•Car crash mortality rate (per population) in Alabama did not change during COVID.•Deaths per injury rate increased for all road classes in 2020 compared to 2017–2019.•Vehicle miles traveled dropped ...for all road classes in 2020 compared to 2017–2019.•Largest increase in deaths per injury in 2020–2022 occurred for rural arterials.•Novel component factor analysis of car crash mortality rate was used.
Motor vehicle collisions are the leading cause of unintentional injury death in Alabama and at various points during the COVID-19 pandemic there were documented increases in the following risk driving behaviors: speeding, driving under the influence, and seat belt citations. Thus, the objective was to characterize the overall motor vehicle collision (MVC)-related mortality rate in Alabama and the contribution of each component over the first two years of the pandemic compared to before the pandemic by three different road classes: urban arterials, rural arterials, and all other road classes.
MVC data were derived from the Alabama eCrash database, an electronic crash reporting system used by police officers across the state. Data on vehicle miles traveled each year were collected from the U.S. Department of Transportation’s Federal Highway Administration estimates of traffic volume trends. MVC-related mortality in Alabama was the primary outcome and year of MVC was the exposure. The novel decomposition method broke down population mortality rate into four parts: deaths per MVC injury, injury per MVC, MVC per vehicle miles traveled (VMT), and VMT per population. Poisson models with scaled deviance were used to estimate rate ratios of each component. Relative contribution (RC) of each component was calculated by taking the absolute value of the component’s beta coefficient and dividing by the sum of the absolute values of all components' beta coefficients. Models were stratified by road class.
Across all road classes combined, there were no significant changes to the overall MVC-related mortality rate (per population) and its components when comparing 2020–2022 to 2017–2019; this was due to the increased case fatality rate (CFR) being offset by decreases in the VMT rate and MVC injury rate. In 2020, among rural arterials a non-significant increased mortality rate was offset by a decreased VMT rate (RR 0.91, 95% CI 0.84–0.98, RC 19.2%) and MVC injury rate (RR: 0.89, 95% CI: 0.82–0.97, RC: 22.2%) when compared to 2017–2019. For non-arterials, a non-significant decreased MVC mortality rate was observed in 2020 when compared to 2017–2019 (RR 0.86, 95% CI 0.71–1.03). When considering 2021–2022 versus 2020, the only significant component for any road class was a decreased MVC injury rate for non-arterials (RR: 0.90,95% CI: 0.89–0.93) but this was offset by an increased MVC rate and CFR, resulting in no significant change to the mortality rate (per population).
In a state with one of the highest MVC-related mortality rates in the country, despite decreases in VMTs per population and injuries per MVC, the MVC mortality rate per population did not change during the pandemic due in part to the contributions of an increase in the case fatality rate. Future research should determine whether the increase in CFR was associated with risky driving behaviors during the pandemic.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Persons who experience paraquat poisoning rapidly develop damage to a variety of organ systems including acute kidney injury (AKI), the occurrence of which is associated with an increased risk of ...death. However, little is known about the effects of chronic paraquat exposure on renal function and the onset of chronic renal disease. The objective of the current study is to assess the association between paraquat exposure and the incidence of end stage renal disease (ESRD) in the United States.
Data on the incidence of ESRD for the period 2010 through 2017 and kilograms of paraquat use per square mile for each county in the conterminous United States was obtained from the United States Renal Data System (USRDS) and the National Water Quality Assessment (NAWQA) Program, respectively. Negative binomial regression was used to estimate rate ratios (RRs) and 95% confidence intervals (CIs) for the association between quartiles of paraquat exposure and the incidence of ESRD.
The incidence of ESRD increased with increasing paraquat density. Based on a 20-year exposure lag, those in the highest paraquat density quartile had a 21% higher rate of ESRD compared to the lowest quartile whereas for a 15-year lag the increase was 26%. Adjusted associations were attenuated though still followed an increasing linear trend across quintiles.
The results of this study are consistent with a large number of studies documenting a high incidence of AKI and a small number of studies chronic renal disease following acute and chronic paraquat exposure, respectively. While the pathophysiological mechanisms underlying kidney injury following paraquat poisoning are well understood, more research is necessary to understand the natural history of chronic kidney disease due to chronic paraquat exposure.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Access to health care is an important issue, particularly in remote areas. Since 2010, 106 rural hospital have closed in the United States, potentially limiting geographic access to health care. The ...aim of this study was to evaluate the impact of these hospital closures on the proportion of the population who can reach a secondary care facility, by road, within 15, 30, 45, or 60 min.
Geographical information system analysis, using population data obtained from the 2010 U.S. Census Bureau and hospital data between 2010 and 2019 from the Center for Medicare and Medicaid Services, created 15-, 30-, 45-, and 60-min drive time isochrones (areas from which a central location can be reached within a set time).
Rural hospital closures resulted in 0%-0.97% of the population no longer being able to access a hospital within 15 min. The most marked changes were in the East South Central (0.97%, 178,478 residents) and West South Central (0.54%, 197,660 residents) divisions. Lesser degrees of change were noted for longer drive times. The changes were more marked when the rural population was analyzed exclusively.
Recent closures of rural hospitals in the United States have impacted population access to hospital care, although the extent varies. There are regions, such as the Southern and Southeastern United States, which demonstrate greater and potentially more concerning losses in population coverage, probably because of the greater number of closures. Future work should evaluate clinical implications of hospital closures and loss of population coverage.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Acute pain is common after injury. This study intended to evaluate the feasibility of quantifying pain experience over an entire admission using “area under the pain curve” and to identify factors ...associated with increased pain.
This retrospective single-center study included all trauma patients admitted from 2013 to 2020. Maximum pain scores were extracted for each day. Pain was defined as area under the curve (AUC) of maximum pain scores/day plotted against time. Injury patterns were analyzed by dichotomizing Abbreviated Injury Scale (AIS) scores (AIS < 3 versus AIS ≥ 3) for each body region. Urinary drug screen results were collected from admission data. A general linear model was used to determine which injury patterns, mechanisms, and age groups were predictive of increased AUC in all patients together and separate by operative and nonoperative groups.
We identified 21,640 patients, of which 70% were male and 83% had suffered blunt injury. Overall injury severity was associated with increased pain experience. Serious head injury, younger age, and older age (compared to 45-49 y) were associated with decreased pain. Spinal injuries, thoraco-abdominal injuries, and combined thoracic and lower extremity injuries were predictive of increased pain. Compared to patients with no positive test for illicit substances or documentation of prehospital narcotic medications, the pain experience was greater for both, those who had been administered a narcotic in the prehospital setting and those who tested positive for illicit substances.
This study extends the concept of total pain experience using AUC methodology. Our results demonstrate associations between increased pain and certain patterns of injury, ages, and presence of drugs on admission. Measuring total pain experience could assist in comparing pain-management strategies. Future research should focus on validating pain experience against quality-of-life measurements.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Background Standard hemodynamic evaluation of patients in shock may underestimate severity of hemorrhage given physiologic compensation. Blood lactate (BL) is an important adjunct in characterizing ...shock, and point-of-care devices are currently available for use in the prehospital (PH) setting. The objective of this study was to determine if BL levels have better predictive value when compared with systolic blood pressure (SBP) for identifying patients with an elevated risk of significant transfusion and mortality in a hemodynamically indeterminant cohort. Study Design We selected trauma patients admitted to a level I trauma center over a 9-year period with SBP between 90 and 110 mmHg. The predictive capability of initial emergency department (ED) BL for needing ≥6 units packed RBCs within 24 hours postinjury and mortality was compared with PH-SBP and ED-SBP by comparing estimated area under the receiver operator curve (AUC). Results We identified 2,413 patients with ED-SBP and 787 patients with PH-SBP and ED-BL. ED-BL was statistically better than PH-SBP (p = 0.0025) and ED-SBP (p < 0.0001) in predicting patients who will need ≥ 6 U packed RBCs within 24 hours postinjury (AUC: ED-BL, 0.72 vs PH-SBP, 0.61; ED-BL, 0.76 vs ED-SBP, 0.60). ED-BL was also a better predictor than both PH-SBP (p = 0.0235) and ED-SBP (p < 0.0001) for mortality (AUC: ED-BL, 0.74 vs PH-SBP, 0.60; ED-BL, 0.76 vs ED-SBP, 0.61). Conclusions ED-BL is a better predictor than SBP in identifying patients requiring significant transfusion and mortality in this cohort with indeterminant SBP. These findings suggest that point-of-care BL measurements could improve trauma triage and better identify patients for enrollment in interventional trials. Further studies using BL measurement in the PH environment are warranted.
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GEOZS, NUK, OILJ, SBCE, SBJE, UL, UPUK
BACKGROUND:Prior research has reported an association among trauma patients between blood type O and adverse events. More recently, another study reported that severely injured trauma patients of ...mostly O Rh positive blood type were more likely to die.
OBJECTIVE:The objective of the current study is to examine whether the same increased association is observed for blood type O severely injured patients in a more generalizable population comprised of Rh positive and Rh negative individuals.
METHODS:Patients admitted to a Level-I academic trauma center between 2015 and 2018 with severe injury (Injury Severity Score >15) were included in this retrospective cohort study. Logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) for the association between blood type and mortality.
RESULTS:Among 3,913 patients, a majority were either blood type O (47.5%) or A (34.7%) and 60% were Rh positive. There was no observed difference in complication rates by blood type, and there was no observed significant association with death overall or by cause of death. There were weak, increased associations for blood type B (OR 1.61, 95% CI 0.74–3.53) and type O (OR 1.57, 95% CI 0.90–2.76) compared with blood type A patients.
CONCLUSION:Contrary to prior research, the current results suggest no association between blood type and mortality among severely injured trauma patients.
Abstract Background Massive transfusion in pediatric trauma has been described in combat populations and other single institutions studies. We aim to define the incidence of massive transfusion in a ...large US civilian pediatric trauma population, identify predictive parameters of MT, and the mortality associated with massive transfusion. Methods Data from the National Trauma Databank (2010-2012), a trauma registry maintained by the American College of Surgeons, was analyzed. We included pediatric trauma patients ≤ 14 years that underwent massive transfusion, as defined by 40 ml/kg of blood products within the first 24 hours following admission. We compared the massive transfusion group with children receiving any transfusion within the same time frame. Univariate and multivariate analysis were performed. Results Of 356,583 pediatric trauma patients, 13,523 (4%) received any transfusion in the first 24 hours and 173 (0.04%) had a massive transfusion. On multivariate analysis, factors predicting massive transfusion were: older patients (5 to 12: OR 2.71, p=0.006, and ≥ 12: OR 5.14, p<0.001), hypothermic patients (Temperature < 35: OR 2.48, p< 0.025), low GCS (GCS<8: OR 2.82, p=0.009), and ISS≥25 (OR 2.01, p=0.03). Overall mortality for the entire group, any transfusion group, and massive transfusion group were 2.5%, 13.6%, and 50.6% respectively (p<0.001). Conclusions Massive transfusion in pediatric trauma is an uncommon event associated with a significant mortality. Patients undergoing massive transfusion are older, more likely to be hypothermic, and have sustained more severe injuries as measured by traditional trauma scoring systems than transfused trauma patients.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Purpose To assess between- and within-individual variability of macular cone topography in the eyes of young adults. Design Observational case series. Methods Cone photoreceptors in 40 eyes of 20 ...subjects aged 19–29 years with normal maculae were imaged using a research adaptive optics scanning laser ophthalmoscope. Refractive errors ranged from −3.0 diopters (D) to 0.63 D and differed by <0.50 D in fellow eyes. Cone density was assessed on a 2-dimensional sampling grid over the central 2.4 mm × 2.4 mm. Between-individual variability was evaluated by coefficient of variation (COV). Within-individual variability was quantified by maximum difference and root mean square (RMS). Cones were cumulated over increasing eccentricity. Results Peak densities of foveal cones are 168 162 ± 23 529 cones/mm2 (mean ± SD) (COV = 0.14). The number of cones within the cone-dominated foveola (0.8–0.9 mm diameter) is 38 311 ± 2319 (COV = 0.06). The RMS cone density difference between fellow eyes is 6.78%, and the maximum difference is 23.6%. Mixed-model statistical analysis found no difference in the association between eccentricity and cone density in the superior/nasal ( P = .8503), superior/temporal ( P = .1551), inferior/nasal ( P = .8609), and inferior/temporal ( P = .6662) quadrants of fellow eyes. Conclusions New instrumentation imaged the smallest foveal cones, thus allowing accurate assignment of foveal centers and assessment of variability in macular cone density in a large sample of eyes. Though cone densities vary significantly in the fovea, the total numbers of foveolar cones are very similar both between and within subjects. Thus, the total number of foveolar cones may be an important measure of cone degeneration and loss.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Bed rest and immobility in patients on mechanical ventilation or in an intensive care unit (ICU) have detrimental effects. Studies in medical ICUs show that early mobilization is safe, does not ...increase costs, and can be associated with decreased ICU and hospital lengths of stay (LOS).
The purpose of this study was to assess the effects of an early mobilization protocol on complication rates, ventilator days, and ICU and hospital LOS for patients admitted to a trauma and burn ICU (TBICU).
This was a retrospective cohort study of an interdisciplinary quality-improvement program.
Pre- and post-early mobility program patient data from the trauma registry for 2,176 patients admitted to the TBICU between May 2008 and April 2010 were compared.
No adverse events were reported related to the early mobility program. After adjusting for age and injury severity, there was a decrease in airway, pulmonary, and vascular complications (including pneumonia and deep vein thrombosis) post-early mobility program. Ventilator days and TBICU and hospital lengths of stay were not significantly decreased.
Using a historical control group, there was no way to account for other changes in patient care that may have occurred between the 2 periods that could have affected patient outcomes. The dose of physical activity both before and after the early mobility program were not specifically assessed.
Early mobilization of patients in a TBICU was safe and effective. Medical, nursing, and physical therapy staff, as well as hospital administrators, have embraced the new culture of early mobilization in the ICU.
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DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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