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Martino AM, Santos J, Giron A, Schomberg J, Goodman LF, Nahmias J, Nguyen DV, Grigorian A, Olaya J, Yu P, Guner YS. Variability in Standardized Mortality Rates Among Pediatric Traumatic Brain Injury Patients: A Comparative Analysis of Trauma Centers. J Pediatr Surg 2024:S0022-3468(24)00166-0. [PMID: 38580548 DOI: 10.1016/j.jpedsurg.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/01/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION Traumatic brain injury (TBI) causes significant morbidity and mortality in pediatric patients and care is highly variable. Standardized mortality ratio (SMR) summarizes the mortality rate of a specific center relative to the expected rates across all centers, adjusted for case-mix. This study aimed to evaluate variations in SMRs among pediatric trauma centers for TBI. METHODS Patients aged 1-18 diagnosed with TBI within the National Trauma Data Bank (NTDB) from 2017 to 2019 were included. Center-specific SMRs and 95% confidence intervals identified centers with mortality rates significantly better or worse than the median SMR for all centers. RESULTS 316 centers with 10,598 patients were included. SMRs were risk-adjusted for patient risk factors. Unadjusted mortality ranged from 16.5 to 29.5%. Three centers (1.5%) had significantly better SMR (SMR <1) and three centers (1.5%) had significantly worse SMR (SMR >1). Significantly better centers had a lower proportion of neurosurgical intervention (2.4% vs. 11.8%, p < 0.001), a higher proportion of supplemental oxygen administration (93.7% vs. 83.5%, p = 0.004) and venous thromboembolism prophylaxis (53.2% vs. 40.6%, p < 0.001) compared to significantly worse centers. CONCLUSIONS This study identified centers that have significantly higher and lower mortality rates for pediatric TBI patients relative to the overall median rate. These data provide a benchmark for pediatric TBI outcomes and institutional quality improvement. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective Comparative Study.
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Affiliation(s)
- Alice M Martino
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA.
| | - Jeffrey Santos
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA
| | - Andreina Giron
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, CA, USA
| | - John Schomberg
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, CA, USA
| | - Laura F Goodman
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, CA, USA
| | - Jeffry Nahmias
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine Medical Center, Orange, CA, USA
| | - Danh V Nguyen
- Department of Medicine, Division of General Internal Medicine, University of California Irvine Medical Center, Orange, CA, USA
| | - Areg Grigorian
- Department of Surgery, Division of Trauma, Burns and Surgical Critical Care, University of California Irvine Medical Center, Orange, CA, USA
| | - Joffre Olaya
- Division of Pediatric Neurosurgery, Children's Hospital Orange County, Orange, CA, USA
| | - Peter Yu
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, CA, USA
| | - Yigit S Guner
- Department of Surgery, University of California Irvine Medical Center, Orange, CA, USA; Division of Pediatric Surgery, Children's Hospital Orange County, Orange, CA, USA
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DiMaggio CJ, Avraham JB, Frangos SG, Keyes K. The role of alcohol and other drugs on emergency department traumatic injury mortality in the United States. Drug Alcohol Depend 2021; 225:108763. [PMID: 34049099 PMCID: PMC8282716 DOI: 10.1016/j.drugalcdep.2021.108763] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alcohol and other drugs (AOD) increase the risk of traumatic injury occurring, but data suggest a protective benefit in preventing trauma-related mortality. The objective of this study is to describe the epidemiology of AOD-related traumatic injury in the US over a recent 7 year period and assess the interaction of traumatic injury and AOD on pre-admission fatality on both an additive scale using incidence contrasts and on a statistical multiplicative scale using survey-adjusted logistic regression. METHODS Using the National Emergency Department Sample (NEDS), we describe the epidemiology of alcohol and substance-related emergency department traumatic injury over a recent period. AOD-related injury was assessed using survey-adjusted counts and means. Ratio estimates and differences were calculated using simulations based on survey-adjusted counts and standard errors. Differences in trends over time were evaluated by comparing the slopes of linear regression equations with year as the predictor variable. RESULTS Alcohol and substance-related emergency department injury discharges increased 9.8 % during the study period. There was a statistically significant interaction between traumatic injury death and AOD on both an additive scale and multiplicative scale. (Odds Ratio for interaction term = 1.76, 95 % CI = 1.53, 2.03). CONCLUSIONS AOD use does not provide a protective benefit in the setting of trauma, but rather is an important contributor to traumatic injury mortality.
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Affiliation(s)
- Charles J. DiMaggio
- Department of Surgery, Division of Trauma and Acute Care Surgery, New York University School of Medicine, New York, NY, United States,Department of Population Health, New York University School of Medicine, New York, NY, United States
| | - Jacob B. Avraham
- Department of Surgery, Division of Trauma and Acute Care Surgery, NorthShore University HealthSystem, Evanston, IL, United States,corresponding author. NorthShore University HealthSystem, 2625 Ridge Avenue, Walgreen Building, Suite 2507 Evanston, IL 60201. .
| | - Spiros G. Frangos
- Department of Surgery, Division of Trauma and Acute Care Surgery, New York University School of Medicine, New York, NY, United States
| | - Katherine Keyes
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, United States
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Sasaki K, Obinata H, Yokobori S, Sakamoto T. Alcohol does not increase in-hospital mortality due to severe blunt trauma: an analysis of propensity score matching using the Japan Trauma Data Bank. Acute Med Surg 2021; 8:e671. [PMID: 34262778 PMCID: PMC8254651 DOI: 10.1002/ams2.671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/02/2021] [Indexed: 11/10/2022] Open
Abstract
Aim Alcohol‐related problems, including trauma, are a great burden on global health. Alcohol metabolism in the Japanese population is genetically inferior to other races. This study aimed to evaluate the effects of alcohol use among a Japanese severe blunt trauma cohort. Methods This retrospective observational study analyzed the data of trauma patients registered in the Japan Trauma Data Bank between 2004 and 2019. The primary outcome of this study was in‐hospital mortality. The lengths of hospital and intensive care unit stay were the secondary outcomes. Propensity score matching was used to adjust the anatomical severity and patient background to reduce the potential alcohol use bias. Results We analyzed 46,361 patients categorized into nondrinking (n = 37,818) and drinking (n = 8,543) groups. After a 1:1 propensity score matching (n = 8,428, respectively), despite the Glasgow Coma Scale and Revised Trauma Score scores being significantly lower in the drinking group (14 vs. 13 and 7.84 vs. 7.55, P < 0.001, respectively) and intensive care unit length of stay being significantly longer in the drinking group (6 vs. 7 days, P = 0.002), in‐hospital mortality was significantly lower in the alcohol group (11.8% vs. 9.0%, P < 0.001) and there were no differences in the duration of hospital stay (19 vs. 19 days, P = 0.848). Conclusion Despite increasing physiological severity on admission, after adjusting for anatomical severity, alcohol consumption could be beneficial in severe blunt trauma patients as regards in‐hospital mortality.
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Affiliation(s)
- Kazuma Sasaki
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Hirofumi Obinata
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan.,Shock and Trauma Center Nippon Medical School Chiba Hokusoh Hospital Chiba Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan
| | - Taigo Sakamoto
- Department of Emergency and Critical Care Medicine Nippon Medical School Tokyo Japan.,Shock and Trauma Center Nippon Medical School Chiba Hokusoh Hospital Chiba Japan
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Knight MT, Li T, Dhillon NK, Srour M, Huang R, Margulies DR, Ley EJ, Barmparas G. Walking Under the Influence : Association of Time of the Day With the Incidence and Outcomes of Intoxicated Pedestrians Struck by Vehicles. Am Surg 2020; 87:354-363. [PMID: 32988238 DOI: 10.1177/0003134820947365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Pedestrian fatalities commonly involve alcohol. We sought to characterize alcohol intoxication among pedestrians struck by vehicles and examine correlations between admission time and injury severity. METHODS The Los Angeles County Trauma and Emergency Medicine Information System database was reviewed for pedestrians struck by vehicles over a 16-year period starting January 2000. Subjects aged ≥18 years with available time and day of admission were selected. Patients with available blood alcohol content (BAC) were analyzed and those with positive (+) BAC (≥ 0.01%) were compared with those with negative (-) BAC. The primary outcome was mortality. RESULT 35 840 patients met criteria, with 12 122 (33.8%) tested for BAC. 71.2% were (+) BAC. The proportion of (+) BAC pedestrians peaked at 02:00 (48.9% of admitted pedestrians, 88.5% of BAC tested pedestrians). Patients with a (+) BAC were more likely hypotensive (3.5% vs 2.7%, P = .019) and admitted with a Glasgow Coma Scale ≤ 8 (9.4% vs 7.1%, P < .001). Overall mortality was 4.6%. Those admitted from 06:00 to 11:00 had the highest odds of mortality in (+) BAC patients (4.7%, adjusted odds ratio 3.16, adjusted P < .001). CONCLUSION Pedestrians struck by vehicles during late hours are commonly intoxicated. These findings could help legislators to implement changes and strategies to decrease the risk and burden of injury in intoxicated pedestrians.
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Affiliation(s)
- Margot T Knight
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tong Li
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Navpreet K Dhillon
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marissa Srour
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Raymond Huang
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel R Margulies
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Eric J Ley
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Galinos Barmparas
- 22494 Department of Surgery, Division of Trauma and Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Dadashova B, Arenas-Ramires B, Mira-McWillaims J, Dixon K, Lord D. Analysis of crash injury severity on two trans-European transport network corridors in Spain using discrete-choice models and random forests. TRAFFIC INJURY PREVENTION 2020; 21:228-233. [PMID: 32160016 DOI: 10.1080/15389588.2020.1733539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 06/10/2023]
Abstract
Objective: The objective of this paper is to identify the list of crash severity contributing factors and evaluate their impact on multiple-vehicle crashes on two high use Trans-European interurban, freight corridors in Spain (southern Europe): Madrid - Irùn and Barcelona - Almerìa.Methods: We have used both logistic regression and random forests to identify crash severity predictors and estimate their impacts on crash outcomes. Although both statistical methods can provide useful information to help explain the safety implications of highway crashes, using both methods may further enable a more comprehensive understanding of this phenomenon. For this effort, we disaggregated the crash data into different crash types (i.e., head-on, angle, sideswipe and rear-end) and analyzed this data using roadway design elements, driver characteristics, and environmental factors. To identify the most important predictors of crash severity, we used the random forests data mining approach. We then used ordered logit models to estimate the effect of external factors on the severity of each crash type. Finally, we assessed the accuracy of the model estimates using bootstrap sampling.Results: The results of data mining analyses indicated that roadway design factors such as horizontal and vertical curvature, super elevation, and lane and shoulder width are among the most important factors associated with crash severity. The results of logistic regression show that the impact of the selected roadway element on the crash outcome is conditional on the crash type and the direction of the effects is not always consistent.Conclusions: The contribution of this paper to the existing literature is two-fold: the first important contribution of the paper is related to the safety analysis of two of the most important freight corridors in Spain and southern Europe. The second contribution of this paper is to address the existing gap in the literature relating to the comparison and compatibility of data mining and the logistic regression model.
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Affiliation(s)
- Bahar Dadashova
- Texas A&M Transportation Insitute, Texas A&M University System, College Station, Texas, USA
| | - Blanca Arenas-Ramires
- University Institute of Automobile Research (INSIA), Technical University of Madrid (UPM), Madrid, Spain
| | - Jose Mira-McWillaims
- University Institute of Automobile Research (INSIA), Technical University of Madrid (UPM), Madrid, Spain
| | - Karen Dixon
- Texas A&M Transportation Insitute, Texas A&M University System, College Station, Texas, USA
| | - Dominique Lord
- Texas A&M Transportation Insitute, Texas A&M University System, College Station, Texas, USA
- Zachary Department of Civil and Environmental Engineering, Texas A&M University System, College Station, Texas, USA
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6
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Fatal falls involving stairs: an anthropological analysis of skeletal trauma. Forensic Sci Med Pathol 2018; 14:152-162. [DOI: 10.1007/s12024-018-9964-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2018] [Indexed: 10/17/2022]
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Afshar M, Burnham EL, Joyce C, Clark BJ, Yong M, Gaydos J, Cooper RS, Smith GS, Kovacs EJ, Lowery EM. Cut-Point Levels of Phosphatidylethanol to Identify Alcohol Misuse in a Mixed Cohort Including Critically Ill Patients. Alcohol Clin Exp Res 2017; 41:1745-1753. [PMID: 28792620 DOI: 10.1111/acer.13471] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/02/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Although alcohol misuse is associated with deleterious outcomes in critically ill patients, its detection by either self-report or examination of biomarkers is difficult to obtain consistently. Phosphatidylethanol (PEth) is a direct alcohol biomarker that can characterize alcohol consumption patterns; however, its diagnostic accuracy in identifying misuse in critically ill patients is unknown. METHODS PEth values were obtained in a mixed cohort comprising 122 individuals from medical and burn intensive care units (n = 33), alcohol detoxification unit (n = 51), and healthy volunteers (n = 38). Any alcohol misuse and severe misuse were referenced by Alcohol Use Disorders Identification Test (AUDIT) and AUDIT-C scores separately. Mixed-effects logistic regression analysis was performed, and the discrimination of PEth was evaluated using the area under the receiver-operating characteristic (ROC) curve. RESULTS The area under the ROC curve for PEth was 0.927 (95% CI: 0.877, 0.977) for any misuse and 0.906 (95% CI: 0.850, 0.962) for severe misuse defined by AUDIT. By AUDIT-C, the area under the ROC curves was 0.948 (95% CI: 0.910, 0.956) for any misuse and 0.913 (95% CI: 0.856, 0.971) for severe misuse. The PEth cut-points of ≥250 and ≥400 ng/ml provided optimal discrimination for any misuse and severe misuse, respectively. The positive predictive value for ≥250 ng/ml was 88.7% (95% CI: 77.5, 95.0), and the negative predictive value was 86.7% (95% CI: 74.9, 93.7). PEth ≥ 400 ng/ml achieved similar values, and similar results were shown for AUDIT-C. In a subgroup analysis of critically ill patients only, test characteristics were similar to the mixed cohort. CONCLUSIONS PEth is a strong predictor and has good discrimination for any and severe alcohol misuse in a mixed cohort that includes critically ill patients. Cut-points at 250 ng/ml for any, and 400 ng/ml for severe, are favorable. External validation will be required to establish these cut-points in critically ill patients.
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Affiliation(s)
- Majid Afshar
- Stritch School of Medicine , Burn and Shock Trauma Research Institute, Loyola University Health Sciences Campus, Maywood, Illinois.,Alcohol Research Program , Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois.,Department of Public Health Sciences , Stritch School of Medicine, Loyola University Chicago Health Sciences Campus, Maywood, Illinois
| | - Ellen L Burnham
- Department of Medicine , Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Cara Joyce
- Department of Public Health Sciences , Stritch School of Medicine, Loyola University Chicago Health Sciences Campus, Maywood, Illinois
| | - Brendan J Clark
- Department of Medicine , Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Meagan Yong
- Stritch School of Medicine , Burn and Shock Trauma Research Institute, Loyola University Health Sciences Campus, Maywood, Illinois.,Alcohol Research Program , Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
| | - Jeannette Gaydos
- Department of Medicine , Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Richard S Cooper
- Department of Public Health Sciences , Stritch School of Medicine, Loyola University Chicago Health Sciences Campus, Maywood, Illinois
| | - Gordon S Smith
- Shock Trauma and Anesthesiology Research (STAR) - Organized Research Center , Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Elizabeth J Kovacs
- Department of Surgery , University of Colorado School of Medicine, Aurora, Colorado
| | - Erin M Lowery
- Stritch School of Medicine , Burn and Shock Trauma Research Institute, Loyola University Health Sciences Campus, Maywood, Illinois.,Alcohol Research Program , Stritch School of Medicine, Loyola University Health Sciences Campus, Maywood, Illinois
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Demographic and socioeconomic factors influencing disparities in prevalence of alcohol-related injury among underserved trauma patients in a safety-net hospital. Injury 2016; 47:2635-2641. [PMID: 27771038 DOI: 10.1016/j.injury.2016.10.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 10/12/2016] [Accepted: 10/17/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Alcohol-related trauma remains high among underserved patients despite ongoing preventive measures. Geographic variability in prevalence of alcohol-related injury has prompted reexamination of this burden across different regions. We sought to elucidate demographic and socioeconomic factors influencing the prevalence of alcohol-related trauma among underserved patients and determine alcohol effects on selected outcomes. METHODS A retrospective analysis examined whether patients admitted to a suburban trauma center differed according to their blood alcohol concentration (BAC) on admission. Patients were stratified based on their BAC into four categories (undetectable BAC, BAC 1-99mg/dL, BAC 100-199mg/dL, and BAC ≥ 200mg/dL). T-tests and X2 tests were used to detect differences between BAC categories in terms of patient demographics and clinical outcomes. Multivariate linear and logistic regressions were used to investigate the association between patient variables and selected outcomes while controlling for confounders. RESULTS One third of 738 patients analyzed were BAC-positive, mean (SD) BAC was 211.4 (118.9) mg/dL, 80% of BAC-positive patients had levels ≥ 100mg/dL. After risk adjustments, the following patient characteristics were predictive of having highly elevated BAC (≥200mg/dL) upon admission to the Trauma Center; Hispanic patients (adjusted odds ratio (OR)=1.91, 95% confidence interval (CI): 1.14-3.21), unemployment (OR=1.74, 95% CI: 1.09-2.78), Medicaid beneficiaries (OR=3.59, 95% CI: 1.96-6.59), and uninsured patients (OR=2.86, 95% CI: 1.60-5.13). Patients with BAC of 100-199mg/dL were likely to be more severely injured (P=0.016) compared to undetectable-BAC patients. There was no association between being intoxicated, and being ICU-admitted or having differences in length of ICU or hospital stay. CONCLUSION Demographic and socioeconomic factors underlie disparities in the prevalence of alcohol-related trauma among underserved patients. These findings may guide targeted interventions toward specific populations to help reduce the burden of alcohol-related injury.
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Zakharov S, Pelclova D, Urban P, Navratil T, Nurieva O, Kotikova K, Diblik P, Kurcova I, Belacek J, Komarc M, Eddleston M, Hovda KE. Use of Out-of-Hospital Ethanol Administration to Improve Outcome in Mass Methanol Outbreaks. Ann Emerg Med 2016; 68:52-61. [PMID: 26875060 DOI: 10.1016/j.annemergmed.2016.01.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 12/29/2015] [Accepted: 01/05/2016] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVE Methanol poisoning outbreaks are a global public health issue, with delayed treatment causing poor outcomes. Out-of-hospital ethanol administration may improve outcome, but the difficulty of conducting research in outbreaks has meant that its effects have never been assessed. We study the effect of out-of-hospital ethanol in patients treated during a methanol outbreak in the Czech Republic between 2012 and 2014. METHODS This was an observational case-series study of 100 hospitalized patients with confirmed methanol poisoning. Out-of-hospital ethanol as a "first aid antidote" was administered by paramedic or medical staff before the confirmation of diagnosis to 30 patients; 70 patients did not receive out-of-hospital ethanol from the staff (12 patients self-administered ethanol shortly before presentation). RESULTS The state of consciousness at first contact with paramedic or medical staff, delay to admission, and serum methanol concentration were similar among groups. The median serum ethanol level on admission in the patients with out-of-hospital administration by paramedic or medical staff was 84.3 mg/dL (interquartile range 32.7 to 129.5 mg/dL). No patients with positive serum ethanol level on admission died compared with 21 with negative serum ethanol level (0% versus 36.2%). Patients receiving out-of-hospital ethanol survived without visual and central nervous system sequelae more often than those not receiving it (90.5% versus 19.0%). A positive association was present between out-of-hospital ethanol administration by paramedic or medical staff, serum ethanol concentration on admission, and both total survival and survival without sequelae of poisoning. CONCLUSION We found a positive association between out-of-hospital ethanol administration and improved clinical outcome. During mass methanol outbreaks, conscious adults with suspected poisoning should be considered for administration of out-of-hospital ethanol to reduce morbidity and mortality.
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Affiliation(s)
- Sergey Zakharov
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic.
| | - Daniela Pelclova
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Pavel Urban
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Tomas Navratil
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic; Department of Biomimetic Electrochemistry, J. Heyrovsky Institute of Physical Chemistry of the AS CR, Prague, Czech Republic
| | - Olga Nurieva
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Katerina Kotikova
- Toxicological Information Center, Department of Occupational Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Pavel Diblik
- Department of Ophthalmology, General University Hospital, Prague, Czech Republic
| | - Ivana Kurcova
- Department of Toxicology and Forensic Medicine, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Jaromir Belacek
- Institute of Biophysics and Informatics, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Martin Komarc
- Institute of Biophysics and Informatics, First Faculty of Medicine, Charles University, and General University Hospital, Prague, Czech Republic
| | - Michael Eddleston
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Knut Erik Hovda
- Norwegian CBRNe Center of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
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Afshar M, Netzer G, Salisbury-Afshar E, Murthi S, Smith GS. Injured patients with very high blood alcohol concentrations. Injury 2016; 47:83-8. [PMID: 26556488 PMCID: PMC4852150 DOI: 10.1016/j.injury.2015.10.063] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 10/05/2015] [Accepted: 10/22/2015] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Most data regarding high blood alcohol concentrations (BAC) ≥400 mg/dL have been from alcohol poisoning deaths. Few studies have described this group and reported their alcohol consumption patterns or outcomes compared to other trauma patients. We hypothesised trauma patients with very high BACs arrived to the trauma centre with less severe injuries than their sober counterparts. METHOD Historical cohort of 46,222 patients admitted to a major trauma centre between January 1, 2002 and October 31, 2011. BAC was categorised into ordinal groups by 100 mg/dL intervals. Alcohol questionnaire data on frequency and quantity was captured in the BAC ≥400 mg/dL group. The primary analysis was for BAC ≥400 mg/dL. RESULTS BAC was recorded in 44,502 (96.3%) patients. Those with a BAC ≥400 mg/dL accounted for 1.1% (147) of BAC positive cases. These patients had the lowest proportion of severe trauma and in-hospital death in comparison with the other alcohol groups (p<0.001). In adjusted analysis, the risk for severe injury increased with the BAC groups between 1 and 199 mg/dL and was not different or decreased for groups above 200 mg/dL in reference to the BAC negative group (test for trend p=0.001). BAC ≥400 group encountered more injuries caused by blunt trauma in comparison with the other alcohol groups (p<0.001), and the group comprised mainly of falls. Admission Glasgow Coma Scale was a poor predictor for traumatic brain injury in the high BAC group. Readmission occurred in 22.4% (33) of patients the BAC ≥400 group. The majority of these patients reported drinking alcohol 4 or more days per week (81, 67.5%) and five or more drinks per day (79, 65.8%), evident of risky alcohol use. CONCLUSIONS Most traumas admitted with BAC ≥400 mg/dL survived and their injuries were less severe than their less intoxicated and sober counterparts. They also had evidence for risky alcohol use and nearly one-quarter returned to the trauma centre with another injury over the study period. Recognition of this highest BAC group presents an opportunity to provide focused care for their risky alcohol use.
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Affiliation(s)
- Majid Afshar
- Division of Pulmonary and Critical Care Medicine, Loyola University Health Sciences, Maywood, IL, United States; Department of Public Health Sciences, Loyola University School of Medicine, Maywood, IL, United States.
| | - Giora Netzer
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD, United States; Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, United States
| | | | - Sarah Murthi
- Program in Trauma, R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, United States
| | - Gordon S Smith
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, MD, United States; Shock Trauma and Anesthesiology Research (STAR)-Organized Research Center, University of Maryland, Baltimore, MD, United States
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Abstract
BACKGROUND The association of alcohol use with in-hospital trauma deaths remains unclear. This study identifies the association of blood alcohol content (BAC) with in-hospital death accounting for injury severity and mechanism. METHODS This study involves a historical cohort of 46,222 admissions to a statewide trauma center between January 1, 2002, and October 31, 2011. Blood alcohol was evaluated as an ordinal variable: 1 mg/dL to 100 mg/dL as moderate blood alcohol, 101 mg/dL to 230 mg/dL as high blood alcohol, and greater than 230 mg/dL as very high blood alcohol. RESULTS Blood alcohol was recorded in 44,502 patients (96.3%). Moderate blood alcohol was associated with an increased odds for both penetrating mechanism (odds ratio [OR], 2.22; 95% confidence interval [CI], 2.04-2.42) and severe injury (OR, 1.25; 95% CI, 1.16-1.35). Very high blood alcohol had a decreased odds for penetrating mechanism (OR, 0.75; 95% CI, 0.67-0.85) compared with the undetectable blood alcohol group. An inverse U-shaped association was shown for severe injury and penetrating mechanism by alcohol group (p < 0.001). Moderate blood alcohol had an increased odds for in-hospital death (OR, 1.50; 95% CI, 1.25-1.79), and the odds decreased for very high blood alcohol (OR, 0.69; 95% CI, 0.54-0.87). An inverse U-shaped association was also shown for in-hospital death by alcohol group (p < 0.001). Model discrimination for in-hospital death had an area under the receiver operating characteristic curve of 0.64 (95% CI, 0.63-0.65). CONCLUSION Injury severity and mechanism are strong intermediate outcomes between alcohol and death. Severe injury itself carried the greatest odds for death, and with the moderate BAC group at greatest odds for severe injury and the very high BAC group at the lowest odds for severe injury. The result was a similar inverse-U shaped curve for odds for in-hospital death. Clear associations between blood alcohol and in-hospital death cannot be analyzed without consideration for the different injuries by blood alcohol groups. LEVEL OF EVIDENCE Epidemiologic study, level III.
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12
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Association between blood alcohol concentration and mortality in critical illness. J Crit Care 2015; 30:1382-9. [DOI: 10.1016/j.jcrc.2015.08.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Revised: 06/02/2015] [Accepted: 08/30/2015] [Indexed: 11/20/2022]
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Brattström O, Eriksson M, Larsson E, Oldner A. Socio-economic status and co-morbidity as risk factors for trauma. Eur J Epidemiol 2014; 30:151-7. [PMID: 25377535 DOI: 10.1007/s10654-014-9969-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 10/25/2014] [Indexed: 12/17/2022]
Abstract
Clinical experience and previous studies indicate that low socioeconomic positions are overrepresented in trauma populations. The reason for this social variation in injury risk is likely to be multifactorial. Both individual and environmental sources of explanation are plausible to contribute. We investigated the impact of the influence of socioeconomic factors and co-morbidity on the risk of becoming a trauma victim in a case-control study including 7,382 trauma patients matched in a one to five ratio with controls matched by age-, gender- and municipality from a level 1 trauma centre. Data from the trauma cohort were linked to national registries. Associations between socioeconomic factors and co-morbidity were estimated by conditional logistic regression. The trauma patients had been treated for psychiatric, substance abuse and somatic diagnoses to a higher extent than the controls. In the conditional logistic regression analysis a low level of education and income as well as co-morbidity (divided into psychiatric, substance abuse and somatic diagnoses) were all independent risk factors for trauma. Analysing patients with an injury severity score >15 separately did not alter the results, except for somatic diagnoses not being a risk factor. Recent treatment for substance abuse significantly increased the risk for trauma. Low level of education and income as well as psychiatric, substance abuse and somatic co-morbidity were all independent risk factors for trauma. Active substance abuse strongly influenced the risk for trauma and had a time dependent pattern. These insights can facilitate future implementation of injury prevention strategies tailored to specific risk groups.
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Affiliation(s)
- Olof Brattström
- Section of Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden,
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14
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Blood alcohol content, injury severity, and adult respiratory distress syndrome. J Trauma Acute Care Surg 2014; 76:1447-55. [PMID: 24854314 DOI: 10.1097/ta.0000000000000238] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Elevated blood alcohol content (BAC) is a risk factor for injury. Associations of BAC with adult respiratory distress syndrome (ARDS) have not been conclusively established.We evaluated the association of a BAC greater than 0 mg/dL with the intermediate outcomes, Injury Severity Score (ISS) and Glasgow Coma Scale (GCS) score, and their association with ARDS development. METHODS This is an observational retrospective cohort study of 26,305 primary trauma admissions to a statewide referral trauma center from July 11, 2003, to October 31, 2011. Logistic regression was performed to assess the relationship between admission BAC, ISS, GCS score, and ARDS development within 5 days of admission. RESULTS The case rate for ARDS was 5.5% (1,447). BAC greater than 0 mg/dL was associated with ARDS development in adjusted analysis (odds ratio, 1.50; 95% confidence interval [CI], 1.33-1.71; p < 0.001). High ISS (≥16) had a stronger association with ARDS development (odds ratio, 17.99; 95% CI, 15.51-20.86), as did low GCS score (≤8) (odds ratio, 8.77; 95% CI, 7.64-10.07; p < 0.001). Patients with low GCS score and high ISS had the most frequent ARDS (33.6%) and the highest case-fatality rate without ARDS (24.7%). CONCLUSION Elevated BAC is associated with ARDS development. In the analysis of alcohol exposure, ISS and GCS score occur after alcohol ingestion, making them intermediate outcomes. ISS and GCS score were strong predictors of ARDS and may be useful to identify at-risk patients. Elevated BAC may increase the frequency of the ARDS through influence on injury severity or independent molecular mechanisms, which can be discriminated only in experimental models. LEVEL OF EVIDENCE Epidemiologic study, level III.
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Friedman LS. Complications associated with blood alcohol concentration following injury. Alcohol 2014; 48:391-400. [PMID: 24835008 DOI: 10.1016/j.alcohol.2014.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 01/21/2014] [Accepted: 01/22/2014] [Indexed: 12/20/2022]
Abstract
Alcohol increases the risk of injuring oneself and others. However, following an injury there appears to be a benefit to alcohol in mediating the body's response to a traumatic injury and reducing mortality. The physiological mechanism underlying this reported association is poorly understood. One approach to explaining the pathways by which alcohol affects acute mortality following a traumatic injury is to identify differential prevalence of medical complications associated with increased mortality. The goal of this study was to evaluate the association between blood alcohol concentration and complications subsequent to a traumatic injury that are associated with increased in-hospital mortality. This study involved a retrospective analysis of traumatic injuries occurring between 2000 and 2009 as reported by all level I and II trauma units in the state of Illinois. The study includes all patients with blood alcohol toxicological examination levels ranging from zero to 500 mg/dL and meeting additional inclusion criteria (n = 84,974). A reduction in complications of cardiac and renal function by 23.5% and 30.0%, respectively, was attributable to blood alcohol concentration. In addition, blood alcohol concentration was associated with fewer cases of pneumothorax and convulsions. However, blood alcohol concentration continued to be positively associated with aspiration pneumonitis and acute pancreatitis in the final models. The net impact of alcohol following an injury is protective, largely attributable to a reduction in complications relating to cardiac and renal function. This study helps to explain the observed protective effect from blood alcohol concentrations in reducing in-hospital mortality after an injury, as reported in many studies.
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