Lower Injury Severity Research Articles

Extreme Blood Alcohol Level is Associated with Increased Resource use in Trauma Patients

This study aims to examine resource utilization and outcomes of trauma patients with extremely high blood alcohol concentrations. We hypothesized that higher blood alcohol concentration (BAC) predicts greater resource utilization and poorer outcomes. A retrospective analysis was performed on trauma patients admitted to an urban Level I trauma center over a 5-year period. Admission BAC categories were constructed using standard laboratory norms and legal definitions. Demographic data, premorbid conditions, injury severity scores (ISS), resource utilization (intensive care unit (ICU) admission rates/length of stay, total hospital days, use of consultants), and mortality were analyzed. Positive BAC on admission was associated with increased ISS (P < 0.001), length of stay (P < 0.003), and total ICU days (P < 0.001). Increased BAC admission level of patients was associated with a decreased ISS score (P = 0.0073), a higher probability of ICU admission (P = 0.0013), and an increased percentage of ICU days (P = 0.001). A positive BAC at admission was a significant predictor of both ICU admission and mortality (odds ratios 1.72 and 1.27, respectively). This study demonstrates that a positive BAC is associated with increased ISS, increased resource utilization, and worsened outcomes. Extreme levels of BAC are associated with increased resource utilization despite lower injury severity scores.

Serum Ethanol Levels: Predictor of Survival After Severe Traumatic Brain Injury

Recent studies have suggested that moderate doses of ethanol (ETOH) before traumatic brain injury (TBI) may have a neuroprotective role. : The objective of this study is to investigate the effects of serum ETOH levels on outcomes after TBI. Our hypothesis was that ETOH exposure is associated with improved survival in severe TBI patients and that the serum ETOH levels on admission correlate with survival. All patients sustaining severe TBI (head abbreviated injury score >or=3) admitted to the Surgical Intensive Care Unit at the Los Angeles County + University of Southern California Medical Center from January 2000 to December 2005 who had a serum ETOH level measured on admission were analyzed. Patients were classified into ETOH-positive and ETOH-negative groups, according to the serum ETOH levels and compared for differences in outcomes using logistic regression to adjust for clinically and statistically relevant confounding factors. During the 5-year study period, 482 severe TBI patients admitted to the Surgical Intensive Care Unit at Los Angeles County + University of Southern California Medical Center had a serum ETOH level measured on admission. A total of 47% of severe TBI patients were tested for ETOH. ETOH levels were positive in 37% (179) and negative in 63% (303) of the TBI patients. The ETOH-positive group had a higher percentage of males (91% vs. 79%, p = 0.001), lower percentage of penetrating injuries (9% vs. 20%, p = 0.002), and lower injury severity score (25.7 +/- 11.5 vs. 28.4 +/- 14.1, p = 0.05). Overall mortality was significantly lower in the ETOH-positive group at 27% versus 40% (odds ratio = 0.55, 95% confidence interval: 0.37-0.82; p = 0.004). This survival benefit remained significant after multivariable analysis (adjusted odds ratio = 0.54, 95% confidence interval: 0.31-0.92; adjusted p = 0.02). The mean serum ETOH level was significantly higher for survivors than for nonsurvivors (0.11 +/- 0.21 vs. 0.05 +/- 0.10, p < 0.001). The serum ETOH levels significantly correlated with the probability of survival (r = 0.21, p < 0.001), but this correlation was not strong as shown by the low r value. The results of this study suggest that elevated ETOH serum levels are independently associated with higher survival in patients with severe traumatic brain injuries. Additional research is required to further investigate the mechanism and potential therapeutic implications of this association.

Elevated Blood Alcohol Level May be Protective of Trauma Patient Mortality

To determine whether a positive blood alcohol level (BAL) affects morbidity and mortality at a Level I trauma center, a retrospective review of trauma patients 18 years of age and older was performed. There were 7985 trauma patients and 8 per cent (645) had a positive BAL. BAL(+) patients had lower Injury Severity Score (ISS) (8 vs 11, P < 0.01), lower rate of penetrating injury (9 vs 25%, P < 0.01), and were older (38 vs 32 years, P = 0.01). Overall there were 559 deaths (7%); (1% mortality in BAL(+) patients and 7% in BAL(-) patients; P < 0.0001). There were 352 (4.4%) complications with similar rates among BAL(-) and (+) patients. On univariate analysis, a positive BAL was inversely associated with death (OR, 0.17) as was blunt trauma (OR, 0.29), whereas older age (OR 1.009) and increased ISS (OR 1.13) were associated with death. On multivariable analysis, after adjusting for age, ISS, and mechanism of injury, a positive BAL remained protective against death (OR 0.35) as did blunt trauma (OR 0.2). Age (OR 1.04) and increased ISS (OR 1.19) were associated with mortality. In conclusion, a positive BAL was associated with a decreased mortality risk in trauma patients, which persisted after adjusting for multiple confounding variables.

Blunt Cardiac Rupture: A 5-Year NTDB Analysis

Because of its rarity and high rate of mortality, traumatic blunt cardiac rupture (BCR) has been poorly studied. The objective of this study was to use the National Trauma Data Bank to review the epidemiology and outcomes associated with traumatic BCR. After approved by the institutional review board, the National Trauma Data Bank (version 5.0) was queried for all BCR occurring between 2000 and 2005. Demographics, clinical injury data, interventions, and outcomes were abstracted for each patient. Statistical analysis was performed using an unpaired Student's t test or Mann-Whitney U test to compare means and chi analysis to compare proportions. Stepwise logistic regression analysis was performed to identify independent predictors of inhospital mortality. Of 811,531 blunt trauma patients, 366 (0.045%) had a BCR of which 334 were available for analysis, with the mean age of 45 years, 65% were men, and their mean Injury Severity Score was 58 +/- 19. The most common mechanism of injury was motor vehicle collision (73%), followed by pedestrian struck by auto (16%), and falls from height (8%). Twenty-one patients (6%) died on arrival and 140 (42%) died in the emergency room. The overall mortality for patients arriving alive to hospital was 89%. Of the patients surviving to operation, 42% survived >24 hours of which 87% were discharged. Survivors were significantly younger (39 vs. 46 years, p = 0.04), had a lower Injury Severity Score (47 vs. 56, p = 0.02), higher Glasgow Coma Scale (10 vs. 6, p < 0.001), and were more likely to present with an systolic blood pressure >or=90 mm Hg (p = 0.01). Nevertheless, none of these factors was found to be an independent risk factor for mortality. BCR is an exceedingly rare injury, occurring in 1 of 2400 blunt trauma patients. In patients arriving alive to hospital, traumatic BCR is associated with a high mortality rate, however, is not uniformly fatal.

Positive Serum Ethanol Level and Mortality in Moderate to Severe Traumatic Brain Injury

Ethanol exposure is associated with decreased mortality in patients with moderate to severe traumatic brain injury. Retrospective database review. Trauma centers contributing to the National Trauma Data Bank (NTDB). Version 6.2 of the NTDB (2000-2005) was queried for all patients with moderate to severe traumatic brain injury (head Abbreviated Injury Score > or =3) and ethanol levels measured on admission. Demographics and outcomes were compared between patients with traumatic brain injuries with and without ethanol in their blood. Logistic regression analysis was used to investigate the relationship between mortality and ethanol. Mortality and complications. A total of 38 019 patients with severe traumatic brain injuries were evaluated. Thirty-eight percent tested positive for ethanol. Ethanol-positive patients were younger (mean [SD], 37.7 [15.1] vs 44.1 [22.0] years, P < .001), had a lower Injury Severity Score (22.3 [10.0] vs 23.0 [10.3], P < .001), and a lower Glasgow Coma Scale score (10.0 [5.1] vs 11.0 [4.9], P < .001) compared with their ethanol-negative counterparts. After logistic regression analysis, ethanol was associated with reduced mortality (adjusted odds ratio, 0.88; 95% confidence interval, 0.80-0.96; P = .005) and higher complications (adjusted odds ratio, 1.24; 95% confidence interval, 1.15-1.33; P < .001). Serum ethanol is independently associated with decreased mortality in patients with moderate to severe head injuries. Additional research is warranted to investigate the potential therapeutic implications of this association.

Clinical Implications of the Seat Belt Sign in Blunt Trauma

Patients with the seat belt sign (SBS) from motor vehicle crashes (MVCs) are prone to specific regional injury patterns. Investigators at a Level 1 trauma center analyzed the incidence, clinical implications, and spectrum of regional injuries in patients injured in MVC over 2 years. SBS was seen in 11.3 per cent of patients injured in MVCs and 20.5 per cent of patients with known restraint use. Restrained patients were less severely injured with lower injury severity scores (7.62 vs 11.33) and mortality (1.1 vs 5.7%). Patients with SBS had lower mortality rates than patients without SBS (1.4 vs 3.7%). Thoraco-abdominal injuries were present in 47 per cent (34 of 72) of patients with SBS. Compared with patients without SBS, patients had a higher incidence of hollow viscous injuries (HVI) and solid organ trauma (8 and 17% vs 1 and 3%, P < 0.05); splenic trauma was 24-fold higher (9.7 vs 0.4%), liver injuries 3.1-fold higher (6 vs 3%), and rib fractures 2.4-fold higher (P < 0.05). Children had 2.8-fold higher rates of HVI (18 vs 9%, P < 0.05). SBS is associated with underlying regional injuries in nearly half of patients with a higher prevalence of HVI and solid organ trauma.

Small Catheter Tube Thoracostomy: Effective in Managing Chest Trauma in Stable Patients

Image-guided small catheter tube thoracostomy (SCTT) is not currently used as a first-line procedure in the management of patients with chest trauma. We adopted a practice recommendation to use SCTT as a less invasive alternative in the treatment of chest injuries. We reviewed our trauma registry to evaluate our change in practice and the effectiveness of SCTT. Retrospective review of all tube thoracostomies (TT) performed in patients with chest injury at a level I trauma center from September 2002 through March 2006. Data collected included age, sex, indications and timing for TT, use of antibiotics, length of stay, complications, and outcomes. Large catheter tube thoracostomy (LCTT) not performed in the operating room or trauma room and all SCTT were deemed nonemergent. There were 565 TT performed in 359 patients. Emergent TT was performed in 252 (70%) and nonemergent TT in 157 (44%) patients, of which 63 (40%) received LCTT and 107 (68%) received SCTT. Although SCTT was performed later after injury than nonemergent LCTT (5.5 days vs. 2.3 days, p < 0.001), average duration of SCTT was shorter (5.5 days vs. 7 days, p < 0.05). Rates of hemothoraces were similarly low for SCTT versus nonemergent LCTT (6.1% vs. 4.2%, p = NS) and rates of residual/recurrent pneumothoraces were not significantly different (8% vs. 14%, p = NS). The rate of occurrence of fibrothorax, however, was significantly lower for SCTT compared with nonemergent LCTT (0% vs. 4.2%, p < 0.05). In patients receiving a single nonemergent TT, SCTT was performed in 55 (61%) and LCTT in 35 (39%). A comparison of these groups revealed that SCTT was performed in older patients (p < 0.05), and was associated with a lower Injury Severity Score (p < 0.05) and shorter length of stay (p = 0.05). SCTT was increasingly used in younger and more seriously injured patients as our experience grew. SCTT is effective in managing chest trauma. It is comparable with LCTT in stable trauma patients. This study supports adopting image-guided small catheter techniques in the management of chest trauma in stable patients.

TIME FOR A CHANGE IN INJURY AND TRAUMA CARE DELIVERY: A TRAUMA DEATH REVIEW ANALYSIS

Safety and error reduction in medical care is crucial to the future of medicine. This study evaluates trauma patients dying at a level 1 trauma centre to determine the adequacy of care. All trauma deaths at a level 1 trauma centre between 1996 and 2003 were reviewed by an eight-member multidisciplinary death review panel. Errors in care were classified according to their location, nature, impact, outcome and whether the deaths were avoidable or non-avoidable. Avoidable deaths were categorized as potentially, probably and definitely avoidable. Between 1996 and 2003, there were 17 157 trauma admissions, including 307 trauma deaths. The mean patient age was 47.7 years +/- 24.8 years, mean injury severity score 38.1 +/- 19.6. Of all deaths, 69 (22.5%) were deemed avoidable. Of the avoidable deaths, 61 (88%) were potentially avoidable, 7 (10%) probably avoidable and 1 (1.4%) definitely avoidable. Avoidable deaths were associated with patients with increased age, lower injury severity score, admissions to intensive care unit, longer hospital stay and treatment by a non-trauma surgeon (P < 0.05). Of the 307 trauma deaths, 271 (89.3%) patients experienced a total of 1063 errors, an overall error rate of 3.5 per patient. The error rate in the non-avoidable group was 2.9 per patient and 5.3 per patient in the avoidable group (P < 0.0001). Most errors occurred in the resuscitation area. Age, severity of injury, hospital length of stay and care by a non-trauma surgeon are factors associated with avoidable deaths. A new approach to trauma and injury care is required.

Outcomes of Cocaine-Positive Trauma Patients Undergoing Surgery on the First Day After Admission

Concerns regarding complications of cocaine use are frequently used to justify delaying procedures among patients with positive urine cocaine toxicology (UCT); however, there is no evidence to support this practice. We investigated whether UCT+ patients experience a worse outcome than UCT- patients when undergoing surgery on the first day after admission to a trauma center. Files of adult trauma patients undergoing surgery during the first 24 hours after admission were selected from a trauma database. Patients without UCT testing were excluded. UCT+ and UCT- patients were compared in relation to mortality; length of stay; and the development of cardiac, infectious, and neurologic complications. Possible confounders were analyzed. Student's t test, Pearson's chi2 test, and Wilcoxon's statistics were used for analysis (alpha = 0.05). Multiple logistic regression models and Cox proportional hazard methods were used to adjust for possible confounders. Of the 3,477 patients studied, 13% (n = 465) tested positive for cocaine. UCT+ patients had a different age distribution were more likely to be male and to have penetrating injury and had lower Injury Severity Scores than UCT- patients. Outcomes were similar for mortality (3% vs. 4%), for the development of infectious (18% and 19%) and neurologic (2% vs. 1%) complications, and median length of stay (5 days vs. 5 days). Cardiac complications were lower among the UCT+ patients (3% vs. 6%). Multiple logistic regression and Cox proportional hazard revealed results similar to those from the univariate analysis. Outcomes after surgery during the first 24 hours after admission are not negatively affected by the presence of UCT+. An apparent protective effect of UCT+ status in the development of cardiac complications needs to be explained.

Relation of caregiver alcohol use to unintentional childhood injury.

The present study used a case-crossover design to investigate the association of caregiver alcohol consumption and supervision to children's injury occurrence and severity. A community sample of 170 mothers of toddlers was interviewed biweekly about their children's daily injuries for a period of 6 months. Proximal caregiver-reported alcohol use predicted higher likelihood of injury occurrence and higher injury severity, whereas caregiver-reported supervision predicted lower likelihood of injury occurrence and lower injury severity. Even at low levels, proximal caregiver alcohol use may contribute to higher risk for childhood injuries and more severe injuries. The combined effect of supervision and drinking on injury likelihood warrants further exploration.

Predictors of General Health After Major Trauma

Traumatic injury is a leading contributor to the global burden of disease, yet there has been little research on possible predictors of general health after major trauma. This study aims to explore possible predictors of general health after major physical trauma. A survey was performed of 731 surviving consecutive adult patients presenting to a major trauma center with accidental major trauma, between 1 year and 5 years postinjury. Data pertaining to general patient factors, injury severity factors, socioeconomic factors, and claim-related factors were abstracted from the hospital trauma database and the questionnaire. Multiple linear regression was used to develop a predictive model for the main outcome, the physical and mental component summaries of the SF-36 General Health Survey. One hundred and forty nine patients were excluded, 93 refused to participate, and 134 did not respond, leaving 355 participants. On multivariate analysis, better physical health was significantly associated with increasing time since the injury and lower Injury Severity Scores (p = 0.03 and 0.02, respectively). Having a settled compensation claim, having an unsettled compensation claim, and using a lawyer were independently associated with poor physical health (p = 0.02, 0.006, and <0.0001, respectively). Measures of injury severity or socioeconomic status were not associated with mental health. However, having an unsettled compensation claim was strongly associated with poor mental health (p < 0.0001). General health after major physical trauma is more strongly associated with factors relating to compensation than with the severity of the injury. Processes involved with claiming compensation after major trauma may contribute to poor patient outcomes.

Fever and leukocytosis in critically ill trauma patients: it's not the urine.

Infectious complications are a major cause of morbidity and mortality in critically ill trauma patients. Therefore, fever and leukocytosis often trigger an extensive laboratory workup that includes a urine culture (UCx). The purposes of this study were to: 1) Define the current practice for obtaining UCxs in trauma patients admitted to the surgical and trauma intensive care unit (STICU); and 2) determine if there is an association between fever or leukocytosis and urinary tract infections (UTIs) during the initial 14 hospital days. An 18-month retrospective cohort analysis was performed on consecutive trauma patients admitted for at least two days to the STICU at a level I trauma center. Data collected included demographics, injuries, and daily maximal temperature (T(max)), leukocyte count, and UCx results for the first 14 days. Fever and leukocytosis were defined as T(max) > or =38.5 degrees C and leukocyte count > or =12,000/mm(3), respectively. Urinary tract infections were diagnosed with a positive UCx (> or =10(5) organisms/mL of urine). Five hundred ten patients were evaluated for a total of 3,839 patient-days. Their mean age and Injury Severity Score were 49 +/- 1 years and 19 +/- 1 points, respectively. Seventy-two percent were men, and 91% had sustained blunt injuries. Four hundred seven UCxs were obtained; 42 patients (8%) had 60 UTIs. The cohort had an indwelling urinary catheter for 97% of the patient-days, yielding an infection density of 16 UTIs/1,000 urinary catheter-days. There was a significant association between obtaining a UCx and fever and between fever and leukocytosis (both, p < 0.001), but no association of UTI with fever, leukocytosis, or the combination of fever and leukocytosis. Analysis using temperature and leukocyte count as continuous variables identified no temperature or leukocyte range associated with UTIs. Independent risk factors for UTI calculated by logistic regression were female sex, older age, low Injury Severity Score, and no antibiotics within 24 h before the UCx was obtained. The practice of obtaining a UCx from the STICU trauma patient was related to fever and fever with leukocytosis. However, neither fever nor leukocytosis nor both were associated with UTIs. These data suggest that there is an unnecessary emphasis on UTI as a source of fever and leukocytosis in injured patients during their first 14 STICU days. Our results suggest that the paradigm for evaluating UTI as a cause of fever needs to be reevaluated in critically ill trauma patients.

Venous Thromboembolism in Trauma Patients

Serial venous duplex scans (VDS) were done in 507 trauma patients with at least one risk factor (RF) for venous thromboembolism (VTE) during a 2-year study period. Deep vein thrombosis (DVT) was detected in 31 (6.1%) patients. This incidence was 3.1 per cent in low (1-2 RFs), 3.4 per cent in moderate (3-5 RFs), and 7.7 per cent in high (> or =6 RFs) VTE scores (P = 0.172). Incidence was statistically different (3% vs. 7.2%, P = 0.048) on reanalyzing patients in two risk categories, low-risk (1-4 RFs) and high-risk (> or =5 RFs). Only 4 of 16 RFs had statistically higher incidence of DVT in patients with or without RFs: previous VTE (27.3% vs. 5.6%, odds ratio (OR) 6.628, P = 0.024), spinal cord injury (22.6% vs. 5%, OR 5.493, P = 0.001), pelvic fractures (11.4% vs. 5.1%, OR 2.373, P = 0.042), and head injury with a greater than two Abbreviated Injury Score (10.5% vs. 4.2%, OR 2.639, P = 0.014). On reanalyzing patients with > or =5 RFs vs. <5RFs, obesity (14.3 vs. 6.1%, P = 0.007), malignancy (5.6% vs. 0.6%, P = 0.006), coagulopathy (10.8% vs. 1.8%, P = 0.000), and previous VTE (3.2% vs. 0%, P = 0.019) were significant on univariate analysis. Patients with DVT had 3.70 +/- 1.75 RFs and a 9.61 +/- 4.93 VTE score, whereas, patients without DVT had 2.66 +/- 1.50 RFs and a 6.83 +/- 3.91 VTE score (P = 0.000). DVTs had a direct positive relationship with higher VTE scores, length of stay, and number of VDS (>1 r, P < or = 0.001). Increasing age was a weak risk factor (0.03 r, P = 0.5). First two VDS diagnosed 77 per cent of DVTs. Patients with injury severity score of > or =15 and 25 had higher DVTs compared with the ones with lower injury severity score levels (P < or = 0.05). Pulmonary embolism was silent in 63 per cent and DVTs were asymptomatic in 68 per cent.

Relationship Between Early Opioid Prescribing for Acute Occupational Low Back Pain and Disability Duration, Medical Costs, Subsequent Surgery and Late Opioid Use

Retrospective cohort study of workers' compensation (WC) claims with acute disabling low back pain (LBP). To examine the association between early opioid use for acute LBP and outcomes: disability duration, medical costs, "late opioid" use (> or = 5 prescriptions from 30 to 730 days), and surgery in a 2-year period following LBP onset. Opioid analgesics have become more accepted for acute pain management. However, treatment guidelines recommend limited opioid use for acute LBP management. Little is known about the long-term impact on outcomes of opioid use for acute LBP. The sample consisted of 8443 claimants from a large WC database with new-onset, disabling LBP that occurred between January 1, 2002 and December 31, 2003. Based on morphine equivalent amount (MEA) in milligrams received in the first 15 days ("early opioids"), claimants were divided into 5 groups (0, 1-140, 141-225, 226-450, 450+). The associations between early opioids and outcomes were evaluated using multivariate linear and logistic regression models. Covariates included age, gender, job tenure, and low back injury severity. Injury severity was classified using ICD-9 codes. Twenty-one percent of claimants received at least 1 early opioid prescription. After controlling for the covariates, mean disability duration, mean medical costs, and risk of surgery and late opioid use increased monotonically with increasing MEA. Those who received more than 450 mg MEA were, on average, disabled 69 days longer than those who received no early opioids (95% confidence interval [CI], 49.2-88.9). Compared with the lowest MEA group (0 mg opioid), the risk for surgery was 3 times greater (95% CI, 2.4-4.0) and the risk of receiving late opioids was 6 times greater (95% CI, 4.9-7.7) in the highest MEA group. Low back injury severity was a strong predictor of all the outcomes. Given the negative association between receipt of early opioids for acute LBP and outcomes, it is suggested that the use of opioids for the management of acute LBP may be counterproductive to recovery.

Upper limb injuries in road traffic accidents: The influence of airbags

This study was designed to determine the effect of airbags on upper limb trauma in RTA victims. Correlating the nature of the accident with the injuries sustained allows hospital trauma teams to predict injuries based on mechanism. We performed a retrospective case control study of 56 patients with 116 injuries admitted to University Hospital Michigan (Level 1 trauma centre). Based on information from the Crash Injury and Engineering Network (CIREN) we correlated upper limb injury due to airbags with overall injury severity, impact direction and speed of impact (Delta V). We stratified severity according to ISS score. Upper limb regions: Above elbow, elbow to wrist, below wrist. There was no significant difference between male and females according to age, weight, ISS and Delta V. There was a significant difference in height (p lt 0.05). The majority of injuries (n = 75, 65%) occurred below elbow. On the left side (n = 47) there was a bimodal distribution of injuries, 64% below elbow and 36% above elbow. On the right side (n = 61) 77% occurred below elbow. At low overall injury severity scores (ISS lt 20, n = 76) 64% of injuries occurred below elbow, vs. 82% in higher ISS scores. (ISS gt 20 n = 40). At a higher impact velocity there were more injuries to the below elbow region (62% at DV of lt 20 mph vs. 74% at DV of gt 20 mph). At an impact direction of 0-90 degrees 96% (n = 48) of injuries occurred above wrist, 44% of these above elbow. At an impact direction of 270-360 degrees 75% (n = 38) occurred above wrist, 29% of these above elbow. The majority of injuries due to airbags occur below elbow. More severely injured patients are likely to have sustained forearm and wrist fractures. If the car is hit on the right side the driver is twice as likely to sustain an above elbow arm injury.

Quickly and well… A survey on customer satisfaction of low injury severity scores in ER

Emergency Department (ED) overcrowding is a situation in which the demand for emergency services exceeds the ability to provide care within a reasonable time. A recent report by the Canadian Agency for Drugs and Technology in Health addresses the issue. Among the implication for decision making, a strong point is the fact that evidence suggests that fast tracking patients with minor injuries or illnesses can reduce ED length of stay, waiting time, and the number of patients who leave without being seen. According to these findings, the Authors describe their experience with the so called white code ambulatory which is a strategy to divert patients with minor injuries or illnesses in a different setting. The experience has been evaluated with a customer satisfaction survey that has shown a good level of satisfaction among patients. There seems to be no opportunistic increase of demand by patients of health care delivery.

Compensation of seed production after severe injury in the short-lived herb Barbarea vulgaris

A pot experiment with the common ruderal herb Barbarea vulgaris (Brassicaceae) was set up to elucidate to what extent short-lived species sprouting from roots regenerate and compensate for seed production after damage. We tested if sprouting from roots ensures survival after severe aboveground biomass damage, but the number of seeds produced declines with increasing severity of injury, decreasing nutrient availability and progress in the life cycle at the time of injury. Plants of B. vulgaris were cultivated in a 3-year garden experiment at two nutrient levels (high vs. low). During the experiment, two levels of injury severity were applied: high (removal of all aboveground biomass) and low (removal of aboveground biomass leaving basal axillary buds intact). Damage was applied at four life-cycle phases: young rosette, overwintered rosette, flowering plant and fruiting plant. All injured plants survived and resprouted irrespective of life-cycle phase, severity of injury and nutrient availability. Injury significantly affected seed production and also the plants’ life cycle. Plants injured in the second year of their life (overwintered rosette, flowering plant and fruiting plant) postponed reproduction to the third season (in the case of high injury severity) or their seed production was lower than in intact plants (in the case of low injury severity). In plants injured in the first life year, seed production and life cycle were not influenced. Nutrient level only marginally affected resprouting after injury and seed production. The experiment showed that the ability to sprout from roots enables plants to survive a 100% loss of aboveground biomass, and to keep some seed production or even compensate it. The short-lived ruderal species B. vulgaris successfully copes with severe disturbance by resprouting and does not rely only on its seed bank. Mit der weit verbreiteten Ruderalpflanze Barbarea vulgaris (Brassicaceae) wurde ein Topfexperiment aufgestellt, um zu beleuchten, in welchem Ausmaß kurzlebige Arten, die aus Wurzeln sprießen, sich nach einer Beschädigung regenerieren und die Samenproduktion kompensieren. Das Ziel war zu testen, ob das Sprießen aus den Wurzeln das Überleben und die Samenproduktion nach einer ernsthaften oberflächlichen Beschädigung sichert. Pflanzen von B. vulgaris wurden in einem dreijährigen Gartenexperiment bei zwei Nährstoffgehalten (hoch vs. niedrig) kultiviert. Während des Experimentes wurden zwei Level der Beschädigungsschwere angewendet: schwer (Entfernung aller oberflächlichen Biomasse) und leicht (Entfernung aller oberflächlichen Biomasse, aber belassen von intakten basalen Achselknospen). Die Beschädigung wurde in vier Phasen des Lebenszyklus zugefügt: junge Rosette, überwinterte Rosette, blühende Pflanze und fruchtende Pflanze. Alle beschädigten Pflanzen überlebten unabhängig von der Phase des Lebenszyklus, der Schwere der Beschädigung und des Nährstoffgehaltes. Die Beschädigung beeinflusste die Samenproduktion und auch den Lebenszyklus der Pflanze signifikant. Pflanzen, die im zweiten Jahr beschädigt wurden (überwinterte Rosette, blühende Pflanze und fruchtende Pflanze) verschoben die Reproduktion in das dritte Jahr (im Falle der schweren Beschädigung) oder ihre Samenproduktion war geringer als bei intakten Pflanzen. Die Samenproduktion oder der Lebenszyklus wurde bei Pflanzen nicht beeinflusst, die im ersten Jahr beschädigt wurden. Der Nährstoffgehalt beeinflusste das Wiederaussprießen nach der Beschädigung und die Samenproduktion nur marginal. Das Experiment demonstrierte, dass die Fähigkeit aus den Wurzeln zu sprießen die Pflanzen in die Lage versetzt, einen 100% Verlust der oberflächlichen Biomasse zu überleben und die Samenproduktion nicht nur aufrechtzuerhalten, sondern den Verlust sogar wettzumachen. Die kurzlebige Ruderalart B. vulgaris kann erfolgreich mit einer schwerwiegenden Störung umgehen indem sie wiederaussprießt und ist nicht auf die Samenbank angewiesen.

Characteristics and conviction rates of injured alcohol-impaired drivers admitted to a tertiary care Canadian Trauma Centre

Alcohol intoxication is an important factor in motor vehicle crash (MVC) related morbidity and mortality. Despite greater societal attention, medical admission after MVC results in avoidance of legal consequences. We sought to determine characteristics of, and consequences to, injured alcohol-impaired drivers (IAIDs). All injured adults [Injury Severity Score (ISS) >12, age>18] entered in a Trauma Centre registry between April 1 1995 to March 31 2003 were reviewed. Legally intoxicated patients who had been drivers involved in a MVC and who had a blood alcohol content (BAC) > or =80 mg/dl were cross-referenced to municipal and federal databases to identify investigations, charges, and legal outcomes. Of BACs obtained from 1933 (41%) of 4727 patients; 39% (757) were legally intoxicated (BAC > or =80 mg/dl); 185 (24%) were IAIDs. The IAIDs were generally very intoxicated (mean BAC 190 mg/dl); seriously injured (median ISS 22); often in ICU (47%), and had 8% mortality. Charges were laid against 69 (37%) of IAIDs, only 58 (31%) suffered legal consequences; 27 (15%) of impaired driving, and 31 (17%) of other convictions. All IAIDs who caused a fatal injury to another were convicted. A lower severity of injury of the IAIDs, non-fatal injury to another, and occurrence in the more recent years of the study were independently associated with a conviction in multivariable analysis. Despite increasing convictions over time and among most of those charged, the majority of injured drivers escape legal consequences. Increased BAC testing and reporting of this phenomenon could address this.

Invited commentary

Although this article [1] suffers from selection bias, is not randomized, and is not prospective, it still provides valuable long-term information. We have seen previous publications that document less early pain and better cosmetics with video-assisted thoracoscopic surgery (VATS). None, however, have added such comprehensive long-term data. The VATS group may have had a slightly lower severity of injury (potential selection bias), but these data seem quite convincing with regard to less morbidity in the VATS group compared with thoracotomy in the areas of pain, cosmetics, and activity.

The Effect of Pre-Existing Medical Conditions and Age on Mortality After Injury

Pre-existing medical conditions (PMCs) have been shown to increase mortality after trauma even after adjustment for the effect of chronological aging. It has been suggested that there is an interaction between injury severity and physiologic reserve, such that diminished physiologic reserve will have an adverse effect on survival at lower injury severity, but that at higher levels of injury severity, physiologic reserve will have much less of an impact. Records of 65,743 patients, admitted after trauma, were extracted from the database of the United Kingdom Trauma Network to explore the impacts of age, gender and PMCs on mortality, and modification of these effects by severity of injury. PMCs were categorized as absent (23%), present (23%), or unrecorded (54%). There was an increase in mortality with increasing age at all levels of injury severity. Presence of a PMC was associated with a marked increase in mortality of patients with minor injuries (odds ratio [OR] = 5.9, 95% confidence interval [CI] 4.4, 8.0) or moderate injuries (OR = 2.0, 95% CI 1.4, 2.9), but not in those with more severe injuries (OR = 1.1, 95% CI 0.9, 1.4). The impact of age and male gender were also somewhat more pronounced for patients with less severe injuries. These findings support the hypothesis of an interaction between physiologic reserve and injury severity, where PMCs are associated with increased mortality when combined with low to moderate severity injuries, but not when combined with more severe injuries.