Chad T. Wilson

Bicycle helmets are highly protective against traumatic brain injury within a dense urban setting.

BACKGROUND New York City (NYC) has made significant roadway infrastructure improvements, initiated a bicycle share program, and enacted Vision Zero, an action plan to reduce traffic deaths and serious injuries. The objective of this study was to examine whether bicycle helmets offer a protective advantage against traumatic brain injury (TBI) within a contemporary dense urban setting with a commitment to road safety. METHODS A prospective observational study of injured bicyclists presenting to a Level I trauma centre was performed. All bicyclists arriving within 24 h of injury were included. Data were collected between February, 2012 and August, 2014 and included demographics, imaging studies (e.g. computed tomography (CT)), injury patterns, and outcomes including Glasgow Coma Scale (GCS) and Injury Severity Score. RESULTS Of 699 patients, 273 (39.1%) were wearing helmets at the time of injury. Helmeted bicyclists were more likely to have a GCS of 15 (96.3% [95% Confidence Interval (CI), 93.3-98.2] vs. 87.6 [95% CI, 84.1-90.6]) at presentation. Helmeted bicyclists underwent fewer head CTs (40.3% [95% CI, 34.4-46.4] vs. 52.8% [95% CI, 48.0-57.6]) and were less likely to sustain intracranial injury (6.3% [95% CI, 2.6-12.5] vs. 19.7% [14.7-25.6]), including skull fracture (0.9% [95% CI, 0.0-4.9] vs. 15.3% [95% CI, 10.8-20.7]) and subdural hematoma (0.0% [95% CI, 0.0-3.2] vs. 8.1% [95% CI, 4.9-12.5]). Helmeted bicyclists were significantly less likely to sustain significant TBI, i.e. Head AIS ≥3 (2.6% [95% CI: 0.7-4.5] vs.10.6% [7.6-12.5]). Four patients underwent craniotomy while three died; all were un-helmeted. A multivariable logistic regression model showed that helmeted bicyclists were 72% less likely to sustain TBI compared with un-helmeted bicyclists (Adjusted Odds Ratio 0.28, 95% CI 0.12-0.61). CONCLUSIONS Despite substantial road safety measures in NYC, the protective impact of simple bicycle helmets in the event of a crash remains significant. A re-assessment of helmet laws for urban bicyclists is advisable to most effectively translate Vision Zero from a political action plan to public safety reality.

Traumatic injury in the United States: In-patient epidemiology 2000–2011

BACKGROUND Trauma is a leading cause of death and disability in the United States (US). This analysis describes trends and annual changes in in-hospital trauma morbidity and mortality; evaluates changes in age and gender specific outcomes, diagnoses, causes of injury, injury severity and surgical procedures performed; and examines the role of teaching hospitals and Level 1 trauma centres in the care of severely injured patients. METHODS We conducted a retrospective descriptive and analytic epidemiologic study of an inpatient database representing 20,659,684 traumatic injury discharges from US hospitals between 2000 and 2011. The main outcomes and measures were survey-adjusted counts, proportions, means, standard errors, and 95% confidence intervals. We plotted time series of yearly data with overlying loess smoothing, created tables of proportions of common injuries and surgical procedures, and conducted survey-adjusted logistic regression analysis for the effect of year on the odds of in-hospital death with control variables for age, gender, weekday vs. weekend admission, trauma-centre status, teaching-hospital status, injury severity and Charlson index score. RESULTS The mean age of a person discharged from a US hospital with a trauma diagnosis increased from 54.08 (s.e.=0.71) in 2000 to 59.58 (s.e.=0.79) in 2011. Persons age 45-64 were the only age group to experience increasing rates of hospital discharges for trauma. The proportion of trauma discharges with a Charlson Comorbidity Index score greater than or equal to 3 nearly tripled from 0.048 (s.e.=0.0015) of all traumatic injury discharges in 2000 to 0.139 (s.e.=0.005) in 2011. The proportion of patients with traumatic injury classified as severe increased from 22% of all trauma discharges in 2000 (95% CI 21, 24) to 28% in 2011 (95% CI 26, 30). Level 1 trauma centres accounted for approximately 3.3% of hospitals. The proportion of severely injured trauma discharges from Level 1 trauma centres was 39.4% (95% CI 36.8, 42.1). Falls, followed by motor-vehicle crashes, were the most common causes of all injuries. The total cost of trauma-related inpatient care between 2001 and 2011 in the US was

Racial disparities in abdominal aortic aneurysm repair among male Medicare beneficiaries.

240.7 billion (95% CI 231.0, 250.5). Annual total US inpatient trauma-related hospital costs increased each year between 2001 and 2011, more than doubling from

Helmet use is associated with safer bicycling behaviors and reduced hospital resource use following injury

12.0 billion (95% CI 10.5, 13.4) in 2001 to 29.1 billion (95% CI 25.2, 32.9) in 2011. CONCLUSIONS Trauma, which has traditionally been viewed as a predicament of the young, is increasingly a disease of the old. The strain of managing the progressively complex and costly care associated with this shift rests with a small number of trauma centres. Optimal care of injured patients requires a reappraisal of the resources required to effectively provide it given a mounting burden.

A community traffic safety analysis of pedestrian and bicyclist injuries based on the catchment area of a trauma center

HYPOTHESIS Although investigators have reported that abdominal aortic aneurysm (AAA) repair is performed less frequently in black subjects than in white subjects, these findings may be explained by a lower prevalence of AAA disease among black subjects. We examine this assumption by determining the relative rate (RR) of elective AAA repair in black men vs white men after accounting for differences in disease prevalence. DESIGN We used Medicare data from January 2001 to December 2003 to identify men 65 years and older undergoing elective or urgent AAA repair. We calculated the age-adjusted RR of repair in black men vs white men. We then used findings from the Aneurysm Detection and Management Veterans Affairs Cooperative Study to determine the ratio of screen-detected AAA prevalence among black men vs white men. Finally, we calculated prevalence-adjusted RRs of repair. SETTING Medicare data study. PARTICIPANTS Men 65 years and older undergoing elective or urgent AAA repair. MAIN OUTCOME MEASURE Prevalence-adjusted RR of AAA repair in black men vs white men. RESULTS The annual rate of elective AAA repair in black men was less than one-third that in white men (42.5 vs 147.8 per 100,000; RR, 0.29; 95% confidence interval [CI], 0.27-0.31). The disparity in urgent AAA repair was smaller, with black men undergoing repair at roughly half the rate of white men (26.1 vs 50.5 per 100,000; RR, 0.52; 95% CI, 0.48-0.56). The screen-detected disease prevalence of AAA among black men was less than half that among white men. Adjusting for this difference in prevalence diminished but did not erase the disparity in elective AAA repair (RR, 0.73; 95% CI, 0.68-0.77) and suggested that black men face a higher rate of urgent AAA repair (RR, 1.30; 95% CI, 1.21-1.41). CONCLUSIONS Black men undergo elective AAA repair at a lower rate than white men even after accounting for their decreased disease burden. However, the prevalence-adjusted rate of urgent repair is higher among black men. Whether the lower frequency of elective procedures is responsible for the higher frequency of urgent procedures warrants further investigation.

The (f)utility of flexion-extension C-spine films in the setting of trauma.

BACKGROUND While the efficacy of helmet use in the prevention of head injury is well described, helmet use as it relates to bicyclists’ behaviors and hospital resource use following injury is less defined. The objective of this study was to compare the demographics, behaviors, hospital workups, and outcomes of bicyclists based on helmet use. METHODS This study was a subset analysis of a 2.5-year prospective cohort study of vulnerable roadway users conducted at Bellevue Hospital Center, a New York City Level 1 trauma center. All bicyclists with known helmet status were included. Demographics, insurance type, traffic law compliance, alcohol use, Glasgow Coma Scale (GCS) score, initial imaging studies, Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), admission status, length of stay, disposition, and mortality were assessed. Information was obtained primarily from patients; witnesses and first responders provided additional information. RESULTS Of 374 patients, 113 (30.2%) were wearing helmets. White bicyclists were more likely to wear helmets; black bicyclists were less likely (p = 0.037). Patients with private insurance were more likely to wear helmets, those with Medicaid or no insurance were less likely (p = 0.027). Helmeted bicyclists were more likely to ride with the flow of traffic (97.2%) and within bike lanes (83.7%) (p < 0.001 and p = 0.013, respectively). Nonhelmeted bicyclists were more likely to ride against traffic flow (p = 0.003). There were no statistically significant differences in mean GCS score, AIS score, and mean ISS for helmeted versus nonhelmeted bicyclists. Nonhelmeted patients were more likely to have head computed tomographic scans (p = 0.049) and to be admitted (p = 0.030). CONCLUSION Helmet use is an indicator of safe riding practices, although most injured bicyclists do not wear them. In this study, helmet use was associated with lower likelihood of head CTs and admission, leading to less hospital resource use. Injured riders failing to wear helmets should be targeted for educational programs. LEVEL OF EVIDENCE Epidemiologic study, level III.

Needs assessment for a focused radiology curriculum in surgical residency: a multicenter study

BACKGROUND This study was designed to examine the characteristics of pedestrian and bicyclist collisions with motor vehicles within New York City’s high-density hub. The primary objectives were to map crash locations and to identify hot spots within these injury clusters. The secondary objective was to quantify differences in injury severity based on road type and user behaviors. METHODS Between December 2008 and June 2011, data were prospectively collected from pedestrians and bicyclists struck by motor vehicles and brought to Bellevue Hospital, a Level 1 trauma center in New York City. Behaviors by cohort (i.e., crossing patterns for pedestrians, riding patterns for bicyclists), Injury Severity Score (ISS), and collision locations were extracted from the database. Analyses of mean ISS were performed using a Student’s t test with a p < 0.05 considered significant. Geomaps were created to identify clusters or “hot spots,” where higher volumes of crashes occurred over time. Spatial analysis was performed to demonstrate whether these were random events. RESULTS A total of 1,457 patients (1,075 pedestrians and 382 bicyclists) were enrolled. Collision locations were known for 97.5%. Of the injured pedestrians, those crossing avenues (n = 277) had higher ISSs than those crossing streets (n = 522) (p = 0.01) and were more likely to die (p = 0.002). Pedestrians crossing midblock (n = 185) had higher mean ISSs than those crossing with the signal in the crosswalk (n = 320) (8.12 vs. 5.01, p < 0.001). Based on density mapping, hot spots of pedestrian collisions were detected in midtown Manhattan, while hot spots for bicyclists were detected at bridge and tunnel portals. Spatial analysis indicates that these are not random events (p < 0.05). CONCLUSION Pedestrians injured on avenues sustained more serious injuries than those injured on narrower streets. A better understanding of collision locations and features may allow for tailored injury prevention strategies. Trauma centers serve an important role in public health surveillance within their local communities. LEVEL OF EVIDENCE Epidemiologic study, level III.

Risky behaviors associated with pediatric pedestrians and bicyclists struck by motor vehicles.

BACKGROUND Flexion-extension radiographs are often used to assess for removal of the cervical collar in the setting of trauma. The objective of this study was to evaluate their adequacy. We hypothesized that a significant proportion is inadequate. METHODS This was a retrospective review of C-spine clearance at a level 1 trauma center. A trauma-trained radiologist interpreted all flexion-extension radiographs for adequacy. Studies performed within 7 days of injury were considered acute. RESULTS Three hundred fifty-five flexion-extension radiographs were examined. Ninety-five percent% of these studies were inadequate (51% because of the inability to visualize the top of T1, whereas 44% had less than 30° of angulation from neutral). Two hundred ten studies were performed acutely; of these, 97% were inadequate. When performed 7 days or longer from injury, 91% were inadequate. CONCLUSIONS Injury to the C-spine may harbor significant consequences; therefore, its proper evaluation is critical. The majority of flexion-extension films are inadequate. As such, they should not be included in the algorithm for removal of the cervical collar. If used, adequacy must be verified and supplemental radiographic studies obtained as indicated.

Initial Assessment and Management of the Trauma Patient

BACKGROUND Patient instability and limited radiology staffing may compel surgeons to make clinical decisions based on their independent interpretations of imaging studies. Despite potential implications for patients, no research to date has assessed the need for a diagnostic radiology curriculum in general surgery residency. METHODS We performed a cross-sectional study of surgery faculty and residents at 13 teaching hospitals across the United States. Survey responses were summarized using frequency and percentage, and analyzed by chi-square, Mantel-Haenszel chi-square, and McNemar tests. RESULTS Surveys were distributed to 465 faculty and 520 residents, with response rates of 26% and 30%, respectively. Most respondents reported making decisions based on their independent imaging interpretation at least sometimes, with higher frequency in acute scenarios. The majority voiced a need for a dedicated radiology curriculum, with teaching in chest x-rays, abdominal x-rays, abdominal computed tomography, chest computed tomography, and focused assessment with sonography in trauma examinations. CONCLUSIONS Surgeons and surgical residents enact treatment plans based on their independent interpretation of imaging studies, especially during acute patient scenarios. Further curricular development efforts are warranted to ensure trainee accuracy in radiologic interpretation.

U.S. Trends In CABG Hospital Volume: The Effect Of Adding Cardiac Surgery Programs

Objective Road safety constitutes a crisis with important health and economic impacts. In 2010, 11,000 pedestrians and 3500 bicyclists were injured by motor vehicles in New York City (NYC). Motor vehicle injuries represent the second leading cause of injury-related deaths in NYC children aged 5 to 14 years. To better target injury prevention strategies, we evaluated demographics, behaviors, environmental factors, injuries, and outcomes of pediatric pedestrians and bicyclists struck by motor vehicles in NYC. Methods Pediatric data were extracted from a prospectively collected database of pedestrians and bicyclists struck by motor vehicles and treated at a level I regional trauma center between December 2008 and June 2011. Patients, guardians, and first responders were interviewed and medical records were reviewed. Institutional review board approval was granted and verbal consent was obtained. Results Of the 1457 patients, 168 (12%) were younger than 18 years. Compared with injured adults, children were more likely to be in male sex (69% vs 53%), to have minor injuries (83% vs 73% for injury severity scores of <9), and to be discharged without admission (69% vs 67%). Midblock crossings were more common in children pedestrians than in adults (37% vs 19%), often despite supervision (48%). Electronic device use among teenagers aged 13 to 17 years was nearly 3 times that of adults (28% vs 11%). Conclusions Risky behaviors are common among pediatric pedestrians and bicyclists injured by motor vehicles. Road safety education and prevention strategies must stress compliance with traffic laws, readdress the importance of supervision, and reinforce avoidance of common distractors including electronic devices.