No evidence of resistance to itraconazole in a prospective real-world trial of dermatomycosis in India

BACKGROUND

The prevalence of superficial fungal infections in India is believed to have increased substantially in the past decade. We evaluated the treatment outcomes and risk factors associated with clinical response to a treatment course of itraconazole for the management of dermatomycosis in India.

METHODS

In this real-world, prospective pilot study (August 2019 to March 2020), adult participants (18-60 years), diagnosed with T. cruris or T. corporis, received itraconazole 200 mg/day (any formulation) orally for 7 days, and were followed for an additional 7 days.

RESULTS

The study was terminated early due to the COVID-19 pandemic. Of 40 enrolled participants (mean [SD] age, 35.5 [12.73] years; {62.5%}] male; 37 received itraconazole and 20 (50%) completed the study. The median (range) Clinical Evaluation Tool Signs and Symptoms total score at baseline was 5.5 (2-10). Clinical response of "healed" or "markedly improved" based on the Investigator Global Evaluation Tool at day 7 (primary objective) was 42.9% (12/28; 95% CI: 24.53%, 61.19%). Itraconazole minimum inhibitory concentration for identified microorganisms, T. mentagrophytes species complex (91.7%) and T. rubrum (8.3%), was within the susceptibility range (0.015-0.25 mcg/mL). At day 14, 8/13 (61.5%) participants achieved a mycological response, 2/13 participants (15.4%) had a mycological failure and 90% showed a clinical response.

CONCLUSION

COVID-19 pandemic affected patient recruitment and follow-up, so the findings call for a careful interpretation. Nevertheless, this real-world study reconfirmed the clinical efficacy and microbial susceptibility to itraconazole for the fungi causing dermatophytosis in India.

TRIAL REGISTRATION

Trial registration number: Clinicaltrials.gov NCT03923010.

Cyclic fatigue testing of ProTaper NiTi rotary instruments after clinical use

PURPOSE

The purpose of this study was to evaluate the cyclic fatigue of ProTaper nickel-titanium (NiTi) rotary instruments (Tulsa Dental, Tulsa, Okla) after multiple clinical uses.

STUDY DESIGN

Two hundred twenty-five ProTaper instruments were divided into 3 groups: A = 75 used as controls, B = 75 used in 2 molars (6-8 canals), and C = 75 used in 4 molars (12-16 canals). The number of rotations to breakage and the fractured tip length were recorded for each file and the mean was calculated by ANOVA.

RESULTS

No S1-2 or F1-2-3 instrument separated during intracanal use, even if they were reused for a number of cases (x 4 molar cases).

CONCLUSION

It is clear that prolonged reuse of NiTi rotary instruments strongly affects instruments' fatigue, but our data suggest the hypothesis that other factors (primarily errors and misuse) may be more accountable for intracanal instrument separation. Further studies could assess the cyclic fatigue of each instrument at different levels of the shaft by altering the radius of curvature.

Shanxi Province cervical cancer screening study II: Self-sampling for high-risk human papillomavirus compared to direct sampling for human papillomavirus and liquid based cervical cytology

The objective of this study was to compare the sensitivity and specificity of a new method for self-sampling for high risk human papillomavirus (HPV) with direct sampling and liquid based cervical cytology. In Shanxi Province, China, 8,497 women (ages 27-56) underwent a self-sample for HPV using a conical-shaped brush placed into the upper vagina and rotated. Three to sixteen months later the women were screened with liquid-based cytology and direct HPV tests. Subjects with any abnormal test underwent colposcopy and multiple biopsies. Mean age was 40.9 years. 4.4 percent of subjects had >or=CIN II, 26% a positive self-sample and 24% a positive direct test for HPV. The sensitivity for detection of >or=CIN II was 87.5% for self-sampling, and 96.8% for the direct test (P < 0.001). The specificity was 77.2% for the self-sample and 79.7% for the direct test. With an abnormal Pap defined as ASCUS or greater the sensitivity of the Pap for the detection of >CIN II was 88.3% and the specificity was 81.2%. We conclude that self-sampling for HPV is less sensitive for >CIN II than the direct test, but similar to liquid based cytology.

Shanxi Province cervical cancer screening study II: Self-sampling for high-risk human papillomavirus compared to direct sampling for human papillomavirus and liquid based cervical cytology

The objective of this study was to compare the sensitivity and specificity of a new method for self-sampling for high risk human papillomavirus (HPV) with direct sampling and liquid based cervical cytology. In Shanxi Province, China, 8,497 women (ages 27–56) underwent a self-sample for HPV using a conical-shaped brush placed into the upper vagina and rotated. Three to sixteen months later the women were screened with liquid-based cytology and direct HPV tests. Subjects with any abnormal test underwent colposcopy and multiple biopsies. Mean age was 40.9 years. 4.4 percent of subjects had ≥CIN II, 26% a positive self-sample and 24% a positive direct test for HPV. The sensitivity for detection of ≥CIN II was 87.5% for self-sampling, and 96.8% for the direct test (P < 0.001). The specificity was 77.2% for the self-sample and 79.7% for the direct test. With an abnormal Pap defined as ASCUS or greater the sensitivity of the Pap for the detection of ≥ CIN II was 88.3% and the specificity was 81.2%. We conclude that self-sampling for HPV is less sensitive for ≥ CIN II than the direct test, but similar to liquid based cytology.

Patient Acceptance of Self-Sampling for Human Papillomavirus in Rural China

OBJECTIVE.: To test a new survey instrument and determine the acceptance and potential barriers of cervicovaginal self-sampling for high-risk human papillomavirus in rural Chinese women. MATERIALS AND METHODS.: Data from thirteen survey questions assessed acceptance of the self-sampling procedure. Pain, comprehension, and cultural beliefs were potential barriers evaluated by the survey. RESULTS.: A total of 1,560 women were surveyed. The average and mode number of steps of the self-sampling procedure recalled was 5 (out of 7). Ninety-one percent preferred performing the test at a clinic versus their home. The major barrier encountered was related to the educational level of the women. CONCLUSIONS.: The measure performed well in this population. The self-collection brush was well accepted by these women. Education is the largest hurdle to overcome in implementing a self-sampling screening program.

Coprescribing and codispensing of cisapride and contraindicated drugs

CONTEXT

Cisapride, an oral prokinetic drug indicated for the symptomatic treatment of nocturnal heartburn due to gastroesophageal reflux disease, was approved by the US Food and Drug Administration in July 1993. After reports of serious cardiac arrhythmias and deaths during administration of cisapride, most involving concomitant exposure to another drug, a series of label changes and warnings were issued in February 1995, October 1995, June 1998, and June 1999. Cisapride was removed from general distribution in July 2000.

OBJECTIVE

To determine the frequency of contraindicted coprescribing and codispensings, in which cisapride and a contraindicated drug were prescribed or dispensed to the same patient for overlapping periods, and the proportion of contraindicated coprescribing by the same physicians and codispensing by the same pharmacies.

DESIGN AND SETTING

Retrospective study of prescription claims from a managed care organization database for all patients with cisapride prescriptions between July 1993 and December 1998.

PARTICIPANTS

A total of 38 757 adult and pediatric patients who had a cisapride prescription immediately preceded by at least 60 days of insurance eligibility.

MAIN OUTCOME MEASURE

Proportion of cisapride prescriptions or dispensing occurring during the same treatment period as a drug contraindicated at that time prescribed by the same physicians or dispensed by the same pharmacies.

RESULTS

Of 131 485 cisapride prescriptions dispensed after the warnings began, 4414 (3.4%) overlapped with at least 1 drug contraindicated in the labeling at the time of the prescription. Of all overlapping prescription pairs, 2190 (50%) were by the same physicians, 3908 (89%) were by the same pharmacies, and 765 (17%) were dispensed on the same day.

CONCLUSION

Prescriptions dispensed by the same pharmacies accounted for a far higher proportion of contraindicated medication pairs than prescriptions from the same physicians. The pharmacy may be an important and underutilized intervention point to prevent contraindicated drugs from being used together.

Contraindicated medications dispensed with cisapride: temporal trends in relation to the sending of 'Dear Doctor' letters

PURPOSE

'Dear Doctor' letters alert the prescribing community of drug labeling changes that contain new contraindications, warnings, adverse reactions, and precautions. There has been little assessment of the impact of these letters. We quantified the impact of two 'Dear Doctor' letters concerning interactions between cisapride and a series of drugs. A letter in 1995 described a risk of prolonged QT intervals and serious ventricular arrhythmia in patients who received macrolide antibiotics and imidazole antifungals in conjunction with cisapride. A June 1998 letter that expanded the list of contraindicated comedications had wider distribution than an earlier one, was accompanied by substantial Internet and media coverage, and was complemented by an effort to inform large pharmacy dispensing information organizations of the warnings against concurrent use of the named drugs.

METHODS

Health plan members with one or more outpatient pharmacy claims for cisapride during the period 1 January 1995 through 31 May 1999 were identified among members of a large New England health insurer. A retrospective review of concurrent and nearly concurrent dispensings of cisapride and contraindicated comedications was undertaken in the automated pharmacy claims data using both graphical and statistical time-series analysis. We tabulated by month the fraction of cisapride dispensings that occurred in close temporal relation to dispensings of contraindicated comedications. Codispensings that occurred on the same day were taken as the most direct measure of prescriber responsiveness to the letters. Codispensings that occurred in windows of plus or minus 2 weeks (29 day window) and plus or minus 4 weeks (57 day window) were taken as measures of possible simultaneous consumption. Among overlapping dispensings, we counted the proportion dispensed by the same pharmacy. Time series regression analysis of secular, seasonal, and step-effects was conducted.

RESULTS

There was a steady decline in codispensing of cisapride and contraindicated medicines, and a pronounced seasonal effect, arising principally from the seasonal use of macrolide antibiotics. Against this background, the isolated Dear Doctor letter of October 1995 had no discernible effect on prescribing practices. The 1998 letter and surrounding activity, by contrast, were followed by a 66% decline in same-day dispensings and a smaller, but still pronounced decline in dispensings in the wider time windows. For most codispensings of contraindicated medications with cisapride, both medications came from the same pharmacy.

CONCLUSIONS

Publicity and direct intervention with dispensing pharmacies may be an important supplement to Dear Doctor letters when the goal is to eliminate the codispensing of drugs that should not be taken together.

Temporal Patterns of NSAID Spontaneous Adverse Event Reports

OBJECTIVES

Determine whether recent US adverse event reports for several non-steroidal anti-inflammatory drugs (NSAIDs) conform to the temporal pattern observed by Dr JCP Weber in the UK in the early 1980s, i.e. a rising count in the first few years after launch presumably reflecting increased exposure, followed by a decline, presumably reflecting decreased enthusiasm for reporting as adverse events become well known.

STUDY SETTING

US adverse event report data available from the US Food and Drug Administration, reformatted by a commercial vendor.

METHODS

For the 5 NSAIDs launched in the US between 1987 and 1993 that had data suitable for this study, we tabulated by year from launch the number of reports and the reporting rate (number of reports per 1000 prescriptions).

RESULTS

The number of reports for 3 of the 5 NSAIDs showed a temporal pattern approximating that described by Weber. The number of reports for the other 2 NSAIDs showed temporal patterns markedly different from that described by Weber. For 4 of the 5 NSAIDs, reporting rates did not decline consistently with time from launch.

DISCUSSION

The temporal patterns of adverse event reports are more complex than those described in Weber's classic report. The number of reports does not reliably rise and then fall after launch and the reporting rate does not reliably decrease with time from launch.

The risk of seizures associated with tramadol

We conducted a study of the risk of idiopathic incident seizures among users of tramadol derived from data present in the General Practice Research Database based in the United Kingdom for 1994-1996. We used a nested case-control study design, comparing risks of idiopathic incident seizures during exposed and unexposed times among patients who had ever taken tramadol using a 90-day follow-up. Among the 10,916 subjects, we identified 17 cases of idiopathic seizures, 11 of which were definite and 6 possible. None of the patients was exposed to tramadol alone in the prior 90 days. Eight patients were exposed to opiates, five to both tramadol and opiates, three to other analgesics, and one to no analgesics. We found no increased risk of idiopathic incident seizures associated with exposure to tramadol alone. Thus seizures seem rarely attributable to the agent.

Effects of brain injury on college academic performance

Brain injury, a leading cause of mortality, morbidity and disability in the United States, has serious consequences and substantial costs. Although previous studies have assessed a variety of outcomes subsequent to brain injury, documentation of performance prior to brain injury using a case-control approach has not been included; preinjury performance differences may confound the estimate of the effects of brain injury on performance. The primary objective of this study was to compare academic performance before and after brain injury in a population of university undergraduate students to determine the extent to which the academic career of the brain-injured person was altered from what would have been expected in the absence of such an injury. Cases included all undergraduate students in a major university, between the ages of 17 and 27, who incurred a brain injury requiring hospitalization between 1980 and 1984 (n = 99). Two comparison groups were used to determine whether changes in academic performance were specifically related to brain injuries or injuries in general: (1) injured controls, i.e. 121 students between the ages of 17 and 27 years, hospitalized for injuries other than to the central nervous system, and (2) uninjured academic controls, i.e. 198 students with out injuries requiring hospitalization during the study period, matched 2:1 to the brain-injured students by age, gender, and completed course credits categorized as < 90, > or = 90. Although there were no differences when the total groups, including both males and females, were compared, there was a significant pre- to postinjury decrease in the grade point average for female cases when compared to their uninjured academic controls (p < 0.02). This difference was related to the effects of brain injury, and not to the effects of injury in general. No such difference was observed for the males. There were also no differences when the total groups, including males and females, were compared relevant to return to school. However, a significantly higher proportion of the female cases, compared with their uninjured academic controls, did not return to school after their injury; similar findings were identified for the injured controls as well. Thus, these differences were not specific to brain injury but rather to injury in general. In spite of this observation, the difference between female cases who returned and those who did not return was associated with neurological deficits, especially upper left limb motor deficits, as the time of hospital discharge. The findings from this effort are suggestive of gender differences in the consequences of brain injury and serve as a basis for further studies to evaluate the magnitude of this problem.

Laboratory-based reporting of AIDS

To improve the speed and completeness of AIDS reporting, the Philadelphia Board of Health adopted regulations requiring medical laboratories to report directly to the Department of Public Health all results indicative of AIDS-defining diagnoses. Reports were used to focus active AIDS surveillance on physicians who had requested laboratory reports whose results were likely to have diagnosed AIDS recently. One year after implementation, laboratories provided the first lead to 20% of all AIDS reports. Reports originating with laboratories reach our data base sooner after diagnosis and ascertain a slightly higher proportion of women than do other reports. Laboratory-based reporting offers a practical way to focus the limited resources available for active surveillance on health providers likely to have an AIDS diagnosis to report.

Limitations of AIDS reporting under favorable circumstances

To assess completeness of acquired immunodeficiency syndrome (AIDS) reporting by a consortium of Philadelphia physicians, we compared the consortium's patient data base to AIDS case reports received by the Philadelphia Department of Public Health (PDPH). Several circumstances favored better than ordinary reporting. Consortium physicians were highly motivated, specialized in the care of patients with human immunodeficiency virus disease, had worked with PDPH physicians for years, and knew beforehand about the plan to compare data bases. Of 295 patients in the consortium data base diagnosed with AIDS at least nine months prior to this study, 267 (90.5%) had been reported to the PDPH and 28 (9.5%) had not. Only two of the missed reports were deliberately withheld, each in response to the patient's request. Reporting completeness increased with the time elapsed since diagnosis, varied by practice from 70% to 100%, and was unrelated to patient demographic, insurance status, or occupational characteristics. AIDS reporting for patients in health care occupations (11/13 = 85% reported) was not significantly different from reporting for patients in other occupations (256/282 = 91% reported). We conclude that, under conditions favorable to reporting, approximately 10% of AIDS patients are not reported; the only patient characteristic that predicts reporting is the time elapsed since diagnosis; and nearly all reporting failures are inadvertent.

Private medical insurance among Philadelphia residents diagnosed with AIDS

We used medical insurance information gathered on each Philadelphia resident with AIDS to examine time trends in private medical insurance at the time of diagnosis. The proportion of AIDS patients with private medical insurance decreased from 51.9% in July-December 1988 to 28.6% in July-December 1991. During the same time period, an increasing proportion of people diagnosed with AIDS were female, poor, members of minority groups, or abusers of injection drugs. A discrete multivariate model showed that the (point) prevalence of private medical insurance at AIDS diagnosis decreased significantly with time, even after adjustment for changes with time in the age, gender, race, estimated income, history of injection drug use, and history of homosexual contact of those who were affected with AIDS. Thus the decreasing prevalence of private medical insurance among people newly diagnosed with AIDS does not simply reflect changes in the demographic and behavioral characteristics of the people affected.

Changes in AIDS case reporting after hospital site visits

In an effort to improve AIDS case reporting, site visits (meetings with hospital staff to encourage reporting) were made to all Philadelphia hospitals. Comparisons of hospitals visited during a 7-week period with hospitals not visited during that period indicated that the site visits were followed by a marked increase in case reports. No similar increase was observed at the comparison hospitals. The increased reporting was accompanied by an increased lag time from diagnosis to report, suggesting that the additional reports at visited hospitals were the result of the identification of previously missed cases rather than a speedup of reporting. Cases reported after the visits were more likely to have white-collar occupations or private medical insurance than were those reported before the visits.

AIDS and changing patterns of mortality

We compared changes in all-causes mortality rates, 1986 versus 1980, among members 25 to 44 years of age of demographically defined groups with high AIDS cumulative incidence to the changes among same-age, same-sex members of groups with low AIDS cumulative incidence. Among nonwhite men ages 25-44 residing in northeastern New Jersey (NJ) counties, AIDS cumulative incidence was 1,409 cases per 100,000; all-causes mortality was 413.8 deaths per 100,000 per year in 1980 and increased 74% to 726.6 deaths per 100,000 per year by 1986. In contrast, among white men ages 25-44 residing in other NJ counties, AIDS cumulative incidence was 75 cases per 100,000; all-causes mortality fell slightly from 192.6 deaths per 100,000 per year in 1980 to 189.2 deaths per 100,000 per year in 1986. Among nonwhite women ages 25-44 residing in northeastern NJ counties, AIDS cumulative incidence was 435 cases per 100,000; all-causes mortality was 162.07 deaths per 100,000 per year in 1980 and increased 70% to 276.3 deaths per 100,000 per year by 1986. Among white women ages 25-44 residing in other NJ counties, AIDS cumulative incidence was 9.1 cases per 100,000; all-causes mortality was 90.5 deaths per 100,000 per year in 1980 and fell slightly to 83.0 deaths per 100,000 per year in 1986. A substantial portion of the increased mortality of the groups with high AIDS cumulative incidence resulted from causes that have not been associated with HIV infection.

Cumulative AIDS incidence and altered pneumonia mortality

We grouped New Jersey residents according to age, sex, race, and residence-specific cumulative incidence of AIDS since the onset of the AIDS epidemic: less than 15, 15-99, 100-499, and greater than or equal to 500 cases per 100,000 people, respectively. We determined mortality from bacterial and viral pneumonias (International Classification of Diseases [ICD] 480.0-486.9) from underlying cause of death files. Between 1980 and 1986, pneumonia mortality increased from 15.1 deaths per 100,000 per year (95% confidence interval [CI] 10.4, 19.7) to 25.0 deaths per 100,000 per year (95% CI 19.2, 30.8), an increase of 10.0 deaths per 100,000 per year (95% CI 2.6, 17.3), among those 25-44 years of age in the highest cumulative incidence group for AIDS. Increases in other population subgroups were approximately proportional to each subgroup's AIDS cumulative incidence. In particular, pneumonia mortality did not increase among those 25-44 years of age in groups with low cumulative incidence of AIDS. Deficiency of cell-mediated immunity, a diagnosis commonly applied in AIDS cases, was listed as a secondary diagnosis in 14% of the pneumonia deaths of persons 25-44 years of age in 1986 and in none of those in 1980.

Stochastic methods for short term projections of symptomatic HIV disease

We designed and implemented stochastic methods for short term projections of HIV disease at the local level, that accommodate various states or stages of the disease. We gave particular attention to projection of the number of patients with HIV disease who need care, when durations of stay in these various states depend on current methods for treating opportunistic infections. We consider two types of data as input to these projections. One concerns seroprevalence surveys conducted over time and from which we can obtain time series estimates of the numbers of HIV-infected individuals. The other is a reported time series of AIDS cases adjusted for delays in reporting. Several projections, with data from the City of Philadelphia, illustrate this method. In addition, we consider a Monte Carlo method for computing confidence bounds on a projection.

Fatal and nonfatal immersion injuries among New Jersey residents

We identified immersion injuries of New Jersey residents from mortality and hospital discharge data. The incidence rate was 2.3 immersion injuries (1.3 fatal and 1.0 nonfatal) per 100,000 population per year. Incidence rates were elevated among young children, men, blacks, and residents of counties in the southern part of the state. Case fatality ratios increased with age and were higher for men than for women from 10 to 50 years of age.

Cumulative AIDS incidence and altered mortality from mycobacterial disease: New Jersey

Changes in mycobacterial disease mortality between 1980 and 1986 were examined among New Jersey residents aged 25 to 44 using single cause of death data. The demographic group with the highest cumulative incidence of acquired immune deficiency syndrome (AIDS) (non-white residents of the four urban counties adjacent to New York City) sustained an increase of 10.1 deaths/100,000 men/yr and 3.1 deaths/100,000 women/yr. Groups with lower cumulative incidence of AIDS sustained smaller increases in mycobacterial disease mortality. The group with the lowest cumulative incidence of AIDS (white residents outside the four urban counties adjacent to New York City) sustained the smallest increase in tuberculosis (TB) mortality. Using single cause of death data, it was not possible to identify a relationship between increased extrapulmonary TB deaths and AIDS cumulative incidence, but such a relationship was identifiable from multiple cause of death data. Of 30 mycobacterial disease deaths of all ages with cellular immune deficiency as a contributory diagnosis on the death certificate, 21 (70%) were known to the state's AIDS registry as AIDS cases and four more (13%) were known to the registry as having human immunodeficiency virus (HIV) disease not meeting the full clinical criteria for AIDS. Young populations with a high cumulative incidence of AIDS have experienced substantially increased mortality from mycobacterial diseases. The association of mycobacterial disease mortality with HIV disease may be underestimated from AIDS registry data and from searches of single cause of death data for mycobacterial disease deaths.

Cumulative AIDS incidence and altered mortality from bacterial infections

To determine whether populations with high cumulative incidence of acquired immunodeficiency syndrome (AIDS) experienced increased deaths from sepsis, central nervous system abscess, or endocarditis, New Jersey AIDS patients were grouped according to their age, sex, race, and residence-specific cumulative incidence of AIDS since the onset of the AIDS epidemic. Between 1980 and 1986, among 25-44 year olds in the highest cumulative incidence group for AIDS, sepsis mortality increased from 3.3 to 15.2 deaths/100,000/year, an increase of 11.9 deaths/100,000/year (95% confidence interval (6.9, 17.0) deaths/100,000/year); mortality from central nervous system abscesses increased from zero to 1.7 (0.1, 3.2) deaths/100,000/year; and mortality from endocarditis increased from 0.8 deaths/100,000/year to 2.4 deaths/100,000/year, an increase of 1.6 (-0.5, 3.7) deaths/100,000/year. Age-matched New Jersey patient populations with low cumulative incidence of AIDS did not sustain a similar increase. The HIV disease-associated increase in sepsis mortality among young populations represents a new component of the substantial increase in U.S. sepsis mortality that occurred over the last two decades, but was previously limited to older populations.

Microcomputer method to extract subfiles from statewide multiple cause of death files

A simple microcomputer system has been developed using off-the-shelf components. The system permits local access, in an acceptable time frame, to several years of New Jersey multiple cause of death data (approximately 70,000 records per calendar year). This report describes the system, including hardware, software, data storage space requirements, speed of data access, and the effect of abbreviating the list of diagnoses. Prospects for extension of such a system to larger data bases are discussed.

Firearms' decreased role in New Jersey homicides after a mandatory sentencing law

In 1981 New Jersey adopted a law requiring a mandatory minimum prison sentence for use or possession of a firearm in a variety of crimes. New Jersey firearms homicides as a per cent of all New Jersey homicides increased from 1974 to 1980 and decreased from 1981 through 1986. No similar change was observed for homicides in the balance of the U.S. or for suicides in New Jersey or the balance of the U.S. The findings suggest an effect of the mandatory minimum sentencing law on firearms homicides.

Fatal motorcyclist injury from a hinged and rounded rearview mirror

Rigidly mounted sharp projections from automobile exteriors have been replaced by flexibly mounted rounded structures believed to be less hazardous to unprotected road users. The present report of a fatality from an external rearview mirror indicates the continued potential for harm from a projecting structure in spite of a hinged mounting and rounded shape.

Blood alcohol tests, prevalence of involvement, and outcomes following brain injury

We collected data on all residents of San Diego County, California who were hospitalized for or died from a brain injury in 1981. The objectives were to assess the frequency of blood alcohol concentration (BAC) testing and the associations of BAC prevalence with the external cause of the brain injury and case outcome. We found that high BAC levels were most frequent among brain-injured subjects between the ages of 25 and 44 and among those subjects involved in motor vehicle crashes and assaults. Contrary to expectations, injury severity and hospital mortality were inversely related to BAC level, controlling for other predictors. We believe that these inverse associations might be due to differential rates of BAC testing by severity. Among brain-injured survivors with more severe injuries, however, we found that BAC level was positively associated with the prevalence of physician-diagnosed neurological impairment at discharge and with the length of hospitalization.

Analyses of the relationship between blood alcohol and nasal breath alcohol concentrations: implications for assessment of trauma cases

To prevent serious complications and facilitate efficient and effective management of patients admitted to the emergency department or intensive care settings, it is extremely important to differentiate, quickly, between elevated concentrations of alcohol in the blood and compromised neurological status due to brain injury or other pathology. This research analyzed the relationship between blood alcohol concentrations (BACs) estimated from venous blood samples and those estimated from breath samples that were obtained using the Alco-Sensor III device with an attached tube for passive nasal breath sampling. Blood and breath samples, as well as brief medical histories and demographic and environmental data, were obtained and recorded for 35 adult trauma patients admitted to two major urban emergency departments. Passively expired nasal breath provided an excellent estimate of BAC measured from venous blood (range, 0 to 0.32) as evidenced in the extremely high regression coefficient (r = 0.99; slope = 1.22; p less than 0.0001). BAC assessment and monitoring, through the application of passive nasal breath sampling, provides a means of rapidly estimating BAC, and thus can facilitate diagnosis and the initiation of appropriate management and treatment.

Infection as a contributory cause of death in patients hospitalized for motor vehicle trauma

The age and length-of-stay specific incidence of fatal infections and the percentage of deaths due to infection were determined in a population-based sample of patients hospitalized for more than 2 days for motor vehicle injuries. The percentage of deaths due to infection was determined from a statewide sample of death certificates, and the patient fatality rates for hospitalized motor vehicle crash injury patients were determined from statewide Professional Activities Study data. Fatal pulmonary infections were far more common than fatal nonpulmonary infections. The incidence rate of fatal pulmonary infection was highest among those with hospital stays of 7 to 28 days and among those 70 years of age or older. Incidence rates varied substantially by age and length of hospital stay from a low of 8 deaths per 100,000 patient-days for adult female patients with stays longer than 28 days to a high of 102 deaths per 100,000 patient-days for elderly men with stays of 7 to 28 days. The incidence rates documented in this study may improve the identification of blunt trauma patient groups with the greatest need for prophylactic antiinfective measures.

Injuries and deaths among elderly persons

Injury related to a death may be recorded on the death certificate as the underlying cause of death or as a condition associated with death but not causing it. The present study uses the National Center for Health Statistics Multiple Cause of Death data for 1978 to determine the percentage of injury-related deaths for which injury was identified as the underlying cause of death and the variation of this percentage with age at death. Injury was identified as the underlying cause of death in 86% of all cases with injury recorded on the death certificate. The percentage with injury identified as the underlying cause varied with age: 93% for those in the first year of life, 97% for those aged 1-44 years, 87% for those aged 55-64, and 50% for those aged 75 or older. The percentage with injury identified as the underlying cause also varied by cause of injury. In all age groups, assault, suicide, and motor vehicle accidents were identified as the underlying cause of death in more than 90% of the cases in which they were mentioned. Causes other than motor vehicle accidents, assaults, and suicides, especially when occurring in the elderly, were less likely to be identified as the underlying cause of death. Cause of death tabulations based only on the underlying cause of death selectively underestimate the role of injury in the deaths of the elderly.

Time from injury to death (survival time) among fatally injured pedestrians

This study examines the survival time after injury and its relationship to age and Injury Severity Score (ISS) among 322 fatally injured pedestrians. Long survival times were associated with older age and with lower ISS. The association of long survival time with older ages remained present after adjustment for ISS. People with untreatable severe injuries (as defined by the Abbreviated Injury Scale) and people who died of potentially survivable injuries had markedly different survival times. Therefore, in analyses of data relating to survival time, combining the two groups should be avoided.

Head injury with and without hospital admission: comparisons of incidence and short-term disability

All persons with head injuries (skull fracture or injury to the cranial contents resulting in a physician visit or at least one day of disability), regardless of treatment or hospital admission status, were identified from National Health Interview Survey data for the years 1977-81. Among those who reported such head injuries within the two weeks prior to interview, only 16 per cent were admitted to hospitals. Children, members of low-income families, and those injured at home, school, or in a recreational setting were less likely to be admitted to hospital than others. Among those who sustained a head injury in the previous three months and had some disability from that injury during the two weeks prior to interview, those not admitted to hospital included one-half of those with three to seven days of bed disability and one-third of those with more than seven days of bed disability; and they accounted for one-half of all disability days. These findings indicate that hospital-based head injury incidence data are incomplete and may contain substantial biases.

Pediatric brain injuries: the nature, clinical course, and early outcomes in a defined United States' population

Acute brain injury is the cause of approximately 100,000 pediatric hospital admissions per year in the United States. This report examines the nature of the brain injury, clinical diagnosis, hospital course, and discharge outcome of all pediatric cases in the population of San Diego County, California, for 1981 (N = 709). Brain-injured children were identified from hospital records, death certificates, and coroners' records. Severity of injury was determined using the Abbreviated Injury Scale and the Glasgow Coma Scale. Three percent of brain-injured children died at the accident site; an additional 3% died in the hospital. All in-hospital deaths occurred among the 5% of children with Glascow Coma Scale scores of 8 or less, and in this group the case fatality rate was 59%. Fractures of the skull, present in 23% of cases, seemed to be associated with excess mortality even after type of lesion was considered. Type of lesion, but not presence or absence of a skull fracture, had some predictive power for disability among survivors. Concussion was the most frequent diagnosis. Mildly brain-injured children accounted for 93% of all cases and about 90% of all hospital days.

Incidence, severity, and outcomes of brain injuries involving bicycles

We performed a population-based study of bicycle-related brain injuries in San Diego, California, residents during 1981. Incidence rates among males were three times higher than for females and were highest at ages 10-14 years for males. Only one-third of bicycle-related brain injuries involved collision with a motor vehicle, and this proportion was independent of age or gender. Brain injuries from motor-vehicle collisions were more severe than those resulting from other causes. Over half the brain-injured bicyclists aged 15 and older who were blood alcohol tested were legally intoxicated.

The relationship of family income to the incidence, external causes, and outcomes of serious brain injury, San Diego County, California

Among residents of San Diego County, California the incidence and external causes of serious brain injury were related to the median family income of the census tract of residency. Low income tracts had high incidence rates--a finding not changed by adjustment for age and race/ethnicity. For those injured, the type of emergency transport, time from injury to treatment, and outcome of treatment were not related to the median income of the census tract of residency.

Northeastern Ohio Trauma Study: V. Burn injury

Burn injury cases were identified from a population-based sample of trauma visits to hospital emergency departments in northeastern Ohio during 1977. The 199 cases represented 2.4% of all trauma incidence visits by residents of the five-county study region. Ninety-five per cent of the burn cases were released from the emergency department directly after treatment. The annual incidence rate of emergency department-treated burns was 4.7 per 1,000 population. Incidence rates for males were twice those for females. The age groups with the highest annual incidence rates were those under 5 years of age and 25-34 years (seven and eight cases per 1,000 population, respectively). Most burns occurred at home or the workplace. The youngest employed age group sustained the highest rate of work-related burns. Hot or corrosive substances caused two thirds of all burns; fire and flames caused one fourth.

Incidence, severity, and external causes of pediatric brain injury

The number of fatal brain injuries and hospital admissions for brain injuries in children up to 15 years old in San Diego County, California, were ascertained from emergency room and hospital records, coroners' reports, death certificates, and nursing home and extended-care records for 1981. The annual brain-injury rate per 100 000 children was 185 (235 for boys and 132 for girls). The major causes of pediatric brain injury were falls (35%), recreational activities (29%), and motor vehicle crashes (24%). The case-fatality ratio was six deaths per 100 injured children. Of those children admitted to a hospital alive, 88% had a mild brain injury and 44% had no evidence of loss of consciousness. Two thirds of children with mild brain injuries and one third of those with serious brain injuries were transported to a hospital in private nonemergency vehicles.

Incidence and outcome of hospital-treated head injury in Rhode Island

Hospital discharge summary data were used to identify and study all 2,870 Rhode Island residents hospitalized in-state with head injuries during 1979 and 1980. The overall hospitalized incidence rate was 152 per 100,000 of population per year with age and sex variations similar to those found in other studies. This is consistent with the observation that fatal injury rates in Rhode Island are only 75 per cent of the United States average. Hospitalized incidence rates of head injury for the census tracts in the lowest decile of median income were twice those for census tracts in the highest decile. Smaller increases were also observed with increasing population density. Length of hospital stay increased with age. Discharge to chronic care facilities plus in-hospital deaths increased 20-fold with increasing age. In each age group, in-hospital deaths and discharge to chronic care facilities were associated with long hospital stays.

Motor vehicle trauma in northeastern Ohio. I: Incidence and outcome by age, sex, and road-use category

Hospital emergency department visits for motor vehicle trauma occurring in a midwestern metropolitan region (Cleveland and Lorain-Elyria, Ohio Standard Metropolitan Statistical Areas; 2.2 million population) were analyzed to determine the incidence and outcome by age, sex, and road-use category. A 50% incidence sample (n = 20,752) of motor vehicle trauma events to residents of this region was identified from the emergency department records of 41 participating hospitals for a one-year period, 1977. These hospitals accounted for 98% of all emergency department cases in the region. The annual motor vehicle trauma incidence rate per 100,000 population was 1,871. The highest annual incidence rate (4,462) was for ages 20-24; the lowest rates were for infants under one year (837) and for the elderly over 74 years (667). Incidence rate rank-ordered road-use categories were as follows: passenger car occupant, motorized cycle rider, other enclosed vehicle occupant, pedestrian, and pedal cyclist. Above age 4, age-specific male incidence rates significantly exceeded female incidence rates for most road-use categories. There were 80 admissions and 7 fatalities per 1,000 motor vehicle trauma incidence cases. Case-admission ratios were highest for pedestrians (266), riders of motorized cycles (184), and pedal cyclists (115); they were lowest for occupants of partially or fully enclosed vehicles (65). Case-fatality ratios per 1,000 cases were also highest for pedestrians (43) and riders of motorized cycles (11). Male case-fatality ratios exceeded female ratios for each road-use category in nearly all age groups, and male case-admission ratios exceeded those for females ages 10-54. For ages 75 and over, the admission ratios and fatality ratios were nearly twice as high as in any other age group.

Anatomic location of spinal cord injury. Relationship to the cause of injury

In a population based sample, 550 of 619 people with fatal and nonfatal spinal cord injuries were classified according to the cause of injury and according to the anatomic location of the highest spinal cord injury. Motor vehicle occupants accounted for 42% of the people with spinal cord injuries. Sixty percent of those injured had a cervical cord injury, 25% a thoracic cord injury, and 15% a lumbosacral cord injury. The specific anatomic locations most commonly injured were at C1 (12% of all spinal cord injuries), C6 (9%), and L2 (5%). The anatomic site of injury was significantly (P less than 0.001) related to the cause of injury. Thirty-seven percent of the spinal cord injuries from firearms and 97% of those from diving were located in the cervical cord. In contrast, 68% of spinal cord injuries to motor vehicle occupants were cervical; 17% at C1. The distribution of injuries among drivers was similar to that among other occupants.

Incidence, external causes, and outcomes of work-related brain injuries in males

Little published information is available on the incidence of brain injury from work-related activities. A study of brain injury of residents of San Diego County, California, showed that the overall work-related injury rate for males was 19.8 per 100,000 workers (45.9 per 100 million hours). The incidence rates for male civilian and military personnel were 15.2 and 37.0 per 100,000 workers, respectively. In addition, the annual incidence of such injuries was 9.9 per 100 million work hours for males in the work force (18.5 per 100 million hours for military personnel and 7.6 per 100 million hours for civilians). Among military personnel, more than half of all work-related brain injuries were transportation related, primarily from off-road vehicles. Among civilians, more than half were due to falls. For both the military and civilian groups, work-related brain injury rates were markedly higher among young workers than among older ones.

Survival times and case fatality rates of brain-injured persons

Survival time after injury (the time from injury to death) imposes an important constraint on the timing of the delivery of postinjury medical care. From a population-based study of brain-injured people, the survival times in 542 cases with fatal outcomes were studied. Prehospital deaths as well as hospital deaths were included. Survival times were considerably shorter for 95 people with untreatable injuries (Abbreviated Injury Scale level 6) than for the remaining 447 whose injuries were potentially treatable. For the former group, the median survival time was 10 minutes; for the latter, it was 2 hours. For those with potentially treatable injuries, the median time from injury to receiving medical assistance was approximately 30 minutes and 82% received medical assistance within 1 hour of injury. Short survival time was associated with prehospital death, young age, high Injury Severity Score, and having a nonbrain injury as the most severe injury. For patients who arrived alive at a hospital, intracranial surgery was associated with increased survival time.

Empirical development and evaluation of prehospital trauma triage instruments

The field identification of the patients who should be taken to trauma centers is a major problem of trauma care. This study appears to be the first to use multivariate analysis to systematically design a field triage instrument and to evaluate its performance in terms of a meaningful and plausible criterion for which patients ought to be treated at trauma centers. Four new triage instruments were created and their performance compared to that of two existing measures, the Trauma Score and the CRAMS scale. The new measures appear to perform better than the best of existing instruments tested, although independent validation is necessary. The one purely physiologic instrument tested appeared to be inferior to instruments that included anatomic and historic as well as physiologic indices. Simple checklists performed approximately as well as weighted scales. No instrument was found to be high in both sensitivity and positive accuracy.

Slipped capital femoral epiphysis in growth hormone-deficient patients

Slipped capital femoral epiphysis (SCFE), a potentially disabling hip disorder, occurs primarily during the pubertal growth spurt. It has been reported in association with pituitary gigantism, growth hormone deficiency, hypothyroidism, hypogonadism, and panhypopituitarism. We estimated the frequency of SCFE among children with growth hormone deficiency (treated or untreated) and compared it with the reported frequency of SCFE among Connecticut residents under 25 years of age. Based on this comparison, the risk of developing SCFE is significantly greater in growth hormone-deficient children than in the general population.

Northeastern Ohio Trauma Study III: incidence of fractures

To determine the frequency with which fractures are encountered in emergency care and to estimate the incidence of fractures in a well-defined population, a population-based sample of emergency department (ED) visits was examined. Eleven percent of ED visits for trauma involved fractures. The incidence of fractures was 21 per 1,000 persons per year and had two peaks, the first at ages 10 to 14 and the second at ages greater than 60. Among young people, falls (often related to sports or recreation), striking objects, motor vehicle injuries, and assaults were the major causes of fractures. Among the elderly, falls caused 87% of all fractures.

Nursing home residency after head injury

A survey of 93 nursing homes in and near Rhode Island in May 1982 identified all head-injured patients who were State residents. Nineteen were identified, of whom ten were injured in motor vehicle crashes. The median age was 35 years. The median time since injury was 3 years and increased with age. The prevalence of such patients was 2 per 100,000 population. Except for a recent survey by the Connecticut Department of Health, little is known about the prevalence or duration of nursing home residency after head injury. To obtain such data, nursing homes in and near Rhode Island were surveyed for State residents who were patients because of head injury.

The role of motor vehicle crashes in causing certain injuries

Hospital discharge data from Rhode Island were used to assess the role of motor vehicle crashes in causing several types of serious injuries. Motor vehicle crashes were the cause of injury for approximately two-thirds of patients hospitalized with injuries to the chest organs, liver, and spleen, and approximately one-third of those with traumatic pneumothorax or hemothorax, and injuries to the head, kidney, intestine, distal femur, pelvis, and patella.

Effect of alcohol intoxication on the diagnosis and apparent severity of brain injury

Because alcohol intoxication is common among brain-injured patients, we performed this study to determine the extent to which alcohol alters the initial assessment of brain injury severity in these patients by depressing the level of consciousness. The Glasgow coma scale was used to measure the level of consciousness of 257 brain-injured adults admitted to the University of Virginia Hospital, both on arrival in the emergency room and 6 to 10 hours later. Improvement in the level of consciousness between the first and second measurements was significantly related to the blood alcohol concentration on admission. Patients with the highest blood alcohol concentrations showed the greatest improvement. Most of this effect occurred in patients with a blood alcohol concentration of 0.20% or higher. Alcohol intoxication is a potential source of bias in the clinical classification of brain injuries according to severity.

Northeastern Ohio Trauma Study: II. Injury rates by age, sex, and cause

Using a 1977 sample of emergency department visits in five northeastern Ohio counties, population-based injury rates are tabulated by age, sex, and cause. Case fatality ratios are estimated by comparing these injury rates with population-based mortality rates for 1976-1978. For all age and sex groups, injuries are a major cause of emergency department visits. Falls, striking, cuts, and motor vehicle crashes are the leading causes of injury. Case fatality ratios for motor vehicle crash injuries are considerably higher than those for non-transport injuries. Injury rates and case fatality ratios for males exceed those for females except among the elderly. With increasing age, injury rates decline but the fraction of injuries leading to hospital admission or to fatality rises sharply.

The contribution of brain injury to the overall injury severity of brain-injured patients

Several recent population-based studies of the incidence of head injury have identified cases by screening hospitalized patients. This method assumes a close relationship between severity of head injury and overall injury severity, since it is the latter that determines hospital admission. Thus, a patient whose overall injury severity is high will be admitted to the hospital regardless of the degree of his head injury. Similarly, since a patient's outcome status after treatment depends on his response to all his injuries, studies of the prognosis of various types of head injury also assume a close relationship between head injury severity and overall injury severity. The present study examines the relationship between brain injury severity and overall injury severity in a series of hospitalized head-injured patients with evidence of actual or probable brain trauma. Among these patients, brain injury severity was closely related to overall injury severity. Head injury severity and head and neck injury severity were also closely related to overall injury severity. For all other body regions, injury severity was not closely related to overall injury severity in this group of patients.