgow Coma Scale (GCS), hypotension (SBP < or = 90 mm Hg), head Abbreviated Injury Score (AIS), and Injury Severity Score (ISS). Stratification by decade of life revealed the gender survival differential inflection point to occur between ages 40-49 (OR 1.06, 95% CI 0.66-1.71, p = 0.798) and ages 50-59 (OR 0.38, 95% CI 0.20-0.74, p = 0.005). In addition, Revised Trauma Score and Injury Severity Score (TRISS) was used to calculate probability of survival (PS); all patients were then stratified by decade of life, and males and females were compared with regard to mean survival differential (outcome - PS). The identical pattern of improved outcomes in post-menopausal but not pre-menopausal females versus age-matched males was observed. These data suggest that endogenous female sex hormone production is not neuroprotective.

Rollover crashes: predicting serious injury based on occupant, vehicle, and crash characteristics.

The purpose of this research was to determine occupant, vehicle, and crash characteristics predicting serious injury during rollover crashes. We compared 27 case occupants with serious or greater severity injuries with 606 control occupants without injury or with only minor or moderate injury. Odds ratios (OR) for individual variables and logistic regression were used to identify predictive variables for serious injury associated with rollovers. Cases more often had thorax, spine, or head injury compared to controls that more often had extremity injuries. Intrusion (especially roof rail or B-pillar intrusion) at the occupant's position, the vehicle interior side and roof as sources of injury, and improper safety belt use were significantly associated with serious injury. Even when safety belt use or proper use was controlled for, occupants with greater magnitude of intrusion at their seat position were about 10 times more likely to receive serious injury. Although prevention of rollover crashes is the ultimate goal, it is important to develop safer vehicles and safety systems to better protect occupants who are involved in rollover crashes. This also requires improvement in data collection systems documenting these types of crashes.

The impact of aeromedical response to patients with moderate to severe traumatic brain injury.

STUDY OBJECTIVE: Aeromedical crews offer an advanced level of practice and rapid transport to definitive care; however, their efficacy remains unproven. Previous studies have used relatively small sample sizes or have been unable to adequately control for the effect of other potentially influential variables. Here we explore the impact of aeromedical response in patients with moderate to severe traumatic brain injury. METHODS: This was a retrospective analysis using our county trauma registry. All patients with head Abbreviated Injury Score of 3 or greater were included; interfacility transfers were excluded. The impact of aeromedical response was determined using logistic regression, adjusting for age, sex, mechanism, preadmission Glasgow Coma Scale score, head Abbreviated Injury Score, Injury Severity Score, and the presence of preadmission hypotension. Propensity scores were used to account for variability in selection of patients to undergo air versus ground transport. Patients with moderate and severe traumatic brain injury, as defined by head Abbreviated Injury Score and Glasgow Coma Scale score, were compared. Finally, aeromedical patients undergoing field intubation were compared with ground patients undergoing emergency department (ED) intubation. RESULTS: A total of 10,314 patients meeting all inclusion and exclusion criteria and with complete data sets were identified and included 3,017 transported by aeromedical crews. Overall mortality was 25% in the air- and ground-transported cohorts, but outcomes were significantly better for the aeromedical patients when adjusted for age, sex, mechanism of injury, hypotension, Glasgow Coma Scale score, head Abbreviated Injury Score, and Injury Severity Score (adjusted odds ratio [OR] 1.90; 95% confidence interval [CI] 1.60 to 2.25; P<.0001). Good outcomes (discharge to home, jail, psychiatric facility, rehabilitation, or leaving against medical advice) were also higher in aeromedical patients (adjusted OR 1.36; 95% CI 1.18 to 1.58; P<.0001). The primary benefit appeared to be in more severely injured patients, as reflected by head Abbreviated Injury Score and Glasgow Coma Scale score. Improved survival was also observed for air-transported patients intubated in the field versus ground-transported patients given emergency intubation in the ED (adjusted OR 1.42; 95% CI 1.13 to 1.78; P<.001). CONCLUSION: Here we analyze a large database of patients with moderate to severe traumatic brain injury. Aeromedical response appears to result in improved outcomes after adjustment for multiple influential factors in patients with moderate to severe traumatic brain injury. In addition, out-of-hospital intubation among air-transported patients resulted in better outcomes than ED intubation among ground-transported patients. Patients with more severe injuries appeared to derive the greatest benefit from aeromedical transport.

Personal watercraft injuries: 62 patients admitted to the San Diego County trauma services.

OBJECTIVE: To determine the types and patterns of injuries seen in personal watercraft (PWC) accidents. DESIGN: A retrospective review of medical records and imaging studies. SETTING: Level 1 and 2 trauma centers in San Diego County, California. PATIENTS/PARTICIPANTS: Trauma patients treated for PWC-related injuries between 1984 and 1997. MAIN OUTCOME MEASUREMENTS: Evaluation of injury patterns via chart review and imaging studies. INTERVENTION: None. RESULTS: A total of 62 patients were identified. The average age was 23 years (range 2-59 years). There were 41 males and 21 females. A total of 35 injuries (56%) involved another PWC. Of patients, 24 had loss of consciousness, with 8 closed head injuries. There were 17 chest injuries, with 10 pneumothoraces, and 16 lower extremity fractures (9 femur, 3 hip, 3 tibia-fibula, and 1 patella). CONCLUSIONS: Injuries related to PWC have increased dramatically over the past several years, becoming one of the leading causes of recreational water-sport injuries. This study supports a high level of awareness for significant blunt trauma to the chest and lower extremities in patients involved in PWC accidents.

Limb salvage after complex repairs of extremity arterial injuries is independent of surgical specialty training.

BACKGROUND: Major peripheral vascular trauma is managed by several surgical specialties. The impact of surgical specialty training and certification on outcome has not been evaluated. We hypothesized that general surgeons without specialty training in vascular surgery would have outcomes equivalent to surgeons with vascular training in the management of extremity arterial injuries requiring interposition grafting. METHODS: We performed a multicenter, retrospective study of patients undergoing interposition grafting for peripheral vascular injury between 1995 and 2010. Specialty was defined by training and certification. Outcomes were recorded at the time of discharge from the index hospitalization. Factors affecting limb salvage were determined using logistic regression. RESULTS: From the 11 participating centers, 615 patients were identified. General surgeons performed 69.9%, cardiac/vascular surgeons performed 27.3%, and surgeons of other specialties performed 2.8% of the grafts. There were 32 amputations (5.2%). Outcomes did not differ by institution. Factors associated with amputation were blunt mechanism, older age, female sex, hospital length of stay, and Injury Severity Score (ISS). There was no significant difference in limb salvage among specialty groups (general surgeons, 94%; cardiac/vascular, 95%; other, 100%). CONCLUSION: Limb salvage following major peripheral vascular injury is independent of surgeon specialty training. The majority of complex repairs are performed by general surgeons. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Pulsatile intermittent intravenous insulin therapy for attenuation of retinopathy and nephropathy in type 1 diabetes mellitus.

Many hormones are secreted in a pulsatile fashion that is more efficient than continuous secretion when tested in vivo. A trial of multiple daily insulin doses with or without the addition of weekly pulsatile insulin infusion therapy was designed to determine if deterioration of renal and retinal function could be blunted. Sixty-five study subjects were evaluated prospectively in 7 centers. Thirty-six patients were randomly allocated to the infusion group and 29 to the standard therapy group. Mean serum creatinine was 1.6 mg/dL in both groups. Subjects were excluded if clearance was less than 30 mL/min. There were no significant differences between the groups with respect to age, duration of diabetes, sex distribution, glycohemoglobin, blood pressure, angiotensin-converting enzyme inhibitor use, proteinuria, or baseline diabetic retinopathy (DR) severity level (all eyes exhibited DR; 8 were deemed technically not amenable to evaluation). Progression of DR was noted in 31.6% of 57 patients (32.3% treated, 30.8% control; P = 1.0) with both eyes evaluable. For patients with 12 or more months of follow-up, 27.9% of 43 patients demonstrated progression of DR (32.0% treated, 22.2% control; P = .57). There were no significant differences between study groups with respect to progression or marked progression, nor was there any influence of duration of follow-up. Progression of DR was noted in 18.8% of 122 eyes that could be adequately evaluated (17.9% of 67 treated, 20% of 55 controls; P = .39). Serum creatinine increased to 1.7 mg/dL in the treatment group and to 1.9 mg/dL in the control group (P = .03). Statistically significant preservation of renal function by pulsatile insulin infusion was not matched by a statistically significant prevention of DR progression compared with standard diabetes care. Inadequate statistical power or duration of the study, or lack of further benefit of pulsatile insulin infusion on the retina in the presence of angiotensin-converting enzyme inhibition may be responsible.

Association between albuminuria and duration of diabetes and myocardial dysfunction and peripheral arterial disease among patients with stable coronary artery disease in the BARI 2D study.

OBJECTIVE: To evaluate the effect of prior duration of diabetes, glycated hemoglobin level at study entry, and microalbuminuria or macroalbuminuria on the extent and severity of coronary artery disease (CAD) and peripheral arterial disease. PATIENTS AND METHODS: We studied baseline characteristics of the 2368 participants of the BARI 2D (Bypass Angioplasty Revascularization Investigation 2 Diabetes) study, a randomized clinical trial that evaluates treatment efficacy for patients with type 2 diabetes and angiographically documented stable CAD. Patients were enrolled from January 1, 2001, through March 31, 2005. Peripheral arterial disease was ascertained by an ankle-brachial index (ABI) of 0.9 or less, and extent of CAD was measured by presence of multivessel disease, a left ventricular ejection fraction (LVEF) of less than 50%, and myocardial jeopardy index. RESULTS: Duration of diabetes of 20 or more years was associated with increased risk of ABI of 0.9 or less (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.04-2.26), intermittent claudication (OR, 1.61; 95% CI, 1.10-2.35), and LVEF of less than 50% (OR, 2.03; 95% CI, 1.37-3.02). Microalbuminuria was associated with intermittent claudication (OR, 1.53; 95% CI, 1.16-2.02) and ABI of 0.9 or less (OR, 1.31; 95% CI, 0.98-1.75), whereas macroalbuminuria was associated with abnormal ABI, claudication, and LVEF of less than 50%. There was a significant association between diabetes duration and extent of CAD as manifested by number of coronary lesions, but no other significant associations were observed between duration of disease, glycated hemoglobin levels, or albumin-to-creatinine ratio and other manifestations of CAD. CONCLUSION: Duration of diabetes and microalbuminuria or macroalbuminuria are important predictors of severity of peripheral arterial disease and left ventricular dysfunction in a cohort of patients selected for the presence of CAD.

Both hypoxemia and extreme hyperoxemia may be detrimental in patients with severe traumatic brain injury.

An association between hypoxemia and poor outcomes from traumatic brain injury (TBI) is well documented. However, it is unclear whether hyperoxygenation is beneficial. This registry-based analysis explores the relationship between early hypoxemia and hyperoxemia on outcome from moderate-to-severe TBI. TBI patients (Abbreviated Injury Scale score 3+) were identified from the San Diego County trauma registry. Patients were stratified by arrival partial oxygen pressure (Po(2)) value. Trauma and injury severity score (TRISS) was then used to calculate predicted survival for each patient, with the mean observed-predicted survival differential determined for each arrival Po(2) stratification. Logistic regression was used to quantify the relationship between hypoxemia, hyperoxemia, and outcome from TBI after adjusting for multiple variables including intubation and ventilation status. A total of 3420 patients were included in the analysis. TRISS calculations revealed worse outcomes than predicted for both hypoxemia and extreme hyperoxemia. Logistic regression revealed an optimal Po(2) range (110-487 mm Hg), with an independent association observed between decreased survival and both hypoxemia (OR 0.54; 95% CI 0.42, 0.69; p < 0.001) and extreme hyperoxemia (OR 0.50; 95% CI 0.36, 0.71; p < 0.001). The association between hypoxemia and extreme hyperoxemia and worse outcomes was also present with use of "good outcomes" as the outcome variable (discharge to home, rehabilitation, jail, or psychiatric facility, or leaving against medical advice). We conclude that both hypoxemia and extreme hyperoxemia are associated with increased mortality and a decrease in good outcomes among TBI patients.