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1.  An alternate graft for staged flexor tendon reconstruction 
Hand (New York, N.Y.)  2014;10(1):152-154.
We describe the novel use of semitendinosus as a tendon graft for 2-stage flexor digitorum profundus (FDP) reconstruction. To our knowledge, this is the first reported use of a hamstring tendon graft in this setting. The FDP of two digits were reconstructed in a 30 year-old male who presented 18 years after the original injury. The semitendinosus was chosen as a graft as the traditional grafts were deemed inappropriate. The result of the operation is convincing, and we suggest the semitendinosus tendon to be considered an option for FDP reconstruction.
PMCID: PMC4349852  PMID: 25762891
Flexor tendon reconstruction; Hamstring tendon graft; Semitendinosus; Staged reconstruction; Tendon graft
2.  A safety audit of the first 10 000 intravitreal ranibizumab injections performed by nurse practitioners 
Eye  2014;28(10):1161-1164.
To evaluate the safety of a nurse practitioner (NP)-delivered injection service for the treatment of wet age-related macular degeneration (wAMD) with ranibizumab.
An evaluation of medical staffing resources for providing an injection service for wAMD highlighted difficulties covering lists. An alternative strategy of an NP-delivered injection service was evaluated. Two suitable NPs with previous extensive experience in minor surgical procedures were identified. The department's senior vitreo-retinal consultant supervised the NP's training programme. A prospective safety audit was conducted for the first 5.5 years of the service.
The NPs administered 10 006 injections in the first 5.5 years of the service (1 May 2008 to 8 October 2013). This represented 84.1% of the total injections performed during this period. Four patients developed presumed infectious endophthalmitis (1 was culture positive and 3 were culture negative). The incidence of post-injection endophthalmitis was 0.04%. There was no evidence of lens touch, retinal detachment, or systemic thrombo-embolic events.
Carefully selected and well-trained NPs are capable of delivering a safe and effective wAMD injection treatment service. This work demonstrates how such a service can be established and provides safety data that other units can use as a benchmark when evaluating their own practice.
PMCID: PMC4194327  PMID: 25033899
3.  Physiologic Field Triage Criteria for Identifying Seriously Injured Older Adults 
To evaluate the ability of out-of-hospital physiologic measures to predict serious injury for field triage purposes among older adults and potentially reduce the under-triage of seriously injured elders to non-trauma hospitals.
This was a retrospective cohort study involving injured adults 55 years and older transported by 94 emergency medical services (EMS) agencies to 122 hospitals (trauma and non-trauma) in 7 regions of the western United States from January 1, 2006 to December 31, 2008. We evaluated initial out-of-hospital Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate, heart rate, shock index (SBP ÷ heart rate), out-of-hospital procedures, mechanism of injury, and patient demographics. The primary outcome was “serious injury,” defined as Injury Severity Score (ISS) ≥ 16, as a measure of trauma center need. We used multivariable regression models, fractional polynomials and binary recursive partitioning to evaluate appropriate physiologic cut-points and the value of different physiologic triage criteria.
A total of 44,890 injured older adults were evaluated and transported by EMS, of whom 2,328 (5.2%) had ISS ≥ 16. Nonlinear associations existed between all physiologic measures and ISS ≥ 16 (unadjusted and adjusted p ≤ 0.001 for all,), except for heart rate (adjusted p = 0.48). Revised physiologic triage criteria included GCS score ≤ 14; respiratory rate < 10 or > 24 breaths per minute or assisted ventilation; and SBP < 110 or > 200 mmHg. Compared to current triage practices, the revised criteria would increase triage sensitivity from 78.6 to 86.3% (difference 7.7%, 95% CI 6.1–9.6%), reduce specificity from 75.5 to 60.7% (difference 14.8%, 95% CI 14.3–15.3%), and increase the proportion of patients without serious injuries transported to major trauma centers by 60%.
Existing out-of-hospital physiologic triage criteria could be revised to better identify seriously injured older adults at the expense of increasing over-triage to major trauma centers.
PMCID: PMC4397211  PMID: 24933614
EMS; trauma; triage
4.  Gunshot Injuries in Children Served by Emergency Services 
Pediatrics  2013;132(5):862-870.
To describe the incidence, injury severity, resource use, mortality, and costs for children with gunshot injuries, compared with other injury mechanisms.
This was a population-based, retrospective cohort study (January 1, 2006–December 31, 2008) including all injured children age ≤19 years with a 9-1-1 response from 47 emergency medical services agencies transporting to 93 hospitals in 5 regions of the western United States. Outcomes included population-adjusted incidence, injury severity score ≥16, major surgery, blood transfusion, mortality, and average per-patient acute care costs.
A total of 49 983 injured children had a 9-1-1 emergency medical services response, including 505 (1.0%) with gunshot injuries (83.2% age 15–19 years, 84.5% male). The population-adjusted annual incidence of gunshot injuries was 7.5 cases/100 000 children, which varied 16-fold between regions. Compared with children who had other mechanisms of injury, those injured by gunshot had the highest proportion of serious injuries (23%, 95% confidence interval [CI] 17.6–28.4), major surgery (32%, 95% CI 26.1–38.5), in-hospital mortality (8.0%, 95% CI 4.7–11.4), and costs ($28 510 per patient, 95% CI 22 193–34 827).
Despite being less common than other injury mechanisms, gunshot injuries cause a disproportionate burden of adverse outcomes in children, particularly among older adolescent males. Public health, injury prevention, and health policy solutions are needed to reduce gunshot injuries in children.
PMCID: PMC3813400  PMID: 24127481
trauma; children; health services; violence
5.  Triage of Elderly Trauma Patients: A Population-Based Perspective 
Journal of the American College of Surgeons  2013;217(4):10.1016/j.jamcollsurg.2013.06.017.
Elderly patients are frequently under-triaged. However, the associations between triage patterns and outcomes from a population perspective are unknown. We hypothesized that triage patterns would be associated with differences in outcomes.
Study Design
This is a population-based, retrospective cohort study of all injured adults aged ≥55 years from 3 counties in California and 4 in Utah (2006–2007). Pre-hospital data were linked to trauma registry data, state-level discharge data, emergency department (ED) records, and death files. The primary outcome was 60-day mortality. Patients treated at trauma centers were compared to those treated at non-trauma centers. Under-triage was defined as an injury severity score (ISS)>15 with transport to a non-trauma center.
There were 6,015 patients in the analysis. Patients who were taken to non-trauma centers were on average older (79.4 vs. 70.7 years, p<0.001), more often female (68.6% vs. 50.2%, p<0.01), and less often had an ISS>15 (2.2% vs. 6.7%, p<0.01). The number of patients with an ISS>15 was 244 and the under-triage rate was 32.8% (N=80). Overall 60-day mortality for patients with an ISS>15 was 17%, with no difference between trauma and non-trauma centers in unadjusted or adjusted analyses. However, the median per-patient costs were $21,000 higher for severely injured patients taken to trauma centers.
This is the first population-based analysis of triage patterns and outcomes in the elderly. We have shown high rates of under-triage that are not associated with higher mortality, but are associated with higher costs. Future work should focus on determining how to improve outcomes for this population.
PMCID: PMC3839622  PMID: 24054408
6.  Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems 
Reasons for under-triage (transporting seriously injured patients to non-trauma centers) and the apparent lack of benefit of trauma centers among older adults remain unclear; understanding emergency medical services (EMS) provider reasons for selecting certain hospitals in trauma systems may provide insight to these issues. In this study, the authors evaluated reasons cited by EMS providers for selecting specific hospital destinations for injured patients, stratified by age, injury severity, field triage status, and prognosis.
This was a retrospective cohort study of injured children and adults transported by 61 EMS agencies to 93 hospitals (trauma and non-trauma centers) in five regions of the western United States from 2006 through 2008. Hospital records were probabilistically linked to EMS records using trauma registries, state discharge data, and emergency department (ED) data. The seven standardized reasons cited by EMS providers for selecting hospital destinations included: closest facility, ambulance diversion, physician choice, law enforcement choice, patient or family choice, specialty resource center, and other. “Serious injury” was defined as an Injury Severity Score (ISS) ≥ 16, and unadjusted in-hospital mortality was considered as a marker of prognosis. All analyses were stratified by age in 10-year increments, and descriptive statistics were used to characterize the findings.
A total of 176,981 injured patients were evaluated and transported by EMS over the three-year period, of whom 5,752 (3.3%) had ISS ≥ 16, and 2,773 (1.6%) died. Patient or family choice (50.6%), closest facility (20.7%), and specialty resource center (15.2%) were the most common reasons indicated by EMS providers for selecting destination hospitals; these frequencies varied substantially by patient age. The frequency of patient or family choice increased with increasing age, from 36.4% among 21 to 30 year olds to 75.8% among those older than 90 years. This trend paralleled under-triage rates, and persisted when restricted to patients with serious injuries. Older patients with the worst prognoses were preferentially transported to major trauma centers, a finding that was not explained by field triage protocols.
Emergency medical services transport patterns among injured patients are not random, even after accounting for field triage protocols. The selection of hospitals appears to be heavily influenced by patient or family choice, which increases with patient age, and involves inherent differences in patient prognosis.
PMCID: PMC3785298  PMID: 24050797
7.  The Cost Of Overtriage: More Than One-Third Of Low-Risk Injured Patients Were Taken To Major Trauma Centers 
Health affairs (Project Hope)  2013;32(9):1591-1599.
Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients—those who did not meet field triage guidelines for transport to trauma centers—85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.
PMCID: PMC4044817  PMID: 24019364
8.  The Trade-Offs In Field Trauma Triage: A Multi-Region Assessment of Accuracy Metrics and Volume Shifts Associated With Different Triage Strategies 
National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of under- and over-triaged patients compared to current triage practices.
This was a retrospective cohort study of injured children and adults transported by 48 EMS agencies to 105 hospitals in 6 regions of the Western U.S. from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) ≥16. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross validation to generate estimates for sensitivity and specificity.
89,261 injured patients were evaluated and transported by EMS providers over the 3-year period, of whom 5,711 (6.4%) had ISS ≥16. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cut-point from ≤13 to ≤14 (sensitivity increase to 90.4%).
Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in over-triage). A 90% sensitivity target appears more realistic and may be obtainable by modest changes to the current triage algorithm.
Level of Evidence
Study Type
Diagnostic test
PMCID: PMC3726266  PMID: 23609282
triage; emergency medical services; serious injury
9.  Evaluating Age in the Field Triage of Injured Persons 
Annals of emergency medicine  2012;60(3):335-345.
Study Objective
In this study, we evaluated (1) trauma under-triage by age group; (2) the association between age and serious injury after accounting for other field triage criteria and confounders; and (3) the potential impact of a mandatory age triage criterion for field triage.
This was a retrospective cohort study of injured children and adults transported by 48 EMS agencies to 105 hospitals in 6 regions of the Western U.S. from 2006 through 2008. We used probabilistic linkage to match EMS records to hospital records, including: trauma registries, state discharge databases and emergency department databases. The primary outcome measure was serious injury, as measured by an Injury Severity Score (ISS) ≥ 16. We assessed under-triage (ISS ≥ 16 and triage-negative or transport to a non-trauma center) by age decile and used multivariable logistic regression models to estimate the association (linear and non-linear) between age and ISS ≥ 16, adjusted for important confounders. We also evaluated the potential impact of age on triage efficiency and trauma center volume.
260,027 injured patients were evaluated and transported by EMS over the 3-year study period. Under-triage increased for patients over 60 years of age, reaching approximately 60% for those older than 90 years. There was a strong non-linear association between age and ISS ≥ 16. For patients not meeting other triage criteria, the probability of serious injury was most notable after 60 years. A mandatory age triage criterion would have decreased under-triage at the expense of over-triage, with one ISS ≥ 16 patient identified for every 60–65 additional patients transported to major trauma centers.
Trauma under-triage increases in patients older than 60 years. While the probability of serious injury increases among triage-negative patients with increasing age, the use of a mandatory age triage criterion appears inefficient for improving field triage.
PMCID: PMC3428427  PMID: 22633339
10.  Evaluating the Use of Existing Data Sources, Probabilistic Linkage, and Multiple Imputation to Build Population-based Injury Databases Across Phases of Trauma Care 
Academic Emergency Medicine  2012;19(4):469-480.
The objective was to evaluate the process of using existing data sources, probabilistic linkage, and multiple imputation to create large population-based injury databases matched to outcomes.
This was a retrospective cohort study of injured children and adults transported by 94 emergency medical systems (EMS) agencies to 122 hospitals in seven regions of the western United States over a 36-month period (2006 to 2008). All injured patients evaluated by EMS personnel within specific geographic catchment areas were included, regardless of field disposition or outcome. The authors performed probabilistic linkage of EMS records to four hospital and postdischarge data sources (emergency department [ED] data, patient discharge data, trauma registries, and vital statistics files) and then handled missing values using multiple imputation. The authors compare and evaluate matched records, match rates (proportion of matches among eligible patients), and injury outcomes within and across sites.
There were 381,719 injured patients evaluated by EMS personnel in the seven regions. Among transported patients, match rates ranged from 14.9% to 87.5% and were directly affected by the availability of hospital data sources and proportion of missing values for key linkage variables. For vital statistics records (1-year mortality), estimated match rates ranged from 88.0% to 98.7%. Use of multiple imputation (compared to complete case analysis) reduced bias for injury outcomes, although sample size, percentage missing, type of variable, and combined-site versus single-site imputation models all affected the resulting estimates and variance.
This project demonstrates the feasibility and describes the process of constructing population-based injury databases across multiple phases of care using existing data sources and commonly available analytic methods. Attention to key linkage variables and decisions for handling missing values can be used to increase match rates between data sources, minimize bias, and preserve sampling design.
PMCID: PMC3334286  PMID: 22506952
11.  A Multi-Site Assessment of the ACSCOT Field Triage Decision Scheme for Identifying Seriously Injured Children and Adults 
ACSCOT has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multi-site cohort.
Study Design
This was a retrospective cohort study of injured children and adults transported by 94 EMS agencies to 122 hospitals in 7 regions of the Western U.S. from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcome measures were probabilistically linked to EMS records through trauma registries, state discharge data and emergency department data. The primary outcome defining a “major trauma patient” was ISS ≥ 16.
122,345 injured patients were evaluated and transported by EMS over the 3-year period, of who 34.5% met at least one triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0 – 86.6%) and 68.7% (95% CI 68.4 – 68.9%). Triage sensitivity and specificity differed by age: 84.1% and 66.4% (0 – 17 years); 89.5% and 64.3% (18 – 54 years); and 79.9% and 75.4% (≥ 55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings.
The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.
PMCID: PMC3235704  PMID: 22107917
12.  Point of purchase cigarette promotions before and after the Master Settlement Agreement: exploring retail scanner data 
Tobacco Control  2006;15(2):140-142.
Evidence indicates that point of purchase (POP) advertising and promotions for cigarettes have increased since the Master Settlement Agreement (MSA). Retail promotions have the potential to offset the effects of cigarette tax and price increases and tobacco control programmes.
To describe the trend in the proportion of cigarette sales that occur as part of a POP promotion before and after the MSA.
Scanner data were analysed on cigarette sales from a national sample of grocery stores, reported quarterly from 1994 through 2003. The proportion of total cigarette sales that occurred under any of three different types of POP promotions is presented.
The proportion of cigarettes sold under a POP promotion increased notably over the sample period. Large increases in promoted sales are observed following implementation of the MSA and during periods of sustained cigarette excise tax increases.
The observed pattern of promoted cigarette sales is suggestive of a positive relationship between retail cigarette promotions, the MSA, and state cigarette tax increases. More research is needed to describe fully the relationship between cigarette promotions and tobacco control policy.
PMCID: PMC2563558  PMID: 16565464
cigarette promotions; Master Settlement Agreement; policy; scanner data
13.  Children's rights 
PMCID: PMC1720271
15.  Paediatrics in primary care 
PMCID: PMC1719779  PMID: 14736618
16.  Cycle helmets 
Archives of Disease in Childhood  2003;88(6):465-466.
PMCID: PMC1763120  PMID: 12765906
17.  Atoms 
PMCID: PMC1719465
18.  Precocious puberty: a parent's perspective 
Archives of Disease in Childhood  2002;86(5):320-321.
PMCID: PMC1751112  PMID: 11970918
19.  Birth weight symposium 
PMCID: PMC1721366
20.  A-Z of medical writing. 
PMCID: PMC1718782
21.  A hospital led promotion campaign aimed to increase bicycle helmet wearing among children aged 11–15 living in West Berkshire 1992–98 
Injury Prevention  2000;6(2):151-153.
Objectives—To evaluate the effect of a bicycle helmet promotion campaign on helmet wearing among cyclists less than 16 years of age from 1992–98.
Setting—Reading, West Berkshire, UK.
Methods—A hospital led bicycle helmet promotion campaign targeted at 5–15 year olds. The campaign focused on education with active involvement of the children, parents, schools, and safety organisations. Local media and children's celebrities raised the profile of the campaign and a low cost helmet purchase scheme was also set up. A self administered questionnaire survey of 3000, 11–15 year olds was carried out over the period of the campaign. A control group of 3000 teenagers was obtained from a neighbouring area without a helmet campaign. Accident and emergency (A&E) figures were obtained from the local hospital within the campaign area on all children aged under 16 years, attending with bicycle injuries. Unfortunately, no figures were available from the A&E department in the control area.
Results—Self reported helmet use among 11–15 years olds living in the campaign area increased from 11% at the start of the campaign to 31% after five years (p<0.001), with no change in the control group. Hospital casualty figures in the campaign area for cycle related head injuries in the under 16 years age group, fell from 112.5/100 000 to 60.8/100 000 (from 21.6% of all cycle injuries to 11.7%; p<0.005).
Conclusions—This hospital led community bicycle helmet promotion campaign directed at young people showed an increase in the number of children reporting that they "always" wore their helmet while cycling. There was a significantly higher rate of helmet wearing than in the control area, and a significant reduction in head injuries.
PMCID: PMC1730614  PMID: 10875675
22.  Injury in the Young. 
PMCID: PMC1717920  PMID: 10208963
24.  An immunological approach to detect phosphate stress in populations and single cells of photosynthetic picoplankton. 
In the marine cyanobacterium Synechococcus sp. strain WH7803, PstS is a 32-kDa cell wall-associated phosphate-binding protein specifically synthesized under conditions of restricted inorganic phosphate (P1) availability (D. J. Scanlan, N. H. Mann, and N. G. Carr, Mol. Microbiol. 10:181-191, 1993). We have assessed its use as a potential diagnostic marker for the P status of photosynthetic picoplankton. Expression of PstS in Synechococcus sp. strain WH7803 was observed when the P1 concentration fell below 50 nM, demonstrating that the protein is induced at concentrations of P1 typical of oligotrophic conditions. PstS expression could be specifically detected by use of standard Western blotting (immunoblotting) techniques in natural mesocosm samples under conditions in which the N/P ratio was artificially manipulated to force P depletion. In addition, we have developed an immunofluorescence assay that can detect PstS expression in single Synechococcus cells both in laboratory cultures and natural samples. We show that antibodies raised against PstS cross-react with P-depleted Prochlorococcus cells, extending the use of these antibodies to both major groups of prokaryotic photosynthetic picoplankton. Furthermore, DNA sequencing of a Prochlorococcus pstS homolog demonstrated high amino acid sequence identity (77%) with the marine Synechococcus sp. strain WH7803 protein, including those residues in Escherichia coli PstS known to be directly involved in phosphate binding.
PMCID: PMC168535  PMID: 9172363
25.  Web client and ODBC access to legacy database information: a low cost approach. 
A new method has been developed for the Department of Orthopaedics of Vanderbilt University Medical Center to access departmental clinical data. Previously this data was stored only in the medical center's mainframe DB2 database, it is now additionally stored in a departmental SQL database. Access to this data is available via any ODBC compliant front-end or a web client. With a small budget and no full time staff, we were able to give our department on-line access to many years worth of patient data that was previously inaccessible.
PMCID: PMC2233436  PMID: 9357735

Results 1-25 (46)