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1.  Characteristics and Trends of Pediatric Traumatic Brain Injuries Treated at a Large Pediatric Medical Center in China, 2002–2011 
PLoS ONE  2012;7(12):e51634.
Pediatric traumatic brain injuries (TBIs) have not been well studied in China. This study investigated characteristics and trends of hospitalized TBIs sustained by Chinese children.
Methods and Findings
We analyzed 2002–2011 hospitalized TBI patients (0–17 years of age) treated at a large pediatric medical center in China. TBIs were defined using the International Classification of Diseases, Tenth Revision (ICD-10) codes. We examined age patterns across external causes of TBIs. We reported the trend of traffic-related TBIs for each year from 2002 to 2011. Of 4,230 TBI patients, 67.1% (95% CI: 65.4%–68.8%) were city residents and 28.8% (95% CI: 26.3%–31.3%) came from rural villages. Males had disproportionately more TBIs than females (65.2% vs. 34.8%). Falls, struck by/against objects, and traffic collisions were the top three external causes of TBIs for all age groups. Falls were the leading cause of TBI for all ages but peaked at 2 years of age. There were 125 TBIs in 0–2 year olds (5.9% of all TBIs in this age group) that were caused by suspected child abuse. Suspected child abuse was significantly more likely to occur in 0–1 year olds. The proportion of traffic -related TBIs increased significantly from 12.99% in 2002 to 19.68% in 2008 but dropped each subsequent year until it reached a level of 8.91% in 2011.
Our study confirms that falls, struck by/against objects and traffic collisions are the top external causes of TBIs in Chinese children. When compared with national data from the developed countries, gender patterns are similar, but the ranking of external causes is different. This is the first study to highlight the important role of suspected child abuse in causing TBIs in infants in China. TBIs caused by child abuse warrant further research and government attention as a social and medical problem in China.
PMCID: PMC3520936  PMID: 23251600
2.  Overcoming barriers to population-based injury research: development and validation of an ICD-10–to–AIS algorithm 
Canadian Journal of Surgery  2012;55(1):21-26.
Hospital administrative databases are a useful source of population-level data on injured patients; however, these databases use the International Classification of Diseases (ICD) system, which does not provide a direct means of estimating injury severity. We created and validated a crosswalk to derive Abbreviated Injury Scale (AIS) scores from injury-related diagnostic codes in the tenth revision of the ICD (ICD-10).
We assessed the validity of the crosswalk using data from the Ontario Trauma Registry Comprehensive Data Set (OTR-CDS). The AIS and Injury Severity Scores (ISS) derived using the algorithm were compared with those assigned by expert abstractors. We evaluated the ability of the algorithm to identify patients with AIS scores of 3 or greater. We used κ and intraclass correlation coefficients (ICC) as measures of concordance.
In total, 10 431 patients were identified in the OTR-CDS. The algorithm accurately identified patients with at least 1 AIS score of 3 or greater (κ 0.65), as well as patients with a head AIS score of 3 or greater (κ 0.78). Mapped and abstracted ISS were similar; ICC across the entire cohort was 0.83 (95% confidence interval 0.81–0.84), indicating good agreement. When comparing mapped and abstracted ISS, the difference between scores was 10 or less in 87% of patients. Concordance between mapped and abstracted ISS was similar across strata of age, mechanism of injury and mortality.
Our ICD-10–to–AIS algorithm produces reliable estimates of injury severity from data available in administrative databases. This algorithm can facilitate the use of administrative data for population-based injury research in jurisdictions using ICD-10.
PMCID: PMC3270080  PMID: 22269308
3.  Psychiatric illness and subsequent traumatic brain injury: a case control study 
Objective: To determine whether psychiatric illness is a risk factor for subsequent traumatic brain injury (TBI).
Methods: Case control study in a large staff model health maintenance organisation in western Washington State. Patients with TBI, determined by International classification of diseases, 9th revision, clinical modification (ICD-9-CM) diagnoses, were 1440 health plan members who had TBI diagnosed in 1993 and who had been enrolled in the previous year, during which no TBI was ascertained. Three health plan members were randomly selected as control subjects, matched by age, sex, and reference date. Psychiatric illness in the year before the TBI reference date was determined by using computerised records of ICD-9-CM diagnoses, psychiatric medication prescriptions, and utilisation of a psychiatric service.
Results: For those with a psychiatric diagnosis in the year before the reference date, the adjusted relative risk for TBI was 1.7 (95% confidence interval (CI) 1.4 to 2.0) compared with those without a psychiatric diagnosis. Patients who had filled a psychiatric medication prescription had an adjusted relative risk for TBI of 1.6 (95% CI 1.2 to 2.1) compared with those who had not filled a psychiatric medication prescription. Patients who had utilised psychiatric services had an adjusted relative risk for TBI of 1.3 (95% CI 1.0 to 1.6) compared with those who had not utilised psychiatric services. The adjusted relative risk for TBI for patients with psychiatric illness determined by any of the three psychiatric indicators was 1.6 (95% CI 1.4 to 1.9) compared with those without any psychiatric indicator.
Conclusion: Psychiatric illness appears to be associated with an increased risk for TBI.
PMCID: PMC1737873  PMID: 11971048
4.  Emergency department management of mild traumatic brain injury in the USA 
Emergency Medicine Journal : EMJ  2005;22(7):473-477.
Objective: To describe the emergency department (ED) management of isolated mild traumatic brain injury (TBI) in the USA and to examine variation in care across age and insurance types.
Methods: A secondary analysis of ED visits for isolated mild TBI in the National Hospital Ambulatory Medical Care Survey 1998–2000 was performed. Mild TBI was defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9) codes for skull fracture, concussion, intracranial injury (unspecified), and head injury (unspecified). Available ED care variables were analysed by patient age and insurance categories using multivariate logistic regression.
Results: The incidence of isolated mild TBI cases attending ED was 153 296 per year, or 56.4/100 000 people. Of the patients with isolated mild TBI, 44.3% underwent computed tomography, 23.9% underwent other non-extremity, non-chest x rays, 17.1% received wound care and 14.1% received intravenous fluids. However, only 43.8% had an assessment of pain. Of those with documented pain, only 45.5% received analgesics in the ED. Nearly 38% were discharged without recommendations for specific follow up. Several aspects of ED care varied by age but not by insurance type.
Conclusion: Substantial ED resources are devoted to the care of isolated mild TBI. The present study identified deficiencies in and variation around several important aspects of ED care. The development of guidelines specific for mild TBI could reduce variation and improve emergency care for this injury.
PMCID: PMC1726852  PMID: 15983080
5.  The utility of administrative data for neurotrauma surveillance and prevention in Ontario, Canada 
BMC Research Notes  2012;5:584.
Surveillance of neurotrauma events is necessary to guide the development and evaluation of effective injury prevention initiatives. The aim of this paper is to review potential sources of existing population-based data to inform neurotrauma prevention in Canada, using sources available in Ontario as an example. Data sources, including administrative data holdings from Ontario’s publicly funded health care system and ongoing national surveys, were reviewed to determine the degree of relevance for neurotrauma surveillance, using standards outlined by the World Health Organization as a framework.
Five key data sources were identified for neurotrauma surveillance. Five other sources were considered useful; cause of injury was not identifiable in 5 additional sources; and 4 sources were not relevant for surveillance purposes.
We provide information about which existing data sources are most relevant for neurotrauma surveillance and research, as well as examine the strengths and limitations of these sources. Administrative data can be used to facilitate surveillance of neurotrauma and are considered both useful and cost effective for the development and evaluation of injury prevention programs.
PMCID: PMC3532139  PMID: 23098419
Prevention; Surveillance; Spinal cord injuries; Brain injuries; Data sources
6.  ICD-9 to ICD-10: Evolution, Revolution, and Current Debates in the United States 
The International Statistical Classification of Diseases and Related Health Problems (ICD) has undergone a long evolution from its initial inception in the late 18th century. Today, ICD is the internationally recognized classification that helps clinicians, policy makers, and patients to navigate, understand, and compare healthcare systems and services. Currently in the United States, hot debates surround the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). This article presents an analysis of the views of the proponents and opponents of the upcoming change. We also briefly present and analyze the quality of the most frequently cited scientific evidence that underpins the recent debates focusing on two major issues: ICD-10-CM implementation costs and revenue gains and the projected clinical data quality improvement. We conclude with policy and research suggestions for healthcare stakeholders.
PMCID: PMC3692324  PMID: 23805064
7.  Prevalence of associated injuries of spinal trauma and their effect on medical utilization among hospitalized adult subjects – a nationwide data-based study 
This study was wanted to investigate the prevalence of concomitant injuries among hospitalized acute spinal trauma patients aged 20 and over and the effects of those injuries on medical utilization in Taiwan.
Nationwide inpatient datasets of Taiwan's National Health Insurance (NHI) database from between 2000 and 2003 were used. The major inclusion criteria used to select cases admitted due to acute spinal trauma were based on three diagnostic International Classification of Disease, 9th Version (ICD-9) codes items: (1) fracture of vertebral column without mention of spinal cord injury; (2) fracture of vertebral column with spinal cord injury; or (3) spinal cord lesion without evidence of spinal bone injury. To investigate the associated injuries among the eligible subjects, the concomitant ICD-9 diagnosis codes were evaluated and classified into six co-injury categories: (1) head trauma; (2) chest trauma; (3) abdominal trauma; (4) pelvic trauma; (5) upper extremities trauma; (6) lower extremities trauma.
There were 51,641 cases studied; 27.6% of these subjects suffered from neurological deficit, but only 17.3% underwent a surgical procedure for spinal injury. Among them, the prevalence of associated injuries were as follows: head trauma, 17.2%; chest injury, 2.9%; abdominal trauma, 1.5%; pelvic injury or fracture, 2.5%; upper limb fracture, 4.4%; lower limb fracture, 5.9%. The three major locations of acute spinal injury (cervical, thoracic, or lumbar spine) were found to be combined with unequal distributions of associated injuries. By stepwise multiple linear regression, gender, age, location of spinal injury, neurological deficit, surgical intervention and the six combined injuries were identified significantly as associated factors of the two kinds of medical utilization, length of stay (LOS) and direct medical cost. The combinations of acute spinal trauma with lower extremity injury, pelvic injury, chest injury, abdominal injury and upper extremity injury resulted in of the highest utilization of medical resources, the estimated additional LOS being between 4.3 and 1.2 days, and the extra medical cost calculated as being between $1,230 and $320.
The occurrence of associated Injuries among hospitalized acute spinal trauma patients in Taiwan is not uncommon, and results in an obvious effect on medical utilization.
PMCID: PMC2729309  PMID: 19650923
8.  The Impact of Preoperative Hip Heterotopic Ossification Extent on Recurrence in Patients with Head and Spinal Cord Injury: A Case Control Study 
PLoS ONE  2011;6(8):e23129.
The preoperative Heterotopic Ossification (HO) extent is usually one of the main used criteria to predict the recurrence before excision. Brooker et al built a radiologic scale to assess this pre operative extent around the hip. The aim of this study is to investigate the relationship between the recurrence risk after hip HO excision in Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI) patients and the preoperative extent of HO.
Methodology/Principal Findings
A case control study including TBI or SCI patients following surgery for troublesome hip HO with (case, n = 19) or without (control, n = 76) recurrence. Matching criteria were: sex, pathology (SCI or TBI) and age at the time of surgery (+/−4.5 years). For each etiology (TBI and SCI), the residual cognitive and functional status (Garland classification), the preoperative extent (Brooker status), the modified radiological and functional status (GCG-BD classification), HO localization, side, mean age at the CNS damage, mean delay for the first HO surgery, and for the case series, the mean operative delay for recurrence after the first surgical intervention were noted.
The median delay for first HO surgery was 38.6 months (range 4.5 to 414.5;) for the case subgroup and 17.6 months (range 5.7 to 339.6) for the control group. No significant link was found between recurrence and operative delay (p = 0.51); the location around the joint (0.07); the Brooker (p = 0.52) or GCG-BD status (p = 0.79). Including all the matching factors, no significant relationship was found between the recurrence HO risk and the preoperative extent of troublesome hip HO using Brooker status (OR = 1.56(95% CI: 0.47–5.19)) or GCG-BD status (OR class 3 versus 2 = 0.67(95% CI: 0.11–4.24) and OR class 4 versus 2 = 0.79(95%CI: 0.09–6.91)). Until the pathophysiology of HO development is understood, it will be difficult to create tools which can predict HO recurrence.
PMCID: PMC3154269  PMID: 21853078
9.  Coding the circumstances of injury: ICD-10 a step forward or backwards? 
Injury Prevention  1999;5(4):247-253.
The International Classification of Diseases (ICD) E codes are the most widely used coding frame for categorising the circumstances of injury and poisoning. In 1992 major revisions to the E codes were released. The aim of this paper was to consider whether the changes made are a step forward or backwards in terms of facilitating injury prevention.
The approach taken was to reflect on some former injury prevention research needs and the challenges they presented using data coded according to ICD-9, and then to consider how, if at all, ICD-10 has addressed these difficulties.
As with ICD-9, there are essentially two axes associated with each cause: intent and mechanism of injury, and these are captured by one code. This approach can have the unintended effect of hiding the significance of some mechanisms of injury. While there have been significant improvements in some areas, such as falls, in others, such as injuries due to firearms, ICD-10 has taken a step backward. In addition the failure to produce mutually exclusive codes presents problems for determining the incidence of downing events.
A welcome addition are "optional" activity codes which enable the identification of work related and sport related injury for the first time. Nevertheless, the limited range of codes and absence of coding guides limits their utility. The revised place of occurrence codes do not represent a significant improvement on ICD-9 in that they are limited to 10, they are not mutually exclusive, and they do not adequately cover a range of specific places of occurrence.
In summary, relative to its predecessor, ICD-10 represents a significant improvement in many areas. Unfortunately, it still falls far short of the mark for many injury prevention needs.
PMCID: PMC1730542  PMID: 10628910
10.  Cerebral Activation During the Test of Spinal Cord Injury Severity in Children: an fMRI Methodological Study 
The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) are internationally accepted to determine and classify the extent of motor and sensory impairment along with severity (ASIA Impairment Scale [AIS]) following spinal cord injury (SCI). The anorectal examination is a component of the ISNCSCI that determines injury severity. There is a void in the health care literature on the validity of the anorectal examination as an indication of SCI severity.
To validate the use of functional magnetic resonance imagining (fMRI) for the purpose of classifying the severity of SCI in children.
Seventeen patients, with the average age of 14.3 years, underwent 1 complete ISNCSCI examination. Subjects also underwent the anorectal portion of this exam while fMRI data were collected using a 3.0 Tesla Siemens Verio Scanner. Cortical areas of activation were analyzed for possible differences of cortical involvement between complete (AIS A) and incomplete (AIS B, C, and D) SCI subjects. Anxiety/anticipation of the test was also assessed.
This study established an fMRI imaging protocol that captures the cortical locations and intensity of activation during the test of sacral sparing. In addition to developing the data acquisition protocol, we also established the postacquisition preprocessing and statistical analysis parameters using SPM8.
Preliminary findings indicate that fMRI is a useful tool in evaluating the validity of the anorectal examination in determining SCI severity. Assessment of which cortical regions are activated during the testing procedure provides an indication of which pathways are transmitting information to the brain.
PMCID: PMC3641914  PMID: 23671382
functional magnetic resonance imaging; International Standards for Neurological Classification of Spinal Cord Injury; pediatric; spinal cord injury
11.  The impact on relative risk estimates of inconsistencies between ICD‐9 and ICD‐10 
The 10th revision of the International Classification of Diseases (ICD) represents a major change in the ICD system. This paper investigates the impact on relative risk estimates of inconsistencies in outcome classification between ICD‐9 and ICD‐10, including scenarios in which occupational exposure levels are correlated with year of death (and therefore with the ICD revision in effect at death). The setting of interest is a cohort mortality study in which follow up spans the periods during which ICD‐9 and ICD‐10 were in effect. The relative risk estimate obtained when death certificates are coded to the ICD revision in effect at time of death is compared to the relative risk estimate that would be obtained if all death certificates were coded to a consistent ICD revision (that is, ICD‐10). The ratio of these relative risks is referred to as the coefficient of bias.
Simple equations relate the coefficient of bias to the sensitivity and specificity of the classification of decedents into categories of cause of death via ICD‐9 (treating classifications based upon ICD‐10 as the standard). Bridge coded mortality data for 2 296 922 decedents (that is, death certificates coded to ICD‐9 and ICD‐10) are used to derive estimates of sensitivity and specificity by category of cause of death. Numerical examples illustrate the application of these equations.
Estimates of the sensitivity of classification of decedents into categories of death defined by ICD‐9 ranged from 0.26–1.00. Specificity was above 0.98 for all categories of cause of death. Numerical examples illustrate that inconsistencies in outcome classification between ICD‐9 and ICD‐10 may have substantial impact on relative risk estimates if there is a strong relation between exposure status and the proportion of deaths coded to a given ICD revision.
For analyses of mortality outcomes that exhibit poor comparability between ICD‐9 and ‐10, it may be prudent to recode cause of death information to a standard ICD revision in order to avoid bias that can occur when exposures are correlated with the proportion of deaths coded to a given ICD revision.
PMCID: PMC2077995  PMID: 16728499
death certificates; cause of death; occupational mortality; epidemiologic methods
12.  Validity of vascular trauma codes at major trauma centres 
Canadian Journal of Surgery  2013;56(6):405-408.
The use of administrative databases in vascular injury research has been increasing, but the validity of the diagnosis codes used in this research is uncertain. We assessed the positive predictive value (PPV) of International Classification of Diseases, tenth revision (ICD-10), vascular injury codes in administrative claims data in Ontario.
We conducted a retrospective validation study using the Canadian Institute for Health Information Discharge Abstract Database, an administrative database that records all hospital admissions in Canada. We evaluated 380 randomly selected hospital discharge abstracts from the 2 main trauma centres in Toronto, Ont., St. Michael’s Hospital and Sunnybrook Health Sciences Centre, between Apr. 1, 2002, and Mar. 31, 2010. We then compared these records with the corresponding patients’ hospital charts to assess the level of agreement for procedure coding. We calculated the PPV and sensitivity to estimate the validity of vascular injury diagnosis coding.
The overall PPV for vascular injury coding was estimated to be 95% (95% confidence interval [CI] 92.3–96.8). The PPV among code groups for neck, thorax, abdomen, upper extremity and lower extremity injuries ranged from 90.8 (95% CI 82.2–95.5) to 97.4 (95% CI 91.0–99.3), whereas sensitivity ranged from 90% (95% CI 81.5–94.8) to 98.7% (95% CI 92.9–99.8).
Administrative claims hospital discharge data based on ICD-10 diagnosis codes have a high level of validity when identifying cases of vascular injury.
Level of evidence
Observational Study Level III.
PMCID: PMC3859783  PMID: 24284148
13.  Evaluation of Death Certificate-Based Surveillance for Traumatic Brain Injury—Oklahoma 2002 
Public Health Reports  2006;121(3):282-289.
Death certificate data are used to estimate state and national incidence of traumatic brain injury (TBI)-related deaths. This study evaluated the accuracy of this estimate in Oklahoma and examined the case characteristics of those persons who experienced a TBI-related death but whose death certificate did not reflect a TBI.
Data from Oklahoma's vital statistics multiple-cause-of-death database and from the Oklahoma Injury Surveillance System database were analyzed for TBI deaths that occurred during 2002. Cases were defined using the Centers for Disease Control and Prevention (CDC) ICD-10 code case definition. In multivariate analysis using a logistic regression model, we examined the association of case characteristics and the absence of a death certificate for persons who experienced a TBI-related death.
Overall, sensitivity of death certificate-based surveillance was 78%. The majority (62%) of missed cases were due to listing ″multiple trauma″ as the cause of death. Death certificate surveillance was more likely to miss TBI-related deaths among traffic crashes, falls, and persons aged ≥65 years. After adding missed cases to cases captured by death certificate surveillance, traffic crashes surpassed firearm fatalities as the leading external cause of TBI-related death.
Death certificate surveillance underestimated TBI-related death in Oklahoma and might lead to national underreporting. More accurate and detailed completion of death certificates would result in better estimates of the burden of TBI-related death. Educational efforts to improve death certificate completion could substantially increase the accuracy of mortality statistics.
PMCID: PMC1525278  PMID: 16640151
14.  Older adults with acquired brain injury: a population based study 
BMC Geriatrics  2013;13:97.
Acquired brain injury (ABI), which includes traumatic (TBI) and non-traumatic brain injury (nTBI), is a leading cause of death and disability worldwide. The objective of this study was to examine the trends, characteristics, cause of brain injury, and discharge destination of hospitalized older adults aged 65 years and older with an ABI diagnosis in a population with universal access to hospital care. The profile of characteristics of patients with TBI and nTBI causes of injury was also compared.
A population based retrospective cohort study design with healthcare administrative databases was used. Data on acute care admissions were obtained from the Discharge Abstract Database and patients were identified using the International Classification of Diseases – Version 10 codes for Ontario, Canada from April 1, 2003 to March 31, 2010. Older adults were examined in three age groups – 65 to 74, 75 to 84, and 85+ years.
From 2003/04 to 2009/10, there were 14,518 episodes of acute care associated with a TBI code and 51, 233 episodes with a nTBI code. Overall, the rate of hospitalized TBI and nTBI episodes increased with older age groups. From 2007/08 to 2009/10, the percentage of patients that stayed in acute care for 12 days or more and the percentage of patients with delayed discharge from acute care increased with age. The most common cause of TBI was falls while the most common type of nTBI was brain tumours. The percentage of patients discharged to long term care and complex continuing care increased with age and the percentage discharged home decreased with age. In-hospital mortality also increased with age. Older adults with TBI and nTBI differed significantly in demographic and clinical characteristics and discharge destination from acute care.
This study showed an increased rate of acute care admissions for both TBI and nTBI with age. It also provided additional support for falls prevention strategies to prevent injury leading to cognitive disability with costly human and economic consequences. Implications for increased numbers of people with ABI are discussed.
PMCID: PMC3849645  PMID: 24060144
Brain injury; Epidemiology; Outcomes
15.  Assessing limb apraxia in traumatic brain injury and spinal cord injury 
People with traumatic brain injury (TBI) may demonstrate action planning disorders and limb apraxia. Many patients, who sustain a spinal cord injury (SCI), sustain a co-occurring TBI (11-29 percent of people with SCI) and therefore are at risk for limb apraxia. People with SCI and TBI (SCI/TBI) rely on powered assistive devices which amplify movement. Their ability to learn complex motor compensatory strategies, that is, limb praxis, is critical to function. We wished to identify methods of screening for apraxia in patients with SCI/TBI. We reviewed instruments available for limb praxis assessment, presenting information on psychometric development, patient groups tested, commercial/clinical availability, and appropriateness for administration to people with motor weakness. Our review revealed that insufficient normative information exists for apraxia assessment in populations comparable to SCI/TBI patients who are typically young adults at the time of injury. There are few apraxia assessment instruments which do not require a motor response. Non-motoric apraxia assessments would be optimal for patients with an underlying motor weakness.
PMCID: PMC3759515  PMID: 23277082
Rehabilitation; Apraxia; Spinal Cord Injuries; Traumatic Brain Injury; Review
16.  The Global Evidence Mapping Initiative: Scoping research in broad topic areas 
Evidence mapping describes the quantity, design and characteristics of research in broad topic areas, in contrast to systematic reviews, which usually address narrowly-focused research questions. The breadth of evidence mapping helps to identify evidence gaps, and may guide future research efforts. The Global Evidence Mapping (GEM) Initiative was established in 2007 to create evidence maps providing an overview of existing research in Traumatic Brain Injury (TBI) and Spinal Cord Injury (SCI).
The GEM evidence mapping method involved three core tasks:
1. Setting the boundaries and context of the map: Definitions for the fields of TBI and SCI were clarified, the prehospital, acute inhospital and rehabilitation phases of care were delineated and relevant stakeholders (patients, carers, clinicians, researchers and policymakers) who could contribute to the mapping were identified. Researchable clinical questions were developed through consultation with key stakeholders and a broad literature search.
2. Searching for and selection of relevant studies: Evidence search and selection involved development of specific search strategies, development of inclusion and exclusion criteria, searching of relevant databases and independent screening and selection by two researchers.
3. Reporting on yield and study characteristics: Data extraction was performed at two levels - 'interventions and study design' and 'detailed study characteristics'. The evidence map and commentary reflected the depth of data extraction.
One hundred and twenty-nine researchable clinical questions in TBI and SCI were identified. These questions were then prioritised into high (n = 60) and low (n = 69) importance by the stakeholders involved in question development. Since 2007, 58 263 abstracts have been screened, 3 731 full text articles have been reviewed and 1 644 relevant neurotrauma publications have been mapped, covering fifty-three high priority questions.
GEM Initiative evidence maps have a broad range of potential end-users including funding agencies, researchers and clinicians. Evidence mapping is at least as resource-intensive as systematic reviewing. The GEM Initiative has made advancements in evidence mapping, most notably in the area of question development and prioritisation. Evidence mapping complements other review methods for describing existing research, informing future research efforts, and addressing evidence gaps.
PMCID: PMC3141802  PMID: 21682870
17.  Updated evidence-based treatment of male sexual dysfunction among spinal cord injury patients 
Journal of Injury and Violence Research  2012;4(3 Suppl 1): Paper No. 58.
Decreased sexual function is a major concern of men with spinal cord injury (SCI). Erectile dysfunction (ED) and infertility can occur and affect men of any age with subsequent serious impacts on the quality of life. This paper was aimed to conduct a comprehensive review on the latest evidence-based works on prevention and treatment of ED and male infertility.
The MedLine/PubMed was used as the data source to search and collect studies published during January 1, 1995 to August 1, 2012. Cross referencing of discovered articles was also performed. All of the evidences related to male sexual dysfunction in SCI patients were extracted. We designed search strategies using following keywords in both text word and subject heading forms: sexual dysfunction, erectile dysfunction, male infertility, spinal cord injury, veteran, evidence, prevention and treatment. According to the inclusion criteria, 83 studies were selected for further analyses.
There are three common methods proposed in the literature for ED treatment of including medication, surgical procedures, and vacuum constriction devices. Male infertility could be caused by ED, ejaculatory dysfunction and poor sperm quality. Assisted ejaculation and surgical sperm retrieval might be useful.
Treatment of sexual dysfunction would decrease concern in spinal cord injured patients. Several medications and surgical treatments are now available to manage this problem in SCI population. In conclusion, regarding the importance of sexual satisfaction in SCI patients, considering different methods of sexual dysfunction management would lead to higher quality of life and better adherence to rehabilitation programs.
Sexual dysfunction, Erectile dysfunction, Male infertility, Spinal cord injury, Treatment
PMCID: PMC3571584
18.  Review of Critical Factors Related to Employment After Spinal Cord Injury: Implications for Research and Vocational Services 
Employment rates after spinal cord injury (SCI) vary widely because of discrepancies in studies' definition of employment and time of measurement. The objective of this study was to provide a comprehensive summary of the literature on employment rates, predictors of employment, and the benefits and barriers involved.
A search using the terms spinal cord injury and employment in the databases PubMed, PsycINFO, and MEDLINE. The search included a review of published manuscripts from1978 through 2008.
A total of 579 articles were found and reviewed to determine the presence of reported employment rates. Of these, 60 articles were found to include a report of employment rates for individuals with SCI. Results indicated that, in studies that examined paid employment, the average rate of any employment after SCI was approximately 35%.
Characteristics associated with employment after SCI include demographic variables, injury-related factors, employment history, psychosocial issues, and disability benefit status. It is recommended that researchers studying employment after SCI use common outcome measures such as competitive employment rates, duration of employment, and job tenure. Empirical evidence is lacking in regard to the most effective methods of vocational rehabilitation among this population. Evidence-based supported employment practices seem to be the most applicable model for assisting persons with SCI in restoring meaningful employment. Controlled studies are needed to test this assumption.
PMCID: PMC2792457  PMID: 20025147
Evidence-based practice; Employment; Supported employment; Disabilities; Spinal cord injuries; Tetraplegia; Paraplegia; Veterans; Vocational rehabilitation
19.  ICD-10-CA/CCI coding algorithms for defining clinical variables to assess outcome after aortic and mitral valve replacement surgery 
Implementation of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA) and the Canadian Classification of Interventions (CCI) coding system presents challenges for using Canadian administrative data. Thus, a multistep process was conducted to develop ICD-10-CA/CCI coding algorithms to define nine comorbidities and three procedures. These clinical variables have been used in ICD-9-CM data for risk adjustment in assessment of outcomes after aortic and mitral valve replacement surgery. Among patients included in the ICD-9-CM data during 1999 and 2001 and in the ICD-10-CA/CCI data during 2002 and 2003 in a Canadian Health Region, frequencies of the nine comorbidities and the three procedures remained generally similar across databases. The newly developed ICD-10-CA/CCI and previous ICD-9-CM coding algorithms are comparable in detecting these clinical variables. However, performance of ICD-10-CA/CCI coding algorithms in risk adjustment should be evaluated in a larger database.
PMCID: PMC2538989  PMID: 16485052
ICD-9-CM; ICD-10; Outcome; Risk adjustment; Valve surgery
20.  An international review of head and spinal cord injuries in alpine skiing and snowboarding 
Injury Prevention  2007;13(6):368-375.
Alpine skiing and snowboarding are popular winter activities worldwide, enjoyed by participants of all ages and skill levels. There is some evidence that the incidence of traumatic brain injury (TBI) and spinal cord injury (SCI) in these activities may be increasing. These injuries can cause death or severe debilitation, both physically and emotionally, and also result in enormous financial burden to society. Indeed, TBI is the leading cause of death and catastrophic injury in the skiing and snowboarding population. Furthermore, there are severe limitations to therapeutic interventions to restore neurological function after TBI and SCI, and thus the emphasis must be on prevention.
(1) To examine the worldwide epidemiology of TBI and SCI in skiing and snowboarding; (2) to describe and examine the effectiveness of prevention strategies to reduce the incidence of TBI and SCI in skiing and snowboarding.
Search strategy
Searches were performed on a variety of databases to identify articles relevant to catastrophic central nervous system injury in skiing and snowboarding. The databases included PubMed, Medline, EMBASE, CDSR, ACP Journal Club, DARE, CCTR, SportDiscus, CINAHL, and Advanced Google searches.
Selection criteria and data collection
After initial prescreening, articles included in the review required epidemiological data on SCI, TBI, or both. Articles had to be directly associated with the topic of skiing and/or snowboarding and published between January 1990 and December 2004.
24 relevant articles, from 10 different countries, were identified. They indicate that the incidence of TBI and SCI in skiing and snowboarding is increasing. The increases coincide with the development and acceptance of acrobatic and high‐speed activities on the mountains. There is evidence that helmets reduce the risk of head injury by 22–60%. Head injuries are the most common cause of death among skiers and snowboarders, and young male snowboarders are especially at risk of death from head injury.
There should be enhanced promotion of injury prevention that includes the use of helmets and emphasizes the skier's and snowboarder's responsibility code.
PMCID: PMC2598302  PMID: 18056311
21.  Proportion of injury deaths with unspecified external cause codes: a comparison of Australia, Sweden, Taiwan and the US 
Injury Prevention  2007;13(4):276-281.
The proportion of injury deaths with unspecified external cause codes has been used as an indicator of the level of comprehensiveness and specificity of information on death certificates provided by certifiers.
To compare the proportion of unspecified external cause codes across countries.
Multiple‐cause‐of‐death mortality data for people who died in 2001 due to external causes in Australia, Sweden, Taiwan and the USA were used for this international comparison study. The proportion of injury deaths coded as due to an unspecified external cause (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, ICD‐10, chapter XX) to all injury deaths in each block was calculated.
Sweden (33%) had the highest proportion of use of the least specific code (ICD‐10 code X59 exposure to unspecified factor), followed by Australia (17%), Taiwan (13%) and the USA (7%). More than two‐thirds of the deceased for whom an ICD‐10 code X59 was assigned in Sweden and Australia were those aged ⩾65 years, and more than half of them had femoral fractures. The percentage of use of the unspecified codes within specific groups of external causes was relatively high for falls and unintentional drowning.
Caution should be used in examining the compensatory effects of the unspecified external event code (ICD‐10 code X59) on specific external causes (especially falls) when making international comparisons. Efforts are needed to educate certifiers to report sufficient information for specific coding so as to provide more useful information for injury prevention.
PMCID: PMC2598354  PMID: 17686940
22.  Lessons Learned from an ICD-10-CM Clinical Documentation Pilot Study 
On October 1, 2013, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) will be mandated for use in the United States in place of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). This new classification system will used throughout the nation's healthcare system for recording diagnoses or the reasons for treatment or care. A pilot study was conducted to determine whether current levels of inpatient clinical documentation provide the detail necessary to fully utilize the ICD-10-CM classification system for heart disease, pneumonia, and diabetes cases. The design of this pilot study was cross-sectional. Four hundred ninety-one de-identified records from two sources were coded using ICD-10-CM guidelines and codebooks. The findings of this study indicate that healthcare organizations need to assess clinical documentation and identify gaps. In addition, coder proficiency should be assessed prior to ICD-10-CM implementation to determine the need for further education and training in the biomedical sciences, along with training in the new classification system.
PMCID: PMC3329200  PMID: 22548021
ICD-10-CM; clinical documentation; clinical documentation improvement teams; coding proficiency; biomedical sciences
23.  Preparing for ICD-10-CM/PCS: One Payer's Experience with General Equivalence Mappings (GEMs) 
The International Classification of Diseases, Tenth Edition, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) has been mandated as the new code set to be used for medical coding in the United States beginning on October 1, 2013, replacing the use of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). To assist in the transition from ICD-9-CM to ICD-10-CM/PCS, the National Center for Health Statistics developed bidirectional general equivalent mappings (GEMs) between the old and new code sets. This article looks at how the GEMs have been leveraged by Health Care Service Corporation (HCSC) to achieve the goal of transition to ICD-10-CM/PCS. The analysis examines the questions asked and lessons learned in the practical application of the GEMs for the translation of business rules and processes in order to promote a deeper understanding of the data issues involved in the transition from ICD-9-CM to ICD-10-CM/PCS from a payer's perspective.
PMCID: PMC3329202  PMID: 22548023
ICD-9-CM; ICD-10-CM/PCS; GEMs; codes; mapping
24.  Validity of the International Classification of Diseases, Tenth Revision code for acute kidney injury in elderly patients at presentation to the emergency department and at hospital admission 
BMJ Open  2012;2(6):e001821.
To evaluate the validity of the International Classification of Diseases, Tenth Revision (ICD-10) code N17x for acute kidney injury (AKI) in elderly patients in two settings: at presentation to the emergency department and at hospital admission.
A population-based retrospective validation study.
Southwestern Ontario, Canada, from 2003 to 2010.
Elderly patients with serum creatinine measurements at presentation to the emergency department (n=36 049) or hospital admission (n=38 566). The baseline serum creatinine measurement was a median of 102 and 39 days prior to presentation to the emergency department and hospital admission, respectively.
Main outcome measures
Sensitivity, specificity and positive and negative predictive values of ICD-10 diagnostic coding algorithms for AKI using a reference standard based on changes in serum creatinine from the baseline value. Median changes in serum creatinine of patients who were code positive and code negative for AKI.
The sensitivity of the best-performing coding algorithm for AKI (defined as a ≥2-fold increase in serum creatinine concentration) was 37.4% (95% CI 32.1% to 43.1%) at presentation to the emergency department and 61.6% (95% CI 57.5% to 65.5%) at hospital admission. The specificity was greater than 95% in both settings. In patients who were code positive for AKI, the median (IQR) increase in serum creatinine from the baseline was 133 (62 to 288) µmol/l at presentation to the emergency department and 98 (43 to 200) µmol/l at hospital admission. In those who were code negative, the increase in serum creatinine was 2 (−8 to 14) and 6 (−4 to 20) µmol/l, respectively.
The presence or absence of ICD-10 code N17× differentiates two groups of patients with distinct changes in serum creatinine at the time of a hospital encounter. However, the code underestimates the true incidence of AKI due to a limited sensitivity.
PMCID: PMC3533048  PMID: 23204077
25.  Incidence estimate and guideline-oriented treatment for post-stroke spasticity: an analysis based on German statutory health insurance data 
Spasticity after stroke has been internationally recognized as an important health problem causing impairment of mobility, deformity, and pain. The aim of this study was to assess the frequency of first-ever and recurrent stroke and of subsequent spastic and flaccid paresis. Factors influencing the development of spasticity were analyzed. A further major aim was to provide a “real-life” assessment of the treatment of spasticity in Germany and to discuss this in view of the treatment recommended by German and international clinical guidelines.
The database used in this study comprised a cohort of 242,090 insurants from a large statutory health insurance fund in the federal state of Hesse, Germany. A first hospital discharge diagnosis in 2009 with any of the International Classification of Diseases, Tenth Revision (ICD-10) codes I60–I64 was used to identify patients with acute stroke (hemorrhage and ischemic). These patients were followed up six months after stroke to monitor whether they developed spastic or flaccid paresis (hospital or ambulatory care diagnoses ICD-10 code G81–G83 [excluding G82.6/G83.4/G83.8]). For patients with spastic paresis after stroke the spasticity treatment was analyzed for a six-month period (physiotherapy, oral muscle relaxants, intrathecal baclofen, and botulinum toxin).
Standardized to the population of Germany, 3.7 per 1000 persons suffered a stroke in 2009 (raw 5.2/1000). Of all surviving patients, 10.2% developed spasticity within 6 months. Cox regression revealed no significant influence of patient age, gender, morbidity (diabetes, hypertensive diseases, ischemic heart diseases) or type of stroke on development of spasticity. 97% of surviving patients with spasticity received physiotherapy (inpatient care 89%, ambulatory care 48%). Oral muscle relaxants were prescribed to 13% of the patients. No patient received intrathecal baclofen or botulinum toxin.
Claims data enabled analysis of the occurrence of stroke and post-stroke spasticity. These data provide insight into real-life treatment for spasticity in Germany. The proportion of patients who receive physiotherapy, which is the international guideline-recommended basic therapy after transition into ambulatory care, can be improved on. Botulinum toxin as an international guideline-based treatment option for focal spasticity has not been implemented in practice in Germany as yet.
PMCID: PMC3601044  PMID: 23516125
health care utilization; physiotherapy; drug therapy; claims data

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