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1.  Gunshot Injuries in Children Served by Emergency Services 
Pediatrics  2013;132(5):862-870.
OBJECTIVE:
To describe the incidence, injury severity, resource use, mortality, and costs for children with gunshot injuries, compared with other injury mechanisms.
METHODS:
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.
RESULTS:
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).
CONCLUSIONS:
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.
doi:10.1542/peds.2013-1350
PMCID: PMC3813400  PMID: 24127481
trauma; children; health services; violence
2.  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.
Background
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.
Results
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.
Conclusions
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.
doi:10.1016/j.jamcollsurg.2013.06.017
PMCID: PMC3839622  PMID: 24054408
3.  Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems 
Objectives
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1111/acem.12213
PMCID: PMC3785298  PMID: 24050797
4.  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.
doi:10.1377/hlthaff.2012.1142
PMCID: PMC4044817  PMID: 24019364
5.  The Trade-Offs In Field Trauma Triage: A Multi-Region Assessment of Accuracy Metrics and Volume Shifts Associated With Different Triage Strategies 
Background
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.
Methods
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.
Results
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%).
Conclusions
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
III
Study Type
Diagnostic test
doi:10.1097/TA.0b013e31828b7848
PMCID: PMC3726266  PMID: 23609282
triage; emergency medical services; serious injury
6.  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.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1016/j.annemergmed.2012.04.006
PMCID: PMC3428427  PMID: 22633339
7.  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.
Objectives
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1111/j.1553-2712.2012.01324.x
PMCID: PMC3334286  PMID: 22506952
8.  A Multi-Site Assessment of the ACSCOT Field Triage Decision Scheme for Identifying Seriously Injured Children and Adults 
Background
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.
Results
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.
Conclusions
The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.
doi:10.1016/j.jamcollsurg.2011.09.012
PMCID: PMC3235704  PMID: 22107917
9.  Point of purchase cigarette promotions before and after the Master Settlement Agreement: exploring retail scanner data 
Tobacco Control  2006;15(2):140-142.
Background
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.
Objective
To describe the trend in the proportion of cigarette sales that occur as part of a POP promotion before and after the MSA.
Design
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.
Results
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.
Conclusions
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.
doi:10.1136/tc.2005.011262
PMCID: PMC2563558  PMID: 16565464
cigarette promotions; Master Settlement Agreement; policy; scanner data
10.  Children's rights 
doi:10.1136/adc.2004.064899
PMCID: PMC1720271
12.  Paediatrics in primary care 
doi:10.1136/adc.2003.046235
PMCID: PMC1719779  PMID: 14736618
13.  Cycle helmets 
Archives of Disease in Childhood  2003;88(6):465-466.
doi:10.1136/adc.88.6.465
PMCID: PMC1763120  PMID: 12765906
14.  Atoms 
doi:10.1136/adc.88.3.181-a
PMCID: PMC1719465
15.  Precocious puberty: a parent's perspective 
Archives of Disease in Childhood  2002;86(5):320-321.
doi:10.1136/adc.86.5.320
PMCID: PMC1751112  PMID: 11970918
16.  Birth weight symposium 
doi:10.1136/fn.86.1.F2
PMCID: PMC1721366
17.  A-Z of medical writing. 
doi:10.1136/adc.84.6.531d
PMCID: PMC1718782
18.  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.
doi:10.1136/ip.6.2.151
PMCID: PMC1730614  PMID: 10875675
19.  Injury in the Young. 
PMCID: PMC1717920  PMID: 10208963
21.  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
22.  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
23.  ADP-ribosylation of glutamine synthetase in the cyanobacterium Synechocystis sp. strain PCC 6803. 
Journal of Bacteriology  1995;177(12):3527-3533.
Glutamine synthetase (GS) inactivation was observed in crude cell extracts and in the high-speed supernatant fraction from the cyanobacterium Synechocystis sp. strain PCC 6803 following the addition of ammonium ions, glutamine, or glutamate. Dialysis of the high-speed supernatant resulted in loss of inactivation activity, but this could be restored by the addition of NADH, NADPH, or NADP+ and, to a lesser extent, NAD+, suggesting that inactivation of GS involved ADP-ribosylation. This form of modification was confirmed both by labelling experiments using [32P]NAD+ and by chemical analysis of the hydrolyzed enzyme. Three different forms of GS, exhibiting no activity, biosynthetic activity only, or transferase activity only, could be resolved by chromatography, and the differences in activity were correlated with the extent of the modification. Both biosynthetic and transferase activities were restored to the completely inactive form of GS by treatment with phosphodiesterase.
PMCID: PMC177058  PMID: 7768863
24.  Characterization of a zwf mutant of Synechococcus sp. strain PCC 7942. 
Journal of Bacteriology  1995;177(9):2550-2553.
A mutant of the cyanobacterium Synechococcus sp. strain PCC 7942 carrying a disrupted gene encoding glucose-6-phosphate dehydrogenase (zwf) produced no detectable glucose-6-phosphate dehydrogenase as assessed by enzyme assay and Western blot (immunoblot) analysis. This mutant exhibited significantly impaired dark viability.
PMCID: PMC176916  PMID: 7730289

Results 1-25 (43)